One Care Medicare + MassHealth
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Transcript of One Care Medicare + MassHealth
Multicultural Coalition on Aging PresentationSeptember 2013
Health insurance plan combines Medicare and Medicaid payments and services, like a Senior Care Organization (SCO) but with additional features
Person-centered model providing the full range of acute, behavioral health, and long term supports and services
Designed to coordinate care and provide higher quality, more cost-effective care with improved health outcomes
Full Medicare and MassHealth beneficiaries 21-64 years old in service area
Approximately 90,000 dual eligible beneficiaries with some exclusions, such as:
◦ MassHealth Members enrolled in Home and Community-based Services waivers-- Frail Elder, Traumatic Brain Injury, Acquired Brain Injury, Developmental Disability and Money Follow the Person waivers
◦ Residents of ICF/ID- Intermediate Care Facility for Intellectually Disabled
Note: at age 65, beneficiary may remain in the One Care Plan if he/she still meets MassHealth eligibility guidelines
All Medicare and MassHealth benefits are guaranteed
All medically necessary services including inpatient hospital, community health center, DME (durable medical equipment), home health, day habilitation
Expanded benefits like Care Coordination, dental, personal care (PCA), DME training, adaptive technology, vision services, non-medical transportation
Behavioral health care such as inpatient mental heath and substance abuse, community crisis stabilization, psychiatric day, outpatient therapy, case and family consultation, acupuncture, coaching, peer support
A beneficiary who needs additional services such as long term community supports or behavioral health
A beneficiary who has found services to be fragmented and uncoordinated
A beneficiary who has had difficulty accessing services for variety of reasons
A One Care plan must Contract with community based organizations –Independent Living Centers, ASAPS, Recovery Learning Communities, other organizations serving people with disabilities
Promote independent living by using community health workers, qualified peer specialist, non-medical staff, housing specialist for the homeless
Attempt smooth transition of current provider services by obtaining numerous provider contracts and offer individual contracts if feasible
A One Care Plan must Ensure staff and providers are culturally competent and trained in values, beliefs associated with a beneficiary’s age, gender, racial, ethnic, linguistic background
Reasonably accommodate persons and ensure accessibility in scheduling
Provide interpreters or translators, accessible communication
Ensure safe and appropriate physical access
Provide referrals to independent living and recovery, home based services as needed
Initial voluntary enrollment opportunity in September
Three phases of auto-assignment◦ January 1, April 1, July1 members who have not made a decision
At any time a beneficiary may opt in, opt out, or change from one plan to another
Enrollment changes are effective first day of the following month
During 90-day period after enrollment, the One Care plan and enrollee engage in a comprehensive assessment and care planning process
Enrollee’s current services and providers stay in place until care planning process is complete and enrollee agrees to the new plan.
MassHealth/CMS will send information in advance of initial enrollment and 60 days before any auto enrollment periods
At the same time, plans will be allowed to market
Letter will direct calls to MassHealth and SHINE regional offices at1-800-243-4636
Information about One Care plans will be on www.mass.gov/masshealth/onecare, www.medicare.gov and provider lists will be accessible on provider sites
To enroll call MassHealth at 1-800-841-2900
The person-centered care plan and package of services will be developed by the One Care plans during meetings with individual, caregiver, family, care coordinator, health care staff and Independent Living – Long Term Services and Supports (IL-LTSS) coordinator. Grievances will be filed internally.
Appeals are made through MassHealth or Medicare
An independent Ombudsperson role will be developed advocate for consumers and to impartially resolve disagreements, problems with service plan, denials of service
Counselors will Assist eligible beneficiary to understand what One Care is and review choices: join One Care plan, choose among plans, or opt out of One Care and continue to receive current services
Search medicare.gov for plan comparisons and review available provider lists to ensure continuity of careComplete client contact form including new data fields as required by CMS
Provide beneficiaries with relevant information and assist with enrollment processBe culturally competent and ensure accommodation as needed
Three companies offer One Care plans in select counties. All have significant experience with Medicaid and similar models of care:
Commonwealth Care Alliance Contact: 1-866-610-2273, www.commonwealthonecare.org
Fallon Total Care Contact: 1-800-879-0852, www.fallontotalcare.org
Network Health Contact: 1-855-393-3154, www.ChooseUnify.com
County CCA Fallon Network Health
#members can enroll
#members no plan
Essex x 13,452
Franklin x 1,945
Hampden x x 13,981
Hampshire x x 2,452
Middlesex x 16,856
Norfolk x 6,760
Plymouth x* 6,208 723
Suffolk x x 14,664
Worcester x x x 13,922
Total state 90,240 20,933(Barnstable,Berkshire, Bristol, Dukes,Nantucket,partial Plymouth
SHINE 1-800-243-4636, press 3
MassHealth Customer Service 1-800-841-2900 TTY:1-800-497-4648
www.mass.gov/masshealth/onecare
One Care Plan web sites