MassHealth: Senior Care Options (SCO)

Medicare/Medicaid Demonstration

Fact Sheet

Summary:

The Centers for Medicare and Medicaid Services (CMS) and the Division of

Medical Assistance (DMA) for the Commonwealth of Massachusetts have combined

resources to develop a dual eligible demonstration, MassHealth Senior Care Options

(SCO). Three contractors are participating in the demonstration: Evercare

Massachusetts, Senior Whole Health, and Commonwealth Care Alliance. The

demonstration initiated services in March 2004. The demonstration will have

state-wide impact.

Background:

The Office of Research, Development, and Information (ORDI) and DMA have

collaborated for several years in the development of the MassHealth: Senior Care

Options (SCO) Dual Eligible Demonstration. The initiative is the fourth dual

eligible demonstration approved by CMS (the Program for All-inclusive Care for

the Elderly (PACE), Minnesota Senior/Disability Health Options, and the Wisconsin

Partnership Program are the other three).

The SCO program has more extensive eligibility than PACE, which is available only

to community-dwelling beneficiaries requiring nursing home level of care. Like

PACE, SCO contractors provide care through managed care organizations (MCOs)

to beneficiaries who enroll voluntarily. SCOs offer the full range of Medicare and

Medicaid benefits available to dual eligible beneficiaries in Massachusetts. SCOs

serve community-well, community frail (the PACE niche), and institutionalized

people ages 65 and over. Medicare-only beneficiaries will not be eligible to enroll.

SCOs deliver care through a geriatric model that is financed by the pooling of all

Medicare and Medicaid revenues at the health plan level. SCOs are required to

contract with State Aging Services Access Point (ASAP) providers as part of the

SCO care management team, which will deliver home and community-based

services as part of an integrated model of care.

Medicare payment will be based on the M+C methodology, with the exception of the

use of the PACE demographic adjustor (2.39), for the nursing home certifiable rate

cells. SCOs will transition to diagnosis-based comprehensive risk adjustment on the

same schedule as the PACE program and receive a plan-level frailty adjustment in

the same manner as the PACE and other dual eligible demonstrations. Medicare

demonstration waivers are required for the use of the PACE demographic adjustor.

Medicaid waivers are not required for implementation of SCO. Medicaid services

are provided under current State Plan authority.

Current Status

Three contractors participate in the SCO demonstration. Commonwealth Care

Alliance is a non-profit consortium of PACE providers and 6 medical groups.

Senior Whole Health: is a for-profit alliance between Caritas Christi, the Catholic

Health System in Massachusetts, and a start-up managed care firm. Evercare

Massachusetts is a for-profit health care insurer with commercial, M+C and

Medicaid lines of business including the CMS-sponsored Evercare demonstration.

Contact:

Wm D. Clark

786-1484

(abqgxx@r.postjobfree.com)

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