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One Care Medicare + MassHealth. Mass. Councils on Aging Presentation October 2013. What is One Care?. Health insurance plan combines Medicare and Medicaid payments and services, like a Senior Care Organization (SCO) but with additional features

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one care medicare masshealth

One CareMedicare + MassHealth

Mass. Councils on Aging Presentation

October 2013

what is one care
What is One Care?
  • Health insurance plan combines Medicare and Medicaid payments and services, like a Senior Care Organization (SCO) but with additional features
  • Person-centered model providing the full range of acute, behavioral health, and long term supports and services
  • Designed to coordinate care and provide higher quality, more cost-effective care with improved health outcomes
who is eligible
Who is eligible?
  • Full Medicare and MassHealth beneficiaries 21-64 years old in service area
  • Approximately 90,000 dual eligible beneficiaries with some exclusions, such as:
    • MassHealth Members enrolled in Home and Community-based Services waivers-- Frail Elder, Traumatic Brain Injury, Acquired Brain Injury, Developmental Disability and Money Follow the Person waivers
    • Residents of ICF/ID- Intermediate Care Facility for Intellectually Disabled

Note: at age 65, beneficiary may remain in the One Care Plan if he/she still meets MassHealth eligibility guidelines

what does one care cover
What does One Care cover?
  • All Medicare and MassHealth benefits are guaranteed
  • All medically necessary services including inpatient hospital, community health center, DME (durable medical equipment), home health, day habilitation
  • Expanded benefits like Care Coordination, dental, personal care (PCA), DME training, adaptive technology, vision services, non-medical transportation
  • Behavioral health care such as inpatient mental heath and substance abuse, community crisis stabilization, psychiatric day, outpatient therapy, case and family consultation, acupuncture, coaching, peer support
who will benefit from one care
Who Will Benefit from One Care?
  • A beneficiary who needs additional services such as long term community supports or behavioral health
  • A beneficiary who has found services to be fragmented and uncoordinated
  • A beneficiary who has had difficulty accessing services for variety of reasons
care coordination
Care Coordination

A One Care plan must

  • Contractwith community based organizations –Independent Living Centers, ASAPS, Recovery Learning Communities, other organizations serving people with disabilities
  • Promote independent living by using community health workers, qualified peer specialist, non-medical staff, housing specialist for the homeless
  • Attempt smooth transition of current provider services by obtaining numerous provider contracts and offer individual contracts if feasible
cultural competence and americans with disabilities act ada compliance
Cultural Competence and Americans with Disabilities Act (ADA) compliance

A One Care Plan must

  • Ensure staff and providers are culturally competent and trained in values, beliefs associated with a beneficiary’s age, gender, racial, ethnic, linguistic background
  • Reasonably accommodate persons and ensure accessibility in scheduling
  • Provide interpreters or translators, accessible communication
  • Ensure safe and appropriate physical access
  • Provide referrals to independent living and recovery, home based services as needed
enrollment periods
Enrollment Periods
  • Initial voluntary enrollment opportunity in September
  • Three phases of auto-assignment
    • January 1, April 1, July1 members who have not made a decision
  • At any time a beneficiary may opt in, opt out, or change from one plan to another
  • Enrollment changes are effective first day of the following month
  • During 90-day period after enrollment, the One Care plan and enrollee engage in a comprehensive assessment and care planning process
  • Enrollee’s current services and providers stay in place until care planning process is complete and enrollee agrees to the new plan.
enrollment timeline
Enrollment Timeline
  • MassHealth/CMS will send information in advance of initial enrollment and 60 days before any auto enrollment periods
  • At the same time, plans will be allowed to market
  • Letter will direct calls to MassHealth and SHINE regional offices at1-800-243-4636
  • Information about One Care plans will be on, and provider lists will be accessible on provider sites
  • To enroll call MassHealth at 1-800-841-2900
complaints appeals
Complaints/ Appeals
  • The person-centered care plan and package of services will be developed by the One Care plans during meetings with individual, caregiver, family, care coordinator, health care staff and Independent Living – Long Term Services and Supports (IL-LTSS) coordinator. Grievances will be filed internally.
  • Appeals are made through MassHealth or Medicare
  • An independent Ombudsperson role will be developed advocate for consumers and to impartially resolve disagreements, problems with service plan, denials of service
role of shine counselor
Role of SHINE Counselor

Counselors will

  • Assist eligible beneficiary to understand what One Care is and review choices: join One Care plan, choose among plans, or opt out of One Care and continue to receive current services
  • Search for plan comparisons and review available provider lists to ensure continuity of care
  • Complete client contact form including new data fields as required by CMS
  • Provide beneficiaries with relevant information and assist with enrollment process
  • Be culturally competent and ensure accommodation as needed
one care plans
One Care Plans
  • Three companies offer One Care plans in select counties. All have significant experience with Medicaid and similar models of care:
  • Commonwealth Care Alliance
  • Contact: 1-866-610-2273,
  • Fallon Total Care
  • Contact: 1-800-879-0852,

Network Health

  • Contact: 1-855-393-3154,
information sources
Information sources
  • SHINE 1-800-243-4636, press 3
  • MassHealth Customer Service

1-800-841-2900 TTY:1-800-497-4648

  • One Care Plan web sites