Section 9D. (a) As used in this section, the following words shall have the following meanings:—
“Aging services access point” or “ASAP”, any agency designated by the executive office of elder affairs pursuant to section 4B of chapter 19A.
“Capitation”, a set dollar payment per enrollee per month that the division pays to a senior care organization to cover a specified set of services and administrative costs without regard to the actual number of services provided.
“Complex care”, care for an enrollee who is unable to independently perform, without human assistance or cueing, two or more activities of daily living or who is determined to be in need of continuous behavioral health or social services to maintain minimal daily independent functioning. Such care shall address enrollee needs, including any condition or situation that requires coordination of multiple senior care organization services.
“Dually eligible”, any person, aged 65 or older, who is simultaneously qualified for full benefits under Title XIX of the Social Security Act, 42 U.S.C 1396 et seq., and Title XVIII of the Social Security Act, 42 U.S.C 1395 et seq.
“Enrollee”, any dually eligible or MassHealth-only member, aged 65 or older, who is voluntarily enrolled in a senior care organization in accordance with the enrollment criteria as established by the division of medical assistance.
“Geriatric support services coordinator”, a member of a senior care organization primary care team who is employed by an aging services access point, is qualified to conduct and is responsible for arranging, coordinating and authorizing the provision of appropriate community long-term care and social support services.
“MassHealth Senior Care Options”, a program of medical, health and support services covered under Title XIX or Title XVIII of the Social Security Act, provided through senior care organizations. “Medically necessary”, as defined by the division of medical assistance.
“Medicare”, the federal health insurance program for elderly and disabled persons, and persons with kidney failure established pursuant to Title XVIII of the Social Security Act, 42 U.S.C 1395 et seq.
“Primary care team”, a team of health and long-term care professionals established by the senior care organization. Primary care teams shall consist of a primary care physician working in conjunction with a nurse practitioner, registered nurse or physician’s assistant, a geriatric support services coordinator, and other professionals designated by the senior care organization.
“Senior care organization” or “SCO”, a comprehensive network of medical, health care and social service providers that integrates all components of care, either directly or through subcontracts. SCOs will be responsible for providing enrollees with the full continuum of Medicare and MassHealth covered services.
(b) Notwithstanding any general or special law to the contrary, the division may, subject to appropriation and the availability of federal financial participation and pursuant to a memorandum of understanding with the federal Health Care Financing Administration, establish a program of medical and long-term care benefits, known as the MassHealth senior care options initiative for Massachusetts residents, aged 65 and over, who are dually eligible or only eligible for benefits under Title XIX of the Social Security Act. The division may contract with entities, to be known as senior care organizations or SCOs, to provide or arrange to provide a comprehensive network of medical, health care and social services that integrates all components of care, either directly or through subcontracts.
(c) The division shall ensure that enrollment in the program is voluntary. No disincentives for selecting a fee-for-service delivery system shall be included as part of any agreement or waiver regarding the program. The division shall ensure that all enrollees in a SCO have the right to disenroll from the program in any month upon submitting a notice of disenrollment to the division or contracted entity. Disenrollment notices received by the division or contracted entity by the twentieth day of the month shall be effective the first day of the following month.
(d) The benefits provided to persons considered eligible to enroll in the SCO shall include those services covered by Medicare Part A and Part B; the amount, duration and scope of Medicaid-covered services shall be at a minimum no more restrictive than the scope of services provided under MassHealth standard coverage, and shall include services covered under the home and community-based services waiver program; and services necessary for the treatment of mental health or substance abuse.
(e)(1) During the first 3 years of the demonstration project, a SCO shall conform to the minimum medical loss ratio as established by the division for its category. At the end of each fiscal year, the SCO shall provide to the division an audited statement of its medical loss ratio for the past year. Two years after the implementation of the SCO demonstration project, the division shall have 6 months to review the data and audited statements and shall have an additional 6 months to implement revised loss ratios. Beginning the fourth year of the demonstration project and upon renewal of the contract with the division, a SCO shall conform to the revised minimum medical loss ratio as established by the division for its category. Beginning the fourth year of the demonstration project and upon renewal of the contract with the division, if a SCO’s audited medical loss ratio is below the minimum as determined by the division for its category, the SCO shall provide additional benefits or services to its enrollees in the following contract year in an amount that would raise its medical loss ratio to the minimum level established by the division for its category, and shall submit a plan to the division detailing how such benefits or services shall be provided to its plan enrollees.
(2) Not later than the end of the first year of operation as a SCO, the division shall require that all SCOs, with whom the division contracts to deliver such services, establish SCO consumer advisory councils. Such councils shall monitor and make recommendations for the SCOs services delivered under this program and shall be represented by members of its enrolled population, or family members or unpaid caregivers of its enrolled population. The chair or his designee of the SCO consumer advisory council shall have a seat on the board of the SCO and a seat on the division of medical assistance’s SCO advisory committee as created under subsection (m).
(3) The division shall educate consumers and their families as to their enrollment choices under MassHealth senior care options and other available alternatives under Medicare and Medicaid. Neither SCOs nor the division shall offer gifts, payments or other inducements to enroll seniors in a SCO. The division shall also perform outreach services to local councils on aging and other related organizations to educate those councils and organizations on the details of the SCO demonstration project, including, but not limited to, providing the councils and organizations with the SCO educational materials listed in paragraph (4).
(4) The division shall deliver to all prospective enrollees SCO educational materials that shall include, but not be limited to: a definition of a SCO and how it functions; enrollment eligibility standards; the location of SCOs; a complete list of their participating providers; the range of available services; consumer rights under Medicare and Medicaid; an assistance worksheet for determining health care options under MassHealth senior care options, Medicare and Medicaid; and quality of care measurements reported to the division.
(5) The SCO shall be required to evaluate all its enrollees to determine if an enrollee has complex care needs within 30 days of initial enrollment, as well as on an annual basis, or as requested by the enrollee’s primary care physician, or as requested by the enrollee or his authorized representative. If it is determined that an enrollee has complex care needs, the enrollee may receive the ongoing services of a primary care team. If the primary care team determines that the complex care enrollee requires the ongoing services of a primary care team, the primary care team shall develop and monitor a plan of care for said enrollee, and arrange for and deliver all services called for in the plan of care. If an enrollee is deemed to have complex care needs, but the primary care team determines the complex care enrollee does not require the services of a primary care team, the enrollee shall receive the services of a primary care physician and may appeal to the SCO to receive primary care team services. The SCO shall conduct a standard review and make a decision following receipt of all required documentation and, if requested by the primary care physician, the SCO shall conduct an expedited review. The timeline for standard and expedited reviews shall meet the requirements established under 42 C.F.R. 422.568 and 422.572. The SCO shall develop criteria for the primary care team to employ when determining whether the complex care enrollee requires the ongoing services of a primary care team. The SCO shall submit the criteria to the division of medical assistance for its approval.
(f) The division shall develop and issue a document for consumers to be known as the “SCO report card” containing information and data providing a basis upon which SCOs may be evaluated and compared by consumers. The document shall be made available to residents of the commonwealth, upon request. In preparing that report card, the division shall, to the extent possible, use information already reported by the SCO. The division shall consult with the department of public health and the division of insurance in determining the content and format of the report card, and shall make the report card available on the internet web site established by the division. The division shall issue its proposed methodology for the preparation of the SCO report card. The division shall issue the initial report card 1 year from the announcement of the methodology and annually thereafter.
(g) The division shall measure a SCO’s performance using a variety of objective quality assurance measures, including, but not limited to, ongoing provider education, consumer satisfaction surveys, outcome measures and practice guidelines.
(h)(1) Each SCO shall be required to contract with 1 or more ASAPs in its geographic service area unless otherwise provided by this section. The division, in concurrence with the executive office of elder affairs, shall develop procedures and criteria for assessing the circumstances under which a SCO may choose not to contract with any specific ASAP operating in the SCO’s service area and shall make those procedures and criteria available to the SCOs and ASAPs. The procedures and criteria shall include a requirement that any SCO so choosing shall demonstrate its reasons to the division, including, but not limited to, specific contractual, performance, administrative or clinical deficiencies for each ASAP with which the SCO chooses not to contract. The division, in consultation with the executive office of elder affairs, shall determine whether the SCO requesting not to contract with a given ASAP has met the criteria for such a request. The division shall share with the executive office of elder affairs all documentation provided by the SCO regarding its reasons not to contract with an ASAP.
(2) ASAPs under contract with SCOs shall employ geriatric support service coordinators, who shall be members of the primary care team and shall be responsible for:
(i) arranging, coordinating and authorizing the provision of community long-term care and social support services with the agreement of other primary care team members designated by the SCO;
(ii) coordinating non-covered services and providing information regarding other elder services, including, but not limited to, housing, home-delivered meals and transportation services;
(iii) monitoring the provision and outcomes of community long-term care and support services, according to the enrollee’s service plan, and making periodic adjustments to the enrollee’s service plan as deemed appropriate by the primary care team;
(iv) tracking enrollee transfer from one setting to another; and
(v) scheduling periodic reviews of enrollee care plans and assessment of progress in reaching the goals of an enrollee’s care plan.
