MassHealth
Managed Care for Older Members
and Members with Disabilities
Lori Cavanaugh
Director of Purchasing Strategy
NASHP Annual Conference
October 4, 2011
MassHealth Managed Care
■ Program Overview
■ Move toward Integrated Care
■ Policy Goals
■ Key Considerations
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MassHealth Disabled
and Older Members by Program
140,000
115,000
120,000
100,000
80,000
70,037
60,000
48,856
40,000
17,180
20,000
2,624
0
SCO
PACE
MCO
PCCP
FFS Disabled 21-64
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Programs for Older Members
Voluntary Opt-in Enrollment
Dual eligible and Medicaid-only members
Integrates MassHealth, Medicare, other community services
– capitation payments pooled at program level
■
–
–
–
Senior Care Options Program (2004)
4 contracted SCOs
Age 65+, live in any setting (in the community or a facility)
17k enrollees of ~140k members age 65+
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–
–
–
Program for All-inclusive Care for the Elderly – PACE (1990)
6 Programs, 17 PACE Centers
Age 55+, nursing facility level of care, live in the community
2,600 enrollees
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Programs for Disabled <65
Mandatory Enrollment
Medicaid Only (non-dual eligibles)
Statewide coverage
■ MCO Program (1980s)
– 5 contracted MCOs
– Capitated program, including behavioral health, with
FFS wrap for certain services: dental, LTC, PCA and
home-based services
– 49k Disabled members of 495k total members
■ Primary Care Clinician Plan
– PCCM FFS program with capitated behavioral health
carve-out (1992)
– 70k Disabled members of 328k total members
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Disabled <65 by Plan & Age
80,000
70,000
60,000
50,000
5: >=60 years
4: 26-59 years
40,000
3: 21-25 years
2: 13-20 years
1: 0-12 years
30,000
20,000
10,000
0
MCO
PCCP
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Disabled <65 Relative Costs
70%
60%
50%
40%
% of CY10
Enrollment
30%
% of CY10
Total Cost
20%
10%
0%
MCO
PCCP
*Excludes expansion categories of assistance with more limited benefits
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Integrated Care for
Dual Eligible Members 21-64
 In development, partnering with stakeholders and CMS
 Approximately 115,000 eligible members
 Statewide coverage
 Voluntary opt-out enrollment proposed
 Integration of Medicare and MassHealth program
and financing
 Medicare, Medicaid, and expanded covered benefits
BH diversionary services. certain LTSS
 Blended global payment
www.mass.gov/masshealth/duals
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Integrated Care - Policy Goals
■ Maintain members in their homes and communities by
integrating all aspects of preventive, acute and long term care
■ Establish accountability for person-centered delivery,
coordination, and management of quality service and supports
■ Enhance care management, use of care teams to improve the
quality and efficiency of care
■ Improve the quality of/access to BH services and integration of
BH and Medical services
■ Increase cultural competency; reduce racial/ethnic disparities
■ Ensure that spending is value-based and cost-effective; link
quality outcomes and payment
■ Provide members with a variety of managed health plans and
provider choices that satisfy members’ needs
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Program Development
Policy Goals
Benefits
Enrollment
Quality
Demographics
Utilization
Costs
Program
Design
Data
Data
Global
Payments
Stratification
Risk Adjustment
Costs
Rates
Admin Load
Risk Sharing
Savings
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Key Considerations
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■
■
Program Goals
Stakeholder / Member Input
Covered Benefits / Carve-outs
Care Coordination
Capacity of Provider Community
Network Management
Enrollment Policy and Supports
Procurement Strategy
Rate Development / Risk Adjustment
Reporting and Monitoring Performance
– Quality
– Financial
– Encounter Data
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Contact information:
lori.cavanaugh@state.ma.us
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