Health Management Associates (HMA) recently co-hosted a policy forum with the Massachusetts Association of Health Plans (MAHP), entitled Advancing Better Outcomes: How the One Care and SCO Programs Improve Health for Older Adults and People with Disabilities on Medicare and Medicaid. More than 100 key decision makers from MassHealth (Medicaid), health plans, providers, community-based organizations, and advocacy organizations attended the conference, elevating the value of the MassHealth One Care and Senior Care Options (SCO) programs to dually eligible individuals. The policy forum also provided an important opportunity for state legislators and their staff to learn about these complex programs.
MassHealth One Care and SCO Programs
Massachusetts’ One Care and the SCO programs currently serve more than 125,000 individuals covered under MassHealth and Medicare, also known as dually eligible individuals. One Care is a population-specific program for dually eligible adults 21-64 years of age. SCO is a population-specific program for dually eligible older adults 65 and older, tailored to the needs of older adults. The One Care and SCO programs serve individuals with complex chronic conditions and disabilities, including mental health and substance use disorder needs, and high home-and-community-based service (HCBS) needs. The One Care and SCO programs advance independent living, recovery, and community living goals. Approximately 99 percent of One Care enrollees, and 95 percent of SCO enrollees, live in the community.
The One Care program is currently authorized as a Financial Alignment Initiative (FAI) demonstration program. The FAI demonstration ends December 31, 2025. MassHealth will continue the One Care program as a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) model. This transition from the FAI to a FIDE SNP model introduces changes to the program. A FIDE SNP model is a type of Medicare Advantage (MA) Dual Eligible Special Needs Plan (D-SNP).
HMA’s Role: Bringing National and State Expertise
In addition to creating the forum in partnership with MAHP, HMA shared its national and state policy expertise and local market insights with attendees during a series of presentations. HMA outlined ways in which the One Care and SCO programs offer more value to dually eligible individuals than the state’s fee-for-service (FFS) system.
The event focused on three key topics:
- The national landscape for Medicare-Medicaid integrated care programs.
- The value of the One Care and SCO programs and the role that health plans play in improving outcomes for adults who are eligible for both Medicare and Medicaid (“dually eligible”), and
- The upcoming changes to the One Care and SCO programs, as reflected in the 2026 state Medicaid agency contracts (SMACs) with MassHealth.
Key Takeaways from the MAHP-HMA Conference
Key Takeaway #1. Nationwide trends suggest that Medicare-Medicaid integrated care programs will face competition and financial pressures.
Forum attendees were very interested in the national trends. At the national level, D-SNPs have bipartisan support. At the same time, D-SNPs should expect competition from Chronic Condition Special Needs Plans (C-SNPs) and innovation models developed by the Centers for Medicare and Medicaid Innovation (CMMI). CMMI models such as the Guiding an Improved Dementia Experience (GUIDE) Model and Accountable Care Organizations (ACO) Realizing Equity, Access, and Community Health (REACH) Model will compete with D-SNP models in some markets. Finally, presenters and panelists alike raised concerns about the financial risks that D-SNPs will face due to rising pharmacy costs and changes in Medicare payment methodologies.
Key Takeaway #2. The Massachusetts One Care and SCO programs provide significant value to dually eligible individuals in Massachusetts.
The One Care and SCO programs provide significant value to enrollees. As compared to FFS, Medicaid-Medicaid integrated care programs like One Care and SCO provide care coordination, a personal care plan, bundling prescriptions through a single provider, and other services.
Many forum attendees pointed out that the One Care program is one of the most advanced integrated care programs in the nation. One Care’s success is tied in part to the active and critical role that the One Care Implementation Council plays in shaping program policy. For more than a decade, the One Care Implementation Council and MassHealth have worked in partnership to improve the program. As shared by the Massachusetts Medicaid Policy Institute (MMPI): “The Commonwealth intends to preserve the Implementation Council’s role in the next phase of One Care, and to continue engaging the council as an essential partner in policy and program change, monitoring, and oversight.”
