A Guide to the Senior Care Options Program for MassHealth Providers Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Table of Contents MassHealth Senior Care Options Program 1 Receiving Care Under SCO 1 SCO Enrollment 1 Eligibility for SCO Enrollment 1 Enrollment Requirements 2 Enrollment Processing 2 Initial Enrollment 2 Enrollment Confirmations - HIPAA 834 Transaction 3 Submission of Enrollments and Disenrollments 4 Automatic Enrollment Adjustments 4 MassHealth Enrollment Centers 4 Rating Categories 5 Transitional Rating Categories (