SECTION 1. Chapter 118E of the General Laws, as appearing in the 2012 Official Edition, is hereby amended by adding after Section 9F(c) the following new sections-:
(d) 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 an ICO 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.
(e) The benefits provided to persons considered eligible to enroll in the ICO 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, an ICO shall conform to the minimum medical loss ratio as established by the division for its category. At the end of each fiscal year, the ICO shall provide to the division an audited statement of its medical loss ratio for the past year. Two years after the implementation of the ICO dual eligible pilot program, 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, an ICO shall conform to the revised minimum medical loss ratio as established by the division for its category. During any subsequent year of the program and upon renewal of the contract with the division, if an ICO's audited medical loss ratio is below the minimum as determined by the division for its category, the ICO shall provide additional benefits or services to its enrollees in the following contract year in an amountfor 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 an ICO, the division shall require that all ICOs, with whom the division contracts to deliver such services, establish ICO consumer advisory councils. Such councils shall monitor and make recommendations for the ICOs 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.
(3) The division shall educate consumers and their families as to their enrollment choices under MassHealth options and other available alternatives under Medicare and Medicaid. Neither ICOs nor the division shall offer gifts, payments or other inducements to enroll dually eligible individuals in an ICO.
(4) The division shall deliver to all prospective enrollees ICO educational materials that shall include, but not be limited to: a definition of an ICO and how it functions; enrollment eligibility standards; the location of ICOs; 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 , Medicare and Medicaid; and quality of care measurements reported to the division.
(f) The division shall develop and issue a document for consumers to be known as the ""ICO report card'' containing information and data providing a basis upon which ICOs 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 ICO. 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 ICO 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 ICO'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) The division shall ensure that enrollees have a choice of at least 2 integrated care organizations within their geographic area, where available.
(i) An ICO 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.
(j) The commissioner, in consultation with the secretary of the executive office of health and human services, 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 integrated care 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 ICO demonstration project, including: enrollment and disenrollment rates, including detailed reasons for enrolling and disenrolling; the number of ICO enrollees in community settings and other settings; and other information to assist the special commission in completing various studies.
(k)ICO’s shall, at a minimum, pay health care providers and social service programs rates established pursuant to section 13C of chapter 118E.
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