MassHealth Section 1115 Waiver Summary. Key provisions:

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Preston Webster
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MassHealth Section 1115 Waiver Summary With unsustainable spending growth that accounts for nearly 40 percent of the overall state budget, MassHealth released a draft federal waiver touted as an

1 MassHealth Section 1115 Waiver Summary With unsustainable spending growth that accounts for nearly 40 percent of the overall state budget, MassHealth released a draft federal waiver touted as an opportunity to bring in significant federal investments to support restructuring. This waiver, also known as the MassHealth Section 1115 Demonstration, represents a multi-year agreement between the state and the Centers for Medicare and Medicaid Services (CMS) that will begin July 1, This restructuring is meant to change the MassHealth system to a more sustainable and coordinated model that promotes care that is integrated, coordinated and holds providers accountable for quality and total cost of care. One prominent feature is that integration of behavioral health and long-term services and supports (LTSS), which includes home health care, will be supported through upfront investments known as Delivery System Reform Incentive Payments (DSRIP). The funding and proposed framework will be detailed later in this summary. Key provisions: ACO Models: MassHealth proposes three types of Accountable Care Organizations (ACO) that are held contractually responsible for the value rather than volume of care. ACOs are provider-led organizations and, in some cases, Managed Care Organizations (MCOs) and the Mass Behavioral Health Partnership (MBHP) will be integrated with ACO to manage MassHealth services. In all three models, the MassHealth member joins an ACO through their selected Primary Care Provider (PCP). Affiliated Primary Care Providers may also participate in MassHealth FFS and in all MCOs, ACOs and the PCC Plan for non- primary care services (e.g. specialty services). Other providers (such as hospitals and specialists) affiliated with an ACO can also participate in all MCOs, ACOs, the PCC Plan and FFS. The three ACO models are as follows: Model A: Fully integrated model of a ACO and MCO partnership that serves as the MassHealth member s health plan as well as their provider system. ACO/MCO s will receive a prospective payment, as MCOs do today, with financial risk arrangements similar to those for MCOs, including accepting insurance risk. This model can provide ACOs with the means to invest more in new models of care and expanded benefits. Over time, but not initially, Model A ACOs will have financial accountability for LTSS in their scope of covered services and accountability, subject to further stakeholder engagement and MassHealth evaluation.

2 Model A ACO/MCOs must demonstrate competencies and readiness in the independent living philosophy, Recovery Models, wellness principles, cultural competence, accessibility, and a community-first approach, consistent with the One Care model before it takes on accountability for LTSS. Model B: The provider-led entity contracts directly with MassHealth and the Mass Behavioral Health Partnership (MBHP) and operates with a full provider network, although the Model B ACO may have preferred provider relationships. The ACO is accountable for the total cost of care of those members, for MassHealth s ACO quality measures, and for additional contractual expectations of ACOs, including Behavioral Health and LTSS integration through Community Partnerships, which are explained in further detail later in this document. MassHealth serves as the health plan for attributed members, enrolling members, maintaining the provider network and playing a role in authorizing services. Model B ACOs will initially be paid fee for service, reconciled against a total cost of care budget. ACOs must demonstrate the ability to bear risk and guarantee payment of their potential responsibility for shared losses to the Commonwealth. Members will access Model B ACOS through their choice of a PCP that participates in that ACO. Under this model, MassHealth may approve referral circles, which are a preferred provider arrangement subset of the PCC Plan network. The enrolled member will not need a primary care referral for any services rendered by a provider in that ACO s referral circle, making it easier for members to receive coordinated care. Model C: The provider-led entity that contracts with MCOs, which serve as the health plan for those members. The contracted MCO will play a larger role to support population health management, pays claims, and contracts the provider network. MCO-enrolled members will also select an available primary care provider (PCP) from their network or, if they do not select, will be attributed to one. If the member s PCP is part of a Model C ACO, the member will be considered part of that ACO s attributed population. Because Model C ACOs are likely to be less advanced than ACOs in other models, this model is likely to have less risk than a Model B ACO. Delivery System Reform Incentive Payments (DSRIP) and Community Partners (CP): MassHealth is seeking authority for $1.8 billion over the five years of the waiver demonstration that will fund infrastructure building and care coordination capabilities. MassHealth expects that costs associated with enhanced care delivery expectations after the five-year DSRIP program will be managed within the total cost of care budget for ACOs. According to the waiver proposal, the DSRIP ACO funding stream will serve four general purposes: infrastructure and start-up support (e.g. information technology, contracting/networking development, performance management infrastructure, new care delivery models)