(3) SCOs and ASAPs shall be responsible for developing processes for assessing all enrollees upon enrollment to determine the need for involvement of the ASAPs and to assure appropriate ongoing monitoring of the enrollee’s need for medically necessary services.
(4) SCOs shall grant geriatric support services coordinators authorizing responsibility over a range and amount of services for specific conditions or circumstances for which agreement of the primary care team would not be required. In cases where the primary care team members cannot reach agreement regarding an enrollee’s service plan or the authorization thereof, any team member may request that the SCO conduct a clinical review within 3 working days of receiving a request for that review. Clinical reviewers shall not be members of the primary care team presenting the case, and all decisions by the clinical review team shall be final. SCOs shall be required to report the results of all clinical reviews to the division and to the executive office of elder affairs. Such reports shall be a component of a SCO’s performance review by the division.
(i) The division shall develop a capitation system for payment for Medicaid services in which the SCOs shall be at full or partial financial risk for any services that they authorize and purchase on behalf on an enrollee. Capitation rates shall be adequate to ensure the provision of quality health and long-term care services to all enrollees regardless of physical or mental health conditions. The division shall ensure that Medicaid rates are no greater than what the division would pay for an actuarially equivalent unenrolled population. The division may permit a risk-sharing relationship between the SCO and the ASAP, in which the two entities share the financial risk of providing coordinated services to enrollees under a system of capitated or sub-capitated rate payments.
(j) The division shall ensure that enrollees have a choice of at least 2 senior care organizations within their geographic area, where available. The division also shall ensure that enrollees have a choice of at least 2 primary care physicians and nursing facilities within each SCO network. Furthermore, when there is more than 1 home health agency within a SCO’s network, enrollees shall have a choice of home health agencies among those within the SCO’s network.
(k) A SCO shall meet all privacy standards set by the regulations established by the federal Department of Health and Human Services under the Healthcare Insurance Portability and Accountability Act of 1996.
(l) Enrollees in any SCO shall have access to the appropriate ombudsperson within the executive office of elder affairs, and shall have access to the SCO ombudsperson or like person within the SCO. The contacts and method of contact shall be provided, at a minimum, to each SCO enrollee upon enrollment.
(m) The division shall promulgate regulations to enforce the provisions of this chapter, and shall establish a senior care options advisory committee to advise the division regarding the ongoing operations of MassHealth senior care options. The advisory committee shall advise the division with regard to the appropriate outreach, enrollment and disenrollment policies for eligible persons. The SCO advisory committee shall include the chairs of the SCO advisory councils and 51 per cent of the advisory committee shall be SCO enrollees or representatives from elderly consumer groups and aging services organizations chosen by the division and the executive office of elder affairs.
(n) The division shall enter into an interdepartmental service agreement with the executive office of elder affairs in a manner that ensures that any and all coordinated care services are provided pursuant to the requirements specified in this section.
(o) The commissioner, in consultation with the secretary of the executive office of elder affairs, shall semi-annually submit to the house and senate committees on ways and means a report detailing the name and number of entities participating as senior care option organizations and expenditure data, including, but not limited to, an analysis of the program’s aggregate budget neutrality. Furthermore, the division shall collect detailed information on the functioning of the SCO demonstration project, including: enrollment and disenrollment rates, including detailed reasons for enrolling and disenrolling; the number of SCO enrollees in nursing homes, community settings and other settings; and other information to assist the special commission in completing various studies.
(p) A SCO shall meet standards established by 42 U.S.C. section 1395w-22 (f) and (g) and 42 U.S.C. section 1396u-2(b).
(q) Notwithstanding any general or special law to the contrary, the secretary of health and human services may review a request for financial solvency certification by a care delivery organization based in the commonwealth applying to serve as a Medicare Advantage Special Needs Plan caring for residents of the commonwealth who are dually eligible for Medicare and Medicaid. Upon determination that appropriate financial standards, which may be the standards already in place for organizations with contracts pursuant to this section, have been met, the secretary shall so certify to the Centers for Medicare & Medicaid Services. The secretary may require the requesting organization to pay a reasonable certification fee.