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Massachusetts’ Duals Demo 2.0 to Grow the SCO and One Care Programs

This week, our In Focus section comes from Ellen Breslin in our Boston office who provides an overview of MassHealth’s Duals Demonstration 2.0 (“Duals Demo 2.0”) proposal to the Centers for Medicare and Medicaid Services (CMS) which is designed to “grow and sustain One Care and Senior Care Options (SCO) while encouraging innovation and care delivery improvement.” MassHealth currently provides coverage to about 310,000 dually-eligible individuals. Combined, MassHealth and Medicare spend more than $9 billion annually with costs nearly evenly split across the two payers.

The One Care and SCO programs are unique to Massachusetts. The programs provide dually-eligible individuals access to Medicaid and Medicare benefits in an integrated, coordinated and person-centered manner. The fact sheet below describes the key characteristics of each programs.

On June 14, 2018, MassHealth released a concept paper on the Duals Demo 2.0, which describes the five key objectives around which this demonstration has been designed. MassHealth is currently seeking approval from CMS to move One Care and the SCO program to a newly aligned 1115A Demonstration and is requesting federal flexibilities to achieve these five key objectives.

Bringing One Care and SCO to Scale: How Many Dually-Eligible Individuals Live in Massachusetts?

The Duals Demo 2.0 proposal includes two changes in the enrollment policy for the One Care and SCO programs by extending the passive enrollment policy to the SCO program, and a fixed enrollment period for both programs. These changes in the enrollment policies could lead to a big increase in the membership for integrated care plans. In terms of the potential increase, a few facts are helpful to consider. As of January 2018, there were 311,000 dually-eligible individuals in Massachusetts, of whom 23 percent were enrolled in an integrated program including consideration of the three programs: One Care, SCO, and the Program-of-All-Inclusive Care for the Elderly (PACE) model. The following chart provides the numbers, indicating that 77 percent of all dually-eligible individuals or close to 240,000 individuals are not enrolled in a MassHealth integrated program. These members receive care on a fee-for-service (FFS) basis from MassHealth. This includes about 131,000 individuals who are under the age of 65 and about 109,000 individuals who are 65 years and older. The Duals Demo 2.0. would presumably affect these members. Note that PACE is not the focus of the Duals Demo 2.0.

Beyond the Concept Paper: Looking Ahead

On June 15, 2018, the day after the release of the concept paper, the One Care Implementation Council (IC), which oversees implementation of the One Care program, convened a special meeting to talk about the Dual Demo 2.0. Attendees included IC Council members; special guests Tim Engelhardt, Director for the Medicare-Medicaid Coordination Office at the Centers for Medicare and Medicaid Services and his staff; Daniel Tsai, the Assistant Secretary for MassHealth and the Medicaid Director for the Commonwealth of Massachusetts, and his staff; and many key stakeholders including current One Care and SCO plans, dually-eligible individuals, consumer advocacy groups, and members of the public.

At the One Care IC meeting, Director Tim Engelhardt announced that CMS will be able to extend authorization for the One Care program through December 31, 2019. This extension will provide the time for MassHealth and CMS to discuss and negotiate the Duals Demo 2.0. This will also provide the time for One Care enrollees to make a smooth transition to a new program. Assistant Secretary Dan Tsai made the point that “nothing is simple …” but there must be a “better way to structure care for duals.”

Over the next several months, MassHealth and CMS will hold extensive discussions and negotiations, and continue to engage stakeholders. MassHealth hopes that, by 2019, MassHealth and CMS will be ready to execute a Memorandum of Understanding (MOU) granting authorities for “Duals Demo 2.0.” MassHealth does not expect Duals Demo 2.0 to be in effect before 2020. MassHealth plans to re-procure the One Care program.

In the coming months, MassHealth plans to engage stakeholders, who will want to know more about how the financing methodology will work in tandem with the proposed risk mitigation provisions including risk adjustment, risk corridors, and stop-loss, as these will drive payment accuracy and plan incentives to meet person-centered needs, and drive the integrated model. On other fronts, stakeholders, including consumer advocates expressed concerns at this One Care IC meeting about the proposed enrollment policy which includes the adoption of a fixed enrollment period for potential One Care and SCO enrollees. Consumer advocates asked that the Duals Demo 2.0 keep innovation at the center of these integrated programs, adding that MassHealth not “place greater emphasis and value on scale over innovation.”

MassHealth’s concept paper is available at:

MassHealth also recently released a Request for Information (RFI) to health plans and other stakeholders about the development and use of high utilizer risk corridors for One Care: