Work Plan Deliverable 9.1: Description of the Current Case Management
System
Massachusetts Case Management Systems
Case management in Massachusetts is available through several MassHealth programs and services: (1)
Ten 1915(c) Home & Community-Based Services (HCBS) Waivers1; (2) three managed or integrated care
programs; (3) Targeted Case Management provided to members with intellectual disabilities enrolled in
1915(c) waivers and people with mental health needs who are served by state agencies; and (4)
Community Case Management (CCM) for individuals with complex medical needs. In some instances in
the Massachusetts Case Management system, case management is provided by the same entity that
provides direct services. Various mitigation strategies are currently in place to ensure beneficiary choice
and quality of care. A brief description of each case management system and current beneficiary
safeguards is included below.
1915 (c) HCBS Waivers
All HCBS waiver consumers in Massachusetts receive case management, either as an administrative
activity or as Targeted Case Management. Some case management elements, such as requirements for
quality reporting, oversight by the state, and the right to request a Fair Hearing, are common across all
ten HCBS waivers. Procedures for eligibility determination, service coordination and service delivery
vary by HCBS waiver operating agency and are included in the description of case management systems
below.
Department of Developmental Services (DDS) HCBS Waivers: Adult Supports, Intensive
Supports, and Community Living
The target populations of the concurrent DDS Adult Supports, Intensive Supports and Community Living
waivers are adults with intellectual disability age 22 and older with varying support needs. Case
managers for the DDS Adult Supports, Intensive Supports, and Community Living HCBS Waivers are DDSemployed Service Coordinators who work at DDS Area Offices. Eligibility for a DDS HCBS waiver is
determined by Regional Eligibility Teams comprised of a state waiver eligibility specialist, licensed
doctoral level psychologist(s), social worker(s), and a nurse, as needed. The DDS Waiver Management
Unit reviews the Level of Care assessment conducted by the Regional Eligibility Team. If determined
eligible, the consumer works with a DDS Service Coordinator (the case manager) to develop an
1
The ten 1915 (c) HCBS waivers include the Acquired Brain Injury – Non-Residential Waiver, Acquired Brain Injury –
Residential Waiver, DDS Adult Supports Waiver, Children’s Autism Spectrum Disorder Waiver, DDS Community
Living Waiver, Frail Elder Waiver, DDS Intensive Supports Waiver, Money Follows the Person - Community Living
Waiver, Money Follow the Person - Residential Waiver, and Traumatic Brain Injury Waiver. The waivers are
operated by the Department of Developmental Services, Executive Office of Elder Affairs, and Massachusetts
Rehabilitation Commission.
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Individual Supports Plan. The Individual Supports Plan includes services that may be provided by DDS
contracted providers or state-operated providers of Center-Based Day services, Individualized Home
Supports, Residential Habilitation, and Individualized Supported Employment.
Beneficiary choice is maintained and protected with the following procedures and structural conflict
mitigation strategies.
Administrative Firewalls
 Quality management and oversight is conducted by a separate division located at the DDS Central
Office.
Quality Management and Oversight
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DDS utilizes a robust quality management and improvement system (QMIS) that includes a
continuous loop of quality improvement, active participation from individuals, families and
other key stakeholders and integration of data from a variety of sources.2
Staff from the DDS Office of Quality Management conduct bi-weekly reviews of reported critical
incidents that have been identified by risk categories to assure that they received the
appropriate reviews.
All complaints filed with the Disability Persons Protection Commission are entered into the
investigations database (Home and Community Services Information System, HCSIS). Data
reports are reviewed quarterly by both Area and Regional Offices.
The Commonwealth of Massachusetts conducts an annual Single State Audit that includes
sampling from waiver service claims.
As an integral component of the DDS Quality Management and Improvement System, important
information regarding health, safety and quality of life for individuals the Department supports is
published widely and in various formats. Examples include a “Living Well” Newsletter which goes
directly to each group home, ”Quality is no Accident” Briefs which highlight specific practical measures
providers can take to support individuals and reduce risk, health and risk protocols on specific concerns,
timely advisories on current concerns, and quality assurance briefs on issues around health, choice,
human rights, and quarterly webinars.