3 ongoing/ operational costs to support the ACO model of care (e.g. workforce capacity development, ongoing care coordination/management investment) spending for flexible services to address health-related social needs (specific amount to be designated within the broader ACO funding pool) transitional funding for certain safety net hospitals currently receiving funding through the Delivery System Transformation Initiatives program to establish a glide path for reduction in supplemental funding Community Partners (CPs) and Buy versus Build DSRIP funding is also meant to support a philosophy of ACOs buying capacity through existing providers and services rather than having ACOs build potentially duplicative capacity on their own. Part of that buying will involve investment incentives for ACOs to partner with both medical providers and certified Community Partners (CPs) that have expertise in behavioral health and LTSS. The incentive for ACOs is that DSRIP funding will be contingent on a CP-ACO formal relationship with clearly delineated responsibilities for both in regards to integration and coordination of care. The proposed potion of DSRIP funding ($1.8 billion over five years) for CPs is currently about percent. DSRIP accountability to the state will be based on a score with four basic components: 1) Avoidable utilization: a year-one performance benchmark will be set and progress on all-cause hospital readmissions will be measured. 2) State spending reduction: based on state-assigned, ACO-specific spending goals, which will begin in the third performance year of the demonstration. 3) Quality: ACOs will be expected to improve on a full slate of measures. LTSS measured, which are to-be-determined, will be phased in. 4) Integration: based on to-be-determined metrics to review ACO and CP progress on such factors as ED utilization and the amount of members receiving care from a behavioral health community-based provider. As proposed, there are two types of LTSS CPs that would be eligible for funding: DSRIP funds for care management, coordination and counseling: LTSS CPs will receive funds to provide independent assessments, person-centered counseling on service options and referrals to LTSS providers. Funding will also be provided for LTTS CPs participation on the member s care team, which will be led by the ACO. This funding tapers down beginning in year three of the demonstration. DSRIP funds for infrastructure and capacity building: This funding stream is intended for expansion of workforce capacity, health information technology (HIT) investments, performance management and data analytics capacity. Funds may also be used to support start-up for certain services or care coordination approaches. For this stream of funding, the LTSS CP must submit, and MassHealth must approve, a proposed work plan and budget for the abovementioned uses. Additionally, DSRIP funds will allow the state to fund up to ten high priority initiatives in alignment with overall DSRIP goals. These initiatives could include healthcare workforce development, targeted technical assistance, and promotion of clinical/community linkages. DSRIP funding accountability to CMS, different than that of provider/aco accountability, is as follows:

4 ACO Adoption 20 percent: an increasing target of the amount of lives covered by ACOs. Avoidable utilization 30 percent: Matching the ACO-CP accountability, performance will be measured in year one and measured thereafter. Spending 25 percent: Massachusetts will be accountable for reducing per member-per month (PMPM) spending beginning in year three. Quality 25 percent: Massachusetts must maintain or improve on a set of performance measures beginning in year two. Other Key Provisions: Safety Net Care Pool (SNCP) redesign SNCP Overview Established to reduce the percentage of people in Massachusetts who lacked insurance Provides funding to deliver residual uncompensated care, infrastructure expenditures and access to state health programs Current SNCP structure approved through June 30, 2017 to allow for the development and transition to a new SNCP structure Goals of SNCP Redesign Align framework with proposed delivery system reforms Restructured and new payments should be linked to providers performance on ACO models Safety net providers are focused on the same goals as the overall delivery system Substance Use Disorder (SUD) Treatment Waiver proposal to expand MassHealth SUD coverage to address the opioid crisis Expanded MassHealth benefits to include the full continuum of medically necessary 24-hour community-based rehabilitation services MassHealth currently covers Acute Treatment Services (ATS or detoxification services) Clinical Stabilization Services (CSS), Enhanced Transitional Support Services (ETSS) Expanded benefit will include Transitional Support Services (TSS) and Residential Rehabilitation Services (RRS) (American Society of Addiction Medicine levels 3.1 and 3.3) Capacity will expand by nearly 400 beds in FY17, and over 450 additional beds in FY18 Members with SUD will receive care management and recovery support services, including support navigators and recovery coaches Adopt a standardized American Society of Addiction Medicine (ASAM) assessment across all providers Public Comment Period and Timelines June 15 July 17: 1115 waiver proposal posted for 30 day public comment period Proposal can be found at: or picked up in person at 1 Ashburton Place, 11 th Floor, Boston Written comments may be submitted through July 17 at MassHealth.Innovations@State.MA.US

5 Mid-July: 1115 waiver proposal submitted to CMS Implementation timelines Advanced ACO pilot: solicitation spring 2016, launch December 2016 DSRIP funding begins FY18 Community Partners launch early FY18 Full ACO models: solicitation summer 2016, roll-out October 2017 MCO re-procurement effective October 2017 (sequenced after ACO procurement) The Home Care Alliance will be submitting comments on behalf of our members. Anyone with thoughts, concerns or suggestions can contact James Fuccione

MassHealth Delivery System Restructuring Open Meeting

MassHealth Delivery System Restructuring Open Meeting Executive Office of Health & Human Services March 2017 Boston, MA and Springfield, MA Agenda I. Review Goals and Timeline II. Updates III. Members