Medicare Advantage Program in Massachusetts. Topic: HEALTH INSURANCE; HANDICAPPED; MEDICARE; ELDERLY; MANAGED CARE; STATISTICAL INFORMATION; MEDICAID. Location: INSURANCE - HEALTH - MANAGED CARE; WELFARE - MEDICAL ASSISTANCE (MEDICAID). August 1. 7, 2. 00.
R- 0. 46. 0MEDICARE ADVANTAGE- SPECIAL NEEDS PLAN PROGRAM IN MASSACHUSETTSBy: Robin K. Cohen, Principal Analyst. You asked for information on Massachusetts' Medicare Advantage- Special Needs Plans (SNPs), which offer coordinated care to frail elderly individuals who are eligible for both Medicare and Medicaid (dually eligible) through managed care organizations. SUMMARYThe Medicare Prescription Drug, Improvement and Modernization Act of 2. SNPs) for their frail elderly and younger disabled residents using the managed care model begun under Medicare Advantage (MA)(previously called Medicare +Choice). In addition to saving money, Congress hoped that the model will better coordinate acute and chronic care services, particularly for the dually eligible, whose needs and care costs tend to be the highest. In 2. 00. 6, over 8.
Managed Long Term Care Implementation and Waiver Redesign Work Group. United/Evercare, WellCare, VNS, MetroPlus, Affinity, Fidelis, Health. This is the second of two reports that present findings from Phase II of a process evaluation of member experience with the Senior Care Options (SCO) program in Massachusetts, using data gathered from focus groups and. What Is Evercare Insurance? Evercare is an insurance program for seniors, people with disabilities or people who have advanced or chronic illnesses. The program provides a nurse practitioner or a care manager to assist.
UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract. Senior Care Options (SCO) and Providers. MassHealth members enrolled in SCO must receive all health-care services from the Senior Care Organization's network.
SNPs were planning to serve dually eligible beneficiaries, and the Center for Medicare Advocacy reports that 3. SNPs are serving dually eligible people in 2. A big incentive for the plans has been Medicare's willingness to pay risk adjusted rates, taking into account the higher risk the plans face when serving the dually eligible. Many plans under the original MA had dropped that business largely because of the inadequacy of Medicare reimbursements.
Massachusetts was poised to start SNP as it had several years of experience offering managed Medicare and Medicaid for the frail, dually eligible, first with the federally authorized Program of All- Inclusive Care for the Elderly (PACE), followed by a Medicare demonstration program, Senior Care Options (SCO), which integrated PACE into its service delivery model. Massachusetts SNPs have been operational a relatively short time. But reviews of the SCO experience suggest that care costs in the dually eligible SNPs could be high. It appears to be too early to assess whether these plans will ultimately keep more people in the community and save Medicaid and Medicare funds in the long run.
FEDERAL LAW AND CREATION OF SNPSAs part of the Medicare Modernization Act of 2. Congress created the opportunity for MA health plans to develop SNPs as a way to better serve individuals eligible for Medicare, many of whom had chronic health problems but whose care management was not being monitored. Where the traditional MA plans offered managed Medicare to relatively healthy seniors, SNPs would offer coordinated and managed care to individuals with chronic health conditions, possibly preventing more costly health interventions (e. Unlike other MA programs, Congress allowed the SNPs to limit enrollment to people who (1) are living in institutions, (2) are dually eligible for Medicaid and Medicare, or (3) have severe or chronic disabling conditions. For the dually eligible, this offered access to two separate revenue streams, supplemental funds for services not normally available, and care coordination. Providers receive capitation- based, instead of fee- for- service, payments.
In July 2. 00. 6, the Centers for Medicare and Medicaid Services (CMS) reported it have approved 2. SNPs (that figure grew to over 4.
Connecticut- based Center for Medicare Advocacy), most of which were serving dually eligible populations. MASSACHUSETTS' EXPERIENCE WITH COORDINATED CARE FOR DUALLY ELIGIBLEMassachusetts' experience coordinating care for the dually eligible dates back many years. It is one of several states operating a Program of All- Inclusive Care for the Elderly (PACE), a federal demonstration program begun in the 1. Medicare and Medicaid services in the community to people age 5. Building upon its PACE experience, the state, in conjunction with CMS, began developing several years ago a demonstration program to help the state's entire dually eligible population receive services in a more systematic and coordinated fashion.
The program, SCO, which is voluntary, provides seniors with the full range of Medicare and Medicaid benefits. The program serves “community- well,” “community- frail,” and institutionalized people aged 6.