2
Key principles of DDS QMIS: 1) A continuous loop of quality including identification of issues, correction, follow-up, and
analysis of patterns and trends; 2) Quality is imbedded in all activities of the Department and involves everyone; 3) The
measurement of quality is based upon a set of outcomes in peoples’ lives agreed upon with stakeholders; 4) The system
involves active participation from individuals, families, and other key stakeholders; 5) The system rigorously measures health,
safety and human rights, and other quality of life domains; 6) The system integrates data and information from a variety of
different sources; 7) The system collects, aggregates and analyzes data to identify patterns and trends to inform service
improvement activities; 8) Service improvement targets are tracked to allow for measurement of progress over time.
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Beneficiary Complaint System
 Participants have the right to a Fair Hearing on clinical eligibility determination.
 Participants have the right to appeal service plan decisions.
 DDS Service Coordinators are required to inform individuals about how to report alleged cases of
abuse or neglect.
 Investigation and complaint resolution process protects individuals from harm and requires
action plans to prevent reoccurrences.
 Complaint Resolution Teams (CRTs) take the findings from the investigative process and
formulate action plans. Area CRTs are comprised of the Area Director, other DDS staff and at
least one citizen representative.
Additional Safeguards
 Individual Support Plans are reviewed for content, quality, and required components through the
Service Coordinator Supervisor Tool.
 Stakeholder engagement opportunities exist through the Citizen Advisory Board and a statewide
Quality Council.
 The Office of Human Rights within DDS oversees a system of safeguards to affirm, promote and
protect the human and civil rights of people supported by DDS.
 Participants have free choice of qualified providers.
Children’s Autism Spectrum Disorder HCBS Waiver
The Children’s Autism Spectrum Disorder HCBS Waiver (Autism waiver) serves children with Autism
Spectrum Disorder up to eight years of age. Because the Autism waiver is fully participant-directed, case
management is conflict free. Functional eligibility is determined by DDS Autism Eligibility Staff, and case
management and service planning is provided by DDS Autism Clinical Managers. With the assistance of
an Autism Support Broker employed by one of the non-profit private Autism Specialty Providers, families
select Autism waiver services that fit the needs of their child within an approved budget. The family has
full control and choice over services and providers.
Additional safeguards mitigating for conflict in case management include: A review of plans of care for a
random sample of participants to assure that plans address all necessary assurances and that support
brokers are monitoring the implementation of plans, face-to-face interviews with family members by
quality management staff to ensure the family was fully informed of and understood all service options
available and were given a choice of providers, and rights to appeal both eligibility for the Autism waiver
and the service plan.
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Acquired Brain Injury –Residential Habilitation and MFP – Residential Supports HCBS
Waivers
The Acquired Brain Injury Residential Habilitation (ABI – RH) Waiver and the MFP Residential Supports
Waiver are both operated by DDS and serve individuals with 24-hour support needs. The goal of both
HCBS waivers is to (1) transition eligible persons from nursing facilities and chronic disease and
rehabilitation hospitals (CDR) to community-based settings; and (2) furnish home or community-based
services to the consumers following their transition. Functional assessments for these HCBS Waivers are
conducted by a University of Massachusetts Medical School (UMMS) department. UMMS acts as the
Administrative Service Organization. In this role, UMMS solicits direct service providers, assists
providers with MassHealth provider agreements and conducts vendor verification and monitoring
functions. Case management for both waivers is conducted by DDS-employed Service Coordinators
located at the DDS Area Offices.
In order to ensure that beneficiary choice is maintained and protected, DDS has established the
following procedures and structural conflict mitigation strategies: Administrative barriers between case
management (by DDS staff) and direct service (by a provider network procured by UMMS), the right to
appeal waiver eligibility and service plans, robust quality monitoring by the state through the DDS
Quality Management and Improvement System, beneficiary choice of providers from qualified provider
listing, and a statewide quality council. The statewide quality council is comprised of self-advocates,
family members, providers, and DDS staff which reviews and provides guidance on quality. Each DDS
regional office also has a Citizen Advisory Board, which is comprised of self-advocates, family members,
and providers to offer guidance on quality issues.
Acquired Brain Injury – Non-Residential and MFP – Community Living HCBS Waivers
The Acquired Brain Injury Non-Residential Habilitation and MFP – Community Living Waivers are
operated by the Massachusetts Rehabilitation Commission (MRC) and serve individuals with less than
24-hour per day support needs. The goal of both HCBS Waivers is to (1) transition eligible persons from
nursing facilities and chronic and rehabilitation hospitals to community-based settings and (2) furnish
home or community-based services to the waiver participants following their transition. Functional
assessments for the waivers are conducted by a University of Massachusetts Medical School (UMMS)
department. UMMS acts as the waiver Administrative Service Organization. In this role, UMMS solicits
direct service providers, assists providers with MassHealth provider agreements, and conducts vendor
verification and monitoring functions. Case management for both waivers is conducted by MRC Case
Managers.
In order to ensure that beneficiary choice is maintained and protected, MRC has embedded multiple
conflict mitigation strategies and safeguards including: Reviewing consumer progress reports by case
managers on a monthly basis, soliciting feedback from waiver participants regarding their satisfaction
with services, allowing choice of providers based on consumer preferences, and conducting robust
quality monitoring.
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Traumatic Brian Injury HCBS Waiver
The Traumatic Brain Injury (TBI) Waiver is designed to serve individuals with TBI who are at a nursing
facility or chronic disease and rehabilitation hospital level of care. Through this program, individuals with
TBI are able to stay in their homes or other community setting with sufficient supports. The HCBS
Waiver is structured in a manner that avoids conflict between case management function and the
provision of direct services. Staff from MRC, the Operating Agency for this HCBS Waiver, conduct
functional assessments and provide case management to consumers. MRC contracts directly with
service providers for the provision of waiver services. MRC verifies the qualifications of all contracted
providers.
In addition, MRC has established the following safeguards in order to ensure that beneficiary choice is
maintained and protected: Reviewing consumer progress reports by case managers on a monthly basis,
soliciting feedback from waiver participants regarding their satisfaction with services, allowing choice of
providers based on consumer preferences, conducting robust quality monitoring, and providing the right
to appeal waiver eligibility and care plan decisions or adverse actions.
Frail Elder HCBS Waiver
The Frail Elder Waiver serves nursing facility eligible elders ages 60 and over. Aging Services Access
Points (ASAPs) contract with the Executive Office of Elder Affairs (EOEA) to conduct functional
assessments to determine eligibility, provide case management for waiver consumers, and oversee,
monitor and purchase community-based long term services and supports (LTSS) from contracted
providers. ASAPs may also be providers of other Medicaid state plan LTSS including Adult Foster Care
(AFC) and Group Adult Foster Care (GAFC), and ASAPs may also provide skills training as part of their role
as Personal Care Management Agencies through the consumer-directed Personal Care Attendant
program. Though not a waiver service, Frail Elder Waiver consumers may also access AFC. In order to
provide an administrative firewall, eligibility determination for AFC and GAFC is conducted by a single
ASAP which is not an AFC service provider. This separation mitigates the potential for over or
underutilization of such services.
State law3 prohibits ASAPs from being direct providers of HCBS Waiver services, which creates an
administrative firewall between case management and direct service provision under the Frail Elder
Waiver. Any exceptions to this prohibition must be approved by a waiver from the Executive Office of
Elder Affairs. Additional safeguards and mitigation strategies include:
Administrative Firewalls
 ASAPs organize their agencies in a manner that mitigates potential conflict by having separate
reporting structures for any functions that may potentially overlap with service provision;
 Audits/reviews are conducted by state agency staff from EOEA on business practices.
3
M.G.L. Ch. 19a §4b ( https://malegislature.gov/Laws/GeneralLaws/PartI/TitleII/Chapter19a/Section4b)
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Quality Management and Oversight
 The state conducts periodic performance audits or reviews of all ASAPs;
 The state reviews a sample of service plans to ensure that all needs identified have been
addressed through either waiver or non-waiver services;
 The state employs a quality assurance process by which the state monitors waiver quality and
ASAPs must monitor and report on waiver quality.
 All active service plans are fully maintained within a single system of record to which the
Executive Office of Elder Affairs has real-time and unrestricted access. The state can
immediately access the record to analyze any issues of concern.
State monitoring through survey of beneficiary satisfaction
 ASAPs participate in an annual Participant Satisfaction Survey process and are required to
complete a Corrective Action Plan process for contracted providers performing in a substandard
manner. All Corrective Action Plans are sent to EOEA for review.