Key Takeaway #3. Over the last two decades, SCO and One Care plans have established many innovations.
The forum highlighted many innovations in these programs, from primary and urgent home care to place-based supports. It also provided an opportunity to talk about the important role and commitment that the plans have in emergency situations to ensure that members are safe in the face of a community crisis.
Panelists see many opportunities for plans to continue to evolve and improve outcomes and equity. For example, the One Care program has significant opportunities to address the behavioral health needs of dually eligible adults. Dually eligible adults with mental health and/or substance use disorder diagnoses are at higher risk of an emergency department visit and inpatient stay than other enrollees. Health plan per member per month (PMPM) spending on inpatient services for those with a behavioral health condition is much higher as a share of the total PMPM than other populations. The HMA data pointed to a need for further innovation in the mental health arena to advance better outcomes of quality of life and costs.
Key Takeaway #4. Conference attendees focused on the importance of addressing enrollees’ social determinants of health needs.
Throughout the day, the importance of community and addressing the social determinants of health (SDOH) was a common theme. Aging and disability leaders spoke about the importance of community organizations such as Aging Services Access Points (ASAPs), independent living centers (ILCs), recovery learning communities (RLCs) including peer support since most One Care and SCO individuals live in the community.
Many One Care and SCO eligible individuals are often just one unmet health related social need away from the risk of hospitalization or institutionalization. Other attendees underscored the risk that enrollee living situations and recovery can become instantly unstable due to the death of an important family member. One aging leader described her role as “triaging risk.” Other leaders from the disability community urged plans to use z codes to improve plan and provider attention to identify and address the SDOH needs.
Looking Ahead
As Massachusetts prepares for the 2026 One Care and SCO contract year, the forum underscored the progress made over the past decade and the opportunities ahead to improve care coordination, collect z codes, and invest in outcomes-driven partnerships. Massachusetts is well-positioned to continue leading the nation in designing integrated care programs that improve health and support community living for older adults and people with disabilities.
HMA looks forward to supporting all organizations including state Medicaid programs and health plan and provider associations as they convene stakeholders to improve their integrated care programs. Our expertise includes program planning, strategy and implementation, technical support and evaluation, and state-specific knowledge to make projects successful. Please contact Ellen Breslin, Rob Buchanan, and Julie Faulhaber for more information on how HMA can help your organization.
| Summary Facts About the One Care and SCO Programs |
| The One Care and SCO programs are population-specific programs, serving more than 125,000 individuals with MassHealth plus Medicare coverage. MassHealth designed the One Care and SCO programs around the specific needs, preferences and goals of adults and older adults.The One Care program enrolls dually eligible adults with disabilities, ages 21-64 at the time of enrollment, covered under MassHealth Standard or CommonHealth and Medicare (Parts A and B, and eligible for Part D). Enrollees in One Care have multiple chronic conditions and disabilities including significant mental health and substance use disorder needs. The SCO program enrolls dually eligible adults ages 65 and older, covered under MassHealth Standard and Medicare (Parts A and B, and eligible for Part D). SCO enrollees have significant chronic conditions, many of which are associated with aging. |
| MassHealth launched the SCO program in 2004 and One Care in 2013. The One Care program currently operates as a Financial Alignment Initiative (FAI) demonstration. The One Care and the SCO programs combine MassHealth & Medicare benefits into a single plan with one card and one care team. One Care covers medical, mental health, and prescription medications, plus support for daily tasks and independent living and recovery. Care coordinators help members stay healthy and get the services they need. |
| The One Care and SCO Programs Continue to Evolve. The FAI demonstration authority ends in 2025. Massachusetts will shift from the demonstration to a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) structure. The SCO program currently operates as a FIDE SNP model. The state reprocured the One Care and SCO plan network. The state selected five One Care plans and six SCO plans. New contracts for One Care and SCO plans start January 1, 2026.The new contracts create several changes including changes in eligibility for the program and enrollment processes, benefits, and financial payment provisions. |