The community frail component of the SCO is, in fact, the PACE program. The SCO program began accepting applications in 2. It is financed by pooling Medicaid and Medicare revenues at the health plan level. The Medicare payment is based on the Medicare Advantage (MA) methodology, except for people requiring the nursing home level of care who generate a higher capitation rate.
The state received a Medicare waiver to ensure that the payments were adjusted based on the diagnosis. No Medicaid waiver was required to generate higher Medicaid payments. The SCO plans must contract with State Aging Services Access Point providers as part of the care management team.
These entities are affiliated with the state's area agencies on aging (AAA), which administer the state's home- and community- based service care programs, including a Medicaid home- and community- based care waiver. With the passage of the 2.
SCO was revised to incorporate the SNPs. BRANDEIS SNP STUDYIn March 2. Brandeis University reported on an early study it conducted of 1. CMS, viewing them as a prototype of the kinds of integrated care the SNP would offer. Shared Features of 1. Demonstration Projects.
The researchers listed several features common to most or all 1. SNP. For its demonstration, Massachusetts contracted with three SCO plans, all of which were small, new managed care entities: Senior Whole Health, a free- standing, for- profit; Commonwealth Care Alliance, a freestanding nonprofit; and Evercare SCO, a subsidiary of the for- profit United Health Care. The state wanted plans that would serve all Medicaid- only and dual- eligible elders, become statewide, and be willing to work with the state's existing aging network. At the time of the Brandeis researchers' visits, SCO sites had been operating only a year. The success of all three states' SNP programs was contingent on the plans' use of teams of professionals who could coordinate and manage enrollees' care.
In Massachusetts, the contract requires the plans to have a primary care team consisting of a primary care provider (PCP) working in conjunction with a geriatric social services coordinator (GSSC) and a nurse practitioner, registered nurse, or physician's assistant, all of whom must have experience in geriatrics. The researchers found that the nurses tended to run the teams with the GSSC responsible for the community care. The three SCO plans varied in terms of how the teams worked and where they were situated. The plans used one of three models for connecting community care with acute care: single coordinator; nurse/social worker team; or the multidisciplinary team, which included a nurse practitioner. These teams coordinate with physicians through face- to- face contact, phone, and information systems.
Referrals to the SNPs came from various places, including primary care providers. The Massachusetts plans welcomed referrals but relied more on signing up medical groups serving large numbers of dual eligibles in which physicians were willing to work with the plan's care managers. Few plans reported that state waiver programs were good referral sources. CMS reported that the state hired a marketing and promotions firm to promote enrollment in the SCO demonstration plans, with the Governor's Office authorizing an aggressive outreach plan. And the state's Medicaid program, Mass. Health, sends out SCO postcards and birthday cards to notify potential enrollees of the program. The most successful outreach appeared to go to community health centers and practices serving ethnic minorities and immigrants.
The Massachusetts plans believed that these groups were underserved by the home care system and saw the opportunity to include them. Enrollment and Assessment. The researchers found that initial and follow- up assessments were time- consuming, creating a potential “bottleneck” for enrollment growth. Most of the SCO- SNP enrollees were either nursing home- certifiable (NHC), meaning they reside in the community but meet the pre- admission screening requirements for nursing home admission, or non- NHC. Not surprisingly, the researchers found that SCO- SNP enrollees were frailer than the average Medicare Advantage (MA) enrollee, with higher utilization rates for acute care hospitals and prescription drugs.
Because most SNP enrollees tend to be frailer than the average MA enrollee, both Medicare and Medicaid paid the plans higher rates for those enrollees considered to be NHC. The researchers found that all 1. HCC scores and frailty adjusters, when compared to the average Medicare community population. In some cases Medicare spent double at the demonstration sites what it spent for the average Medicare recipient in the area. The state shared the risk with the SCO- SNP contractors during the program's start- up, but the plans assumed full risk after that.
According to the report, the combination of risk- adjusted Medicare and Medicaid payments was covering the plans' high costs, and all reported that they were financially viable. All three states' Medicaid rates for NHC enrollees incorporated (1) the state's average spending for community waiver services for NHC beneficiaries, (2) estimated costs of supplementary services, and (3) a component to cover the plans' risk for nursing home care. The authors suggest that the last component provides a strong incentive to the plans to keep enrollees in the community. In Massachusetts, the plans were at risk for the first 9.
Likewise, if an SCO plan moved a nursing home resident into the community the nursing home rate continued for three months.