Beneficiary complaint system
 Right to a Fair Hearing following adverse actions;
 ASAPs participate in a Staff/Participant Complaint Log process that informs corrective action
planning by the ASAP and contracted provider;
 Participants have choice of qualified providers.
Integrated Care
As noted by the BIP Technical Assistance provider, the coordination of care and colocation of care
management functions and direct service provision, a strength of managed care, make managed care
entities susceptible to potential conflict in case management. Massachusetts managed or integrated
care programs have strong administrative firewalls and participant safeguards to mitigate against
conflict within the care system, as detailed below.
One Care: MassHealth plus Medicare (Massachusetts Duals Demonstration)
Eligibility Determination and Care Planning
Individuals may be eligible for One Care if they have both MassHealth and Medicare and are between
the ages of 21 and 64 at the time of enrollment. No other clinical eligibility assessment is required for
enrollment in One Care. One Care plans, health plans contracted by MassHealth and CMS, are required
to confirm the enrollee’s eligibility status through the Eligibility Verification System (EVS). One Care plan
staff conduct comprehensive needs assessments for identification of support needs and service
planning. A component of this assessment informs rating category determination for plan
reimbursement.
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Several mechanisms are employed to mitigate underutilization of services. All One Care enrollees are
central to their care team and participate in a person-centered planning process to develop their care
plan, as detailed in the provider contract with MassHealth and CMS. One Care enrollees also have the
option to include an Independent Living Long Term Services and Supports (LTS) Coordinator on their
care team who is employed by a community-based organization and is independent from the One Care
plan. This care team member assists the enrollee in working toward the individual’s independent living,
wellness and recovery goals and can advocate on behalf of the individual.
Case Management
Case management is provided primarily by the One Care plan Care Coordinator. The Care Coordinator is
employed by or contracted by the One Care plan or the enrollee’s Primary Care Provider. One Care plans
contract with a network of providers to deliver all covered services and therefore are not providers of
services. Person-centered planning, beneficiary choice and the option for the inclusion of an LTS
Coordinator on the care team, serve as beneficiary safeguards within the One Care case management
system. Additionally, One Care plans are required to implement consumer governance structures within
their plan, providing opportunity for One Care members to have a voice in the operation of the plan.
Beneficiary Complaint System
One Care enrollees have the right to appeal any adverse care plan decisions or file a grievance. Both
grievances and appeals can be filed at an internal (plan) level or an external level (MassHealth Board of
Hearing for MassHealth Services and Medicare Independent Review Entity for Medicare services). One
Care enrollees may also access the One Care Ombudsman who can assist enrollees in understanding
their rights under One Care including how to file an appeal or grievance.
State Oversight
The MassHealth Office of Providers and Plans includes a One Care contract management team that, in
collaboration with CMS, oversees each One Care plan’s compliance with contract requirements.
Contract requirements include participation in quality improvement activities including performance
measurement, performance improvement projects, and member experience surveys.
Additionally, EOHHS has convened a consumer-led Implementation Council to assist in One Care
implementation and monitoring. The Implementation Council and other stakeholder engagement
opportunities such as monthly open meetings and the convening of topical workgroups provides
meaningful stakeholder involvement opportunities and program transparency.
Program of All Inclusive Care for the Elderly (PACE)
Eligibility Determination and Care Planning
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The Program of All-inclusive Care for the Elderly (PACE) is a fully capitated Medicare and Medicaid
managed care program which services frail individuals age 55 and over who meet the nursing facility
clinical criteria. PACE plans perform clinical eligibility assessments of members and submit results to
EOHHS for formal approval and authorization, providing an administrative firewall between eligibility
determination and service provision by PACE plans. PACE members are assigned rate cells according to
whether they are dually eligible for Medicare Part A and MassHealth, therefore results of the functional
assessment do not determine the level of payment to the PACE site.
Case Management
PACE care planning is conducted by the Interdisciplinary Care Team (IDT) that assesses the enrollee’s
medical, functional, psychosocial, and cognitive needs to develop a comprehensive plan of care and
conduct ongoing monitoring of the individualized care plan. The IDT, made up of members covering
eleven (11) distinct roles4 required to be represented on the care team, directly delivers care to PACE
enrollees. The IDT collectively develops, with input from the participant or their caregiver, the care plan
through discussion and consensus and formal care plan meetings. PACE enrollees are entitled to a
choice of health care providers, within the PACE organization’s network.
