Massachusetts Approach to Medicaid Managed Long-Term Service and Supports

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1 Massachusetts Approach to Medicaid Managed Long-Term Service and Supports REPRESENTATIVE JEFFREY SÀNCHEZ HOUSE CHAIRMAN, JOINT COMMITTEE ON PUBLIC HEALTH Need for LTSS Reforms in Massachusetts Current utilization of LTSS Projected Growth in Demand Burden falls largely on state Medicaid (MassHealth) Massachusetts M h is high-cost h state t for LTSS 2 1

2 Massachusetts has experience expanding Medicaid managed care / Mixed Results with MMLTSS MassHealth Coverage 3 Managed Care Organizations: Boston Health Net Network Health Fallon Community Health Plan Neighborhood Health Plan Health New England Primary Care Clinician Plan: MassHealth-administered managed care plan Dual Eligible: Eligible for Medicare coverage due to age Eligible for Medicare coverage due to disability or other reasons Most in FFS Seniors are eligible for SCO & PACE Other FFS: Patients being assigned to an MCO Beneficiaries with third party coverage Members with access to limited benefits Source: MassHealth Strategic Planning Document , April 2013 Chapter 305 of the Acts of 2008: Legislative Mandate to Expand Managed Care Options for Dual Eligibles Notwithstanding any general or special law to the contrary, the executive office of health and human services shall maximize enrollment of eligible ibl persons in the MassHealth Senior Care Options program, the Program of All Inclusive Care for the Elderly, the Enhanced Community Options Program and the Community Choices program, or comparable successor programs, and shall develop dual eligible plans. For the purposes of this section, dual eligible plans shall be plans that offer similar coverage to Medicaid and Medicareeligible disabled persons under age 65. Section 38 of Chapter

3 Overview of the Massachusetts Dual Eligible Population Aged Key Characteristics Approximately 115,000 dual eligible beneficiaries ages 21 to 64 More likely l to report poor health h status, and be a member of a racial or ethnic minority. 65% have behavioral health diagnosis 60% have multiple chronic conditions (e.g. COPD, diabetes, cardiovascular disease) 14% diagnosed with a developmental disability 96% live in community setting Nearly four-fifths of duals living in the community received a low level of support services. 3times more likely to have 3 or more limitations in their activities of daily living, such as dressing, bathing, and eating. 5 Factors Contributing to Sub- Optimal Care Among the most complex care needs of any population high rate of medical service utilization, particularly ER visits and hospitalizations Care is fragments, not patient-centered. These individuals are presently excluded from existing MassHealth managed care options and are ineligible for additional behavioral health services. Care if based on inefficient FFS provider payment system Lacks incentives for care management and coordination Lack access to full range of services Limited range of inpatient and outpatient behavioral health services under Medicaid state plan and Medicare Duals Identified as a Significant Driver of Health Care Costs 6 Source: Dual Eligibles in Massachusetts: A Profile of Health Care Services and Spending for Non-Elderly Adults Enrolled in Both Medicare and Medicaid 3

4 The Massachusetts Approach: OneCare Massachusetts's approach to the dual eligible population evolved into the state Demonstration plan which we call OneCare 7 Informed by simultaneous efforts to adopt broader health care payment and delivery reforms, in particular initiative related to: Accountable Care Organizations Patient-Centered Medical Homes Shift from Fee-for-Service to Alternative ti / Global l Payment Methodologies Supported by key provisions of Affordable Care Act and 1115 Waiver Demonstration renewal OneCare: MassHealth + Medicare 8 Key Objectives of OneCare Ease access to comprehensive care Deliverer person-centered care Promote independence in the community Improve quality of care and reduce health disparities Eliminate cost-shifting between Medicare and MassHealth Operationalize primary-care behavioral health integration Move patients from FFS to Global payments Achieve cost savings for both the state and federal governments through improvements in care and coordination Covered Services through OneCare Medicare Parts A, B and D Medicaid State Plan Services Long-Term Services and Supports Diversionary Behavioral Health Services Community Supports Dental and Vision Additional services to facilitate wellness, self-management and independent living Eligibility Dually eligible individuals aged 21 to64 at time of enrollment with the exception of those: Enrolled in PACE, SCO or serviced by HBCS waiver Residing in ICF/MR (facility for individuals with intellectual disabilities) Covered under other comprehensive private insurance plan Residing outside of a designated service area under the Demonstration 4

5 OneCare Plans Integrated Care Organizations OneCare Plans - Integrated Care Organizations (ICOs) single accountable entity responsible for the delivery and management of all medical and behavioral health and LTSS services. OneCare Plan Contracting and Financing: - One Care plans will receive a combined global payment from the federal and state governments to provide all the services of Medicare Parts A, B and D, and MassHealth Medicaid payment based on rating category assigned to enrollee according to clinical status, need for LTSS and behavioral health services OneCare plans negotiate separately with providers to determine payment rates for network care Key OneCare Plan Operation Capacities:- Internal capacity or contract out to provide all services in an enrollee s care plan through a network of provider Demonstrate core competencies across disability populations, Possess prior experience with integration of behavioral health services, serving the homeless and other unique populations Ensure cultural competency and ADA compliance of the care team and contracted providers OneCare Plans must provide enrollees: - Integrated Medicare and MassHealth benefits Person-centered care with integration i across medical, behavioral health h and LTSS needs Interdisciplinary Care Teams, including Care Coordinators and Independent Living and Long Term Services and Supports (IL- LTSS) Coordinators Individualized Care Plans directed by the enrollee and informed by a comprehensive in-person assessment of medical, behavioral, and functional needs to be conducted within first 90 days Continuity of care. 9 OneCare: Care Team and Care Plan Unique among the state proposals, OneCare plans are required to contract with Independent Living-Long Term Services and Support (LTSS) Coordinators from community-based organizations independent of the demonstration health plans Plans are encouraged to be creative and inclusive in contracting for care team services 10 Clinical Care Manager Primary Care Provider Centered on the Person Additional Members Designated by Enrollee Care Coordinator Behavioral Care teams can pursue Health Long-Term creative strategies to maintain i Provider (as Supports needed under Coordinator care plan) enrollee wellness and meet care goals through appropriate use of global payment Care must be evidence-based supported by accepted practice guidelines, yet balanced with individual care needs 5

6 Issues to Consider in Developing Your Own State Plan Risk-adjustment Enrollment Rate Development Early and Continual Stakeholder Engagement Coordinating i Integrated Care for Duals Population with Other Health Care Delivery Reforms 6 Case Study: Bromley-Heath Housing Development 7 6

7 Case Study: Bromley-Heath Housing Development 8 Applying the Results: Looking To Pediatric Asthma Pediatric Asthma Pilot Based on Community Asthma Initiative at Boston Children s Hospital 9 A h I i i i Ath Asthma Pilt Pilot: Pre- and Post- Intervention Results, Phase 1 Bundled payment Access to additional i services 7

8 Learning from the Past: Successful Public Health Efforts Tobacco cessation and prevention 10 Societal/Policy Factors HIV/AIDS prevention Like prevention, health care delivery does not exist in a vacuum Community Factors Institutional Transformation Individual Factors Extent and Quality of Health Care and Outcomes Some Final Words 11 We are trying to construct a more inclusive society. We are going to make a country in which no one is left out. -Franklin Delano Roosevelt 8