|The State of Massachusetts is moving ahead in its plan to respond to a top priority of the Obama Administration to implement a cost savings strategy aimed at gaining savings from programs that serve individuals who qualify for both Medicare and Medicaid.Under the provisions of the Affordable Care Act enacted in 2009, 15 states were given a grant to develop cost savings strategies to ensure that a single managed care approach was applied to the sizable population. Yesterday Massachusetts released its proposal to combine all Medicare and Medicaid spending and services for adults with disabilities age 21 – 64 years old, including all health care and long-term supports and services (LTSS).
If the Massachusetts plan, is approved by the Federal Government it will bring the services of all 115,000 participants in this age category under the control of new, private, integrated care organizations (ICO). Prior to approval by the Federal Government there must be opportunities for public comment and feedback.
What does this mean?
This means that persons who receive both Medicare and Medicaid (21 to 64 years) will automatically be assigned to an integrated care organization (ICO) based on where they live.
Individuals who receive personal care attendant services, day habilitation services or other services would now have such services approved and funded through an ICO.
There is a possibility that people receiving services through Medicaid waivers, may not be placed into ICOs, however that exemption would have to be granted by the federal government.
What is an ICO?
An ICO is an integrated care organization (ICO) that as a private entity, will manage, monitor and coordinate hundreds of millions of dollars in services. Organizations in the health care arena (insurance companies, health care entities, managed care entities) are the likely candidates to become ICOs. The ICO would receive a “capitated rate,” an annual amount of dollars per person for all of their services. All services would have to be managed from that total amount or capitated amount for that year.
The Arc and ADDP are very concerned about the proposal, as well as the many unresolved details. We commend MassHealth and the EOHHS Secretariat for their efforts on this difficult proposal and their continued willingness to work with stakeholders.
We recognize that much of the impetus to FULLY combine Medicare and Medicaid service delivery is coming from the federal government and the Center for Medicare and Medicaid Services (CMS).
The Arc and ADDP concerns include:
- Blending Medicare and Medicaid health services and setting up new systems of care coordination (or clinical care management) is a difficult process in itself.
- Including community long-term supports may not be the most effective or desirable strategy for the Commonwealth to pursue. We believe the focus should solely be on eliminating health care inequalities.
- An ICO will receive a set amount of funding for both health care and LTSS. This blended rate may cause LTSS to lose ground to health care costs which continue to spiral.
- The proposed demonstration, to fully blend all dollars and services, should be tested on a smaller scale in a specific pilot program.
Some references in the proposal are also troubling, such as: “ICOs have the flexibility to provide all of these services, and others as identified by the care team, as substitution services for high-cost traditional…Medicaid service options.” We believe that considering Medicaid services as high-cost is troubling. After all, Medicaid is the ONLY significant payer of long-term supports and services. Further, all providers have complained about the low reimbursement provided by Medicaid, which is why dental and medical services have been more difficult to obtain when the only payer is Medicaid (MassHealth in our state).
While health care costs per person have increased tremendously, increased costs for long term supports and services is more related to new people needing the services, whether youth with disabilities turning 22 years old, children with complex medical and/or behavior needs, or seniors who are aging; and not necessarily increased overall costs of those services.
Positive features of this plan
There are four positive components of this plan. First, the draft proposal includes providing more support services to dual eligibles than presently exist through the Medicaid State Plan.
Some examples of supports not currently on the State Plan include respite care, day services, peer support counseling, dental services, home modifications, and health coaching. A package of behavioral health services is also anticipated in the new model. A high percentage (nearly 40%) of dual eligible recipients have serious mental illnesses, as defined by MassHealth, include a primary diagnosis of schizophrenia (or other psychoses), bipolar disorders, and/or major depression.
Secondly, there is a reference to a second tier or type of capitated rates suggested for adults who participate in home and community-based waiver services. Much of this population includes persons with intellectual and developmental disabilities along with smaller numbers of adults who participate through the Traumatic Brain Injury waiver or through the Elder Services waiver. However, this additional tier would need to be approved by CMS.
Another positive feature of this plan is that individuals will not be “locked in” to any one organization. A recipient will be able to move to a new ICO or return to the fee-for-service model if not satisfied.
One last positive feature of this plan is that it would provide health care coordination, which is proven as a need for adults with disabilities in The Arc’s health research report.
- Public hearings will be held for feedback on the draft demonstration proposal. The first one will be held on Friday, December 16. (See further details below)
- Stakeholder organizations will be meeting with MassHealth officials.
- More information will be posted by The Arc and ADDP regarding our community’s position.
What can you do?
Stay tuned for upcoming action alerts to help us get our position across to EOHHS.
You can read an earlier response to a MassHealth dual eligibles information request by The Arc at this site.
You can read Massachusetts’ demonstration proposal here. MassHealth has a duals eligible site where information is posted.
Public Comment Hearings on the Draft Demonstration Proposal on Duals:
- December 16, 2011, 1 PM – 4 PM, Worcester Public Library, Saxe Room, 3 Salem Square, Worcester, MA
- January 4, 2012, 9 AM – 12 noon, State Transportation Building, Conference Rooms 2 & 3, 10 Park Place, Boston, MA
These hearings will provide members of the public an opportunity to give oral comments on the draft Demonstration Proposal (see “Related Information” section on MassHealth’s duals website). Commenters may also submit written testimony at the public hearings. Reasonable accommodations will be made for participants who need assistance. Please send any request for accommodations to Donna Kymalainen at Donna.Kymalainen@state.ma.us