Beneficiary Complaint System
Federal regulations require that PACE plans members have a written Bill of Rights designed to protect
and promote the rights of enrollees. Included in these rights is the right to appeal eligibility
determinations and adverse service decisions. Member are informed of these rights in an enrollment
agreement that is signed by the PACE plan and the enrollee. Appeal rights are also presented to
members upon delivery an adverse service decision.
All PACE plans are required to form and convene Advisory Councils that include PACE enrollees and their
representatives.
State Oversight
Each PACE plan must develop and implement a data-driven Quality Assessment and Performance
Improvement (QAPI) plan. Both CMS and EOHHS approve the QAPI plan and review the plan during
periodic monitoring visits. The QAPI program must include objective measures to demonstrate
improved performance with regard to five areas: 1) utilization of services, 2) participant and caregiver
satisfaction, 3) outcome measures that are derived from data collected during participant assessments,
4) effectiveness and safety of staff –provided and contracted services, and 5) non-clinical areas including
grievances and appeals.
4
The PACE IDT is composed of but not limited to the following members: Primary Care Physician, Registered
Nurse, Master’s Level Social Worker, Physical Therapist, Occupational Therapist, Recreational Therapist or Activity
Coordinator, Dietitian, PACE Center Manager, Home Care Coordinator, Personal Care Attendant or his or her
representative, Driver/Transportation Provider or his or her representative.
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EOHHS upholds the opportunity to impose sanctions on PACE programs in violation of contract
requirements.
Senior Care Options (SCO)
Eligibility Determination and Care Planning
Senior Care Options (SCO) is a fully capitated Medicare and Medicaid managed care program that is
offered to eligible MassHealth members age 65 and over, at all levels of need. Enrollment in SCO is
voluntary and certain MassHealth members meeting the age requirement may enroll. SCO members are
assigned rating categories based on the following criteria: Medicaid and Medicare eligibility, region of
residence (Boston/Non-Boston), clinical status, and setting of care. An initial assessment of clinical and
function status is conducted by the SCO plan within 30 days of enrollment in the program.
Case Management
SCO plans provide care management through Primary Care Physicians (PCP) or the Primary Care Team
(PCT). As part of the SCO care management, the PCP or PCT work with the enrollee to develop an
Individualized Plan of Care, perform additional and ongoing assessments, consult with specialists,
maintain records of care and communicate with the enrollee and their family members. Additional case
management support is provided by Geriatric Support Services Coordinators (GSSC) who are employed
by ASAPs. The role of the GSSC is to participate in initial and ongoing assessments and develop
community-based care plans and related service packages to meet the needs of the enrollee. With
agreement from the PCT, the GSSC coordinates and authorizes community long term services and
supports.
Beneficiary Complaint System
As part of each enrollees orientation to the program, SCO plans are required to inform enrollees of their
rights, how to file complaints and appeals with the SCO plan, and how to obtain assistance with the
Medicare and Medicaid appeals process through an Enrollee Service Representative and external
Ombudsman. Enrollees may file appeals at an internal (plan) level or an external (MassHealth Board of
Hearing for MassHealth Services and Medicare Independent Review Entity for Medicare services).
SCO plans include opportunities for consumer and community input through advisory committees and
participation on the plans governing board.
State Oversight
Contract Management Teams comprised of both representatives from EOHHS and CMS monitor overall
contract compliance and provide communication pathways between the state, CMS and the SCO plans.
Additionally, EOHHS conducts periodic audits of SCO plans through an annual independent external
review and annual site visits.
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SCO plans are required to administer an annual survey to all enrollees and report results to EOHHS.
Results of the beneficiary survey are expected to inform quality management and improvement
projects.
Other Case Management Systems
MFP Demonstration Case Management
Case management is available through the Money Follows the Person (MFP) demonstration in
Massachusetts as a demonstration service. The service is available to MFP participants who do not
otherwise have access to case management and is provided by either MRC or ASAPs. Individuals have
the choice to select either an ASAP or MRC. Once the member selects the case management entity, a
case manager is assigned who provides to the individual care coordination and assistance with obtaining
necessary MFP Demonstration and Medicaid state plan services, as well as other medical, social, or
educational services, regardless of the funding source, that support the MFP Demonstration
Participant’s ability to reside in a community setting. MFP Demonstration Case Management is available
to eligible participants during the 365 day period in the community following their transition to the
community.
