SECTION 1. Section 9D of chapter 118E of the General Laws, as appearing in the 2022 Official Edition, is hereby amended by striking out subsection (e)(5) in its entirety and replacing it with the following new section:-
(5) The SCO shall be required to evaluate all its enrollees to determine if an enrollee has complex care needs within 90 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.
Summary: This language will amend the SCO enabling statute to extend the time frame within which new SCO enrollees must be evaluated to assess their complex care needs. Since its creation, SCO has been a program which new enrollees must proactively join. As part of its Duals Demonstration 2.0 waiver request, MassHealth is seeking to passively enroll new members into SCO. Given the differences in passive and active enrollment – difficulty reaching and locating new members, assessing the complex care needs of members who are new to managed care – it will be important for the SCO plans and their Aging Service Access Point (ASAP) partners to have sufficient time to outreach and assess new members’ needs.
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