DMH Targeted Case Management
Targeted Case Management (TCM) is a service that assists individuals in gaining access to needed
medical, social, educational, and other services, including state agency services. In Massachusetts, it is a
Medicaid state plan service for people with serious mental illness (SMI) (for whom the Department of
Mental Health (DMH) staff serve as the providers of TCM). The scope of activities undertaken in TCM
goes significantly beyond the care management and care coordination. TCM is focused on assessing a
member’s need for and providing access to particular state agency services. Targeted Case Managers
provide unique and extensive services for state agencies including:
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Completing a comprehensive assessment of state agency service needs;
Developing the Individual Service Plan (ISP), which delineates the state agency services
individuals will receive;
Monitoring the development of the program-specific treatment plan that is guided by the ISP to
ensure that the services in the ISP are provided;
Coordinating the individual’s access to all of the services for which the state agency provides
and/or contracts; and
Serving as the client’s advocate to resolve client’s issues and concerns regarding care and
treatment provided by state agency and contractor staff and programs.
TCM qualified providers are described in the state plan as individuals meeting the qualifications and
entrance requirements for certain State positions as described by the Commonwealth’s Human
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Resource Department. These providers are staff at state agencies and their responsibilities are governed
by collectively bargained contracts.
DMH Case Management
For individuals who are determined eligible for DMH services and who need case management, a
referral is made to the appropriate DMH case management office where the individual is assigned a case
manager. Case management activities include:
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Arranging for and completing comprehensive assessments of service needs;
Convening service planning meetings;
Developing and reviewing individual service plans;
Reviewing individualized action plans, when applicable, to ensure compatibility with
clients' individual service plans;
Assisting clients in obtaining other available services from public or private entities as
identified in clients' individual service plans;
Coordinating services for clients, and/or monitoring the coordination of DMH and non
DMH services;
Providing outreach, as needed; and
Providing intensive support and advocacy, as needed.
Community Case Management
Community Case Management (CCM) is an administrative activity performed for the express purpose of
authorization and coordination of MassHealth community LTSS to MassHealth-eligible, medically
complex individuals that require at least two hours of continuous skilled nursing to remain in the
community. CCM involves the authorization, coordination and facilitation of services to enable
members to remain in the community and avoid institutionalization.
UMMS administers, by contract with the MassHealth OLTSS, the CCM program and it serves as the
statewide single entry point for authorization of community based LTSS for individuals within the
program. The program includes:
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A toll-free telephone number with the greeting, “Community Case Management,” to be
answered by staff who are knowledgeable in all aspects of CCM to respond to inquiries and
service requests from members, providers, and other interested parties;
Accessible staff during usual work day hours;
Interpreter services as necessary, TTY transmission and reception capabilities for blind, deaf and
hard of hearing individuals; and
A member complaint monitoring and tracking system.
Case managers employed by UMMS perform the following activities:
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Completion of an in-person functional assessment;
Authorization of services; and
Integration and Coordination of community based LTSS;
Overview of Mitigation Strategies
The Case Management Inventory below identifies overlap in functional assessment completion and/or
other case management functions with service provision.
Table 1: Case Management Inventory
1915 (c) HCBS
Waiver/State Plan
Program
Waivers
Frail Elder Waiver (EOEA)
Community Living Waiver
(DDS)
Entity that conducts
functional assessments
Entity that provides
case management
Service provider types
Aging Services Access
Points (ASAPs)
ASAPs
ASAP contract with a network of direct service
providers. As outlined in the ASAP Law, ASAPs
may not directly provide waiver services
beyond nutritional services.
DDS Regional Eligibility
Teams
DDS employed Service
Coordinators at the
area office level.
MFP – Residential
Supports Waiver (DDS)
UMMS
DDS employed Service
Coordinators at the
area office level
Acquired Brain Injury
Residential Habilitation
UMMS
DDS employed Service
Coordinators at the
Intensive Supports Waiver
(DDS)
Adult Supports Waiver
(DDS)
ASAPs may provide other Medicaid
community-based LTSS that may be included
in a participant’s care plan. Ex. Adult Foster
Care, and Personal Care Management services.
Those agencies must apply to MassHealth and
receive a waiver from EOEA to provide these
services.
Services provided by:
 Contracted vendors (through agencyprocured Purchase of Service (POS)
contracts) or
 DDS staff in agency-operated community
programs, or
 As participant-directed services where the
Financial Management Services (FMS) is
responsible for executing the provider
agreement with an individual worker or
agency.
The Medicaid agency contracts with
Administrative Service Organization (ASO). The
ASO solicits direct service providers, assists
these providers in executing MassHealth
provider agreements, verifies vendor
qualifications and conducts vendor and quality
monitoring activities. The ASO for this waiver
is UMMS.
The Medicaid agency contracts with
Administrative Service Organization (ASO). The
ASO solicits direct service providers, assists
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Waiver (DDS)
area office level
these providers in executing MassHealth
provider agreements, verifies vendor
qualifications and conducts vendor and quality
monitoring activities. The ASO for this waiver
is UMMS.
Children’s Autism
Spectrum Disorder Waiver
(DDS)
DDS Autism Clinical
Managers based out of
the DDS Central Office
DDS Autism Clinical
Managers based out of
the DDS Central Office
All services are participant-directed services
provided by independent professionals or
employees of an agency (FMS is responsible
for executing the provider agreement with the
individual worker or agency.)
MFP – Community Living
Waiver -Non-Residential
(MRC)
UMMS
MRC Case Managers
employed by MRC
The Medicaid agency contracts with an
Administrative Service Organization (ASO). The
ASO solicits direct service providers, assists
these providers in executing MassHealth
provider agreements, verifies vendor
qualifications and conducts vendor and quality
monitoring activities. The ASO for this waiver
is UMMS.
Acquired Brain Injury (ABI)
Waiver – Non Residential
(MRC)
UMMS
MRC Case Managers
employed by MRC
The Medicaid agency contracts with an
Administrative Service Organizations (ASO).
The ASO solicits direct service providers,
assists these providers in executing
MassHealth provider agreements, verifies
vendor qualifications and conducts vendor and
quality monitoring activities. The ASO for this
waiver is UMMS.
Traumatic Brain Injury
Waiver (MRC)
MRC
MRC Case Managers
employed by MRC
MRC contracts with direct service providers for
the provision of waiver services. MRC verifies
the qualifications of contracted providers.
One Care plan
One Care plan
One Care plans contract with a network of
qualified providers for the delivery of
Medicare and Medicaid state plan services as
well as additional community support services.
PACE Program
PACE program provides or arranges all covered
services. Contracts to purchase services
provided to PACE participants are subject to
EOHHS approval.
Integrated Care
One Care
MassHealth provides a
proxy rating category for
each enrollee that may
be changed based on
the results of the MDSHC assessment.
Program for All Inclusive
Care for the Elderly (PACE
PACE Program conducts
functional assessment.
MassHealth Office of
Long Term Services and
Supports (OLTSS) Clinical
Staff approve and
authorize eligibility and
rate cell payment
category based on
assessment.
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Senior Care Options (SCO)
The SCO Primary Care
Team conducts the
functional assessment;
however MassHealth
OLTSS clinical staff
makes the
determination for level
of payment.
SCO plan
The SCO plans maintain a provider network
sufficient to provide all enrollees with access
to the full range of covered services.
Other Case Management Systems
MFP Demonstration Case
Management
N/A
MFP participants have
the choice of provider
of case management
services through MRC
or ASAPs.
MFP Transition Entities and contracted
providers
Targeted Case
Management - DMH
DMH Eligibility Staff
Case Managers
employed by DMH
Service is provided by the Department of
Mental Health
DMH Case Management
DMH employed staff
located in area offices
DMH Case Managers
located in DMH case
management offices
Service is provided by the Department of
Mental Health.
Community Case
Management (CCM)
UMMS
UMMS
Service is provided by UMMS staff.
The table below is a summary of the safeguards and mitigation strategies established within each
MassHealth case management system. Only those systems with potential overlap in case management
and service provision or functional assessment and service provision have been included.
Table 2: Safeguards and Mitigation Strategies
Admin
firewalls
State
approval of
plans of
care
Frail Elder
Waiver (EOEA)
X
X5
Community
Living Waiver
(DDS)
X
X
1915 (c) HCBS
Waiver/State
Plan Program
State
monitoring
through
analysis of
referrals
State
monitoring
through
survey of
beneficiary
satisfaction
Beneficiary
complaint
system
X
X
Data-driven
assessments
Other
Waivers
X
 Regular audits of providers.
 Ongoing review by EOEA
 Quality Assurance process at both
state and local level
 Consumer has free choice of qualified
providers
 Robust quality monitoring
 Stakeholder engagement
opportunities through Citizen
Advisory Board and Statewide
5
The state reviews a sample of service plans to ensure that all needs identified have been addressed through
either waiver or non-waiver services.
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Advisory Council opportunities.
 The Office of Human Rights oversees a
system of safeguards to affirm,
promote and protect the human and
civil rights of the people the DDS
supports.
 Participants have free choice of
qualified providers.
 Robust quality monitoring
 Stakeholder engagement
opportunities through Citizen
Advisory Board and Statewide
Advisory Council opportunities.
 The Office of Human Rights oversees a
system of safeguards to affirm,
promote and protect the human and
civil rights of the people the DDS
supports.
 Participants have free choice of
qualified providers.
Intensive
Supports
Waiver (DDS)
X
X
X
Adult Supports
Waiver (DDS)
X
X
X
 Robust quality monitoring
 Stakeholder engagement
opportunities through Citizen
Advisory Board and Statewide
Advisory Council opportunities.
 The Office of Human Rights oversees a
system of safeguards to affirm,
promote and protect the human and
civil rights of the people the DDS
supports.
 Participants have free choice of
qualified providers.
 One Care Ombudsman services
 Long Term Services and Supports
Coordinator Role
 Implementation Council and other
Stakeholder Engagement
opportunities
 Participants have free choice of
health care providers within the PACE
organization’s network.
Integrated Care
One Care
X
X
X
Program for All
Inclusive Care
for the Elderly
(PACE)
X
X
X
Senior Care
Options (SCO)
X
X
X
 Independent case management for
long term services and supports
provided by GSSCs.
 Opportunity for consumer
engagement through advisory
committees and participation on plan
governing boards.
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Conflict Assessment
Massachusetts has a broad reaching case management system and contains many protocols and
safeguards to prevent conflict. A clear strength of the Massachusetts case management system is
beneficiary choice. All 1915 (c) HCBS Waiver programs, Medicaid state plan services, and integrated
care programs adhere to robust quality monitoring and the integrated care programs incorporate
stakeholder input in their governance structure and through surveys of beneficiaries and their
caregivers. While there are many protocols currently in place to ensure consumer choice and to
establish a near conflict free case management system, we identified several areas that could be
strengthened.
Three HCBS waivers (operated by DDS) offer case management through DDS staff members as well as
provide several waiver services delivered by DDS operated providers. While DDS case managers do not
directly provide any waiver services and waiver participants are required to be offered a choice of
providers, additional mitigation strategies will be considered for future implementation.
While overlap between waiver service provision and case management function does not exist in the
Frail Elder Waiver, ASAPs (the contracted agencies charged with conducting functional assessment and
providing case management) may be providers of other Medicaid funded community LTSS that may be
included in a waiver participants care plan. Currently, only one ASAP (Coastline Elderly Services)
conducts eligibility determinations for AFC, and that ASAP cannot contractually provide AFC services.
Beyond the current administrative firewall in place between the eligibility determination and service
delivery for AFC, additional safeguards may be explored. Additionally, ASAPs may also provide Personal
Care Management services for individuals receiving PCA, which is a fully self-directed state plan service.
As a PCM provider, the scope of service is restricted to skills training and does not include the provision
of or payment for direct personal care services. Upon initial assessment there does not appear to be
conflict however the State will further explore to ensure that there is no potential conflict and should it
be necessary institute additional safeguards.
For all three integrated care programs (One Care, PACE and SCO), functional assessments and care
planning are conducted by entities that receive capitated payments for providing all necessary covered
services to the beneficiary which have the potential to create incentives to over or underutilize services.
The state plays a key role in quality monitoring and contract management. In addition, only state staff
can provide approval for the level of MassHealth capitated payment to integrated care organizations
based on assessment results or, in the case of PACE, MassHealth and Medicare eligibility status.
However, additional administrative safeguards and transparency in program design and delivery may be
reviewed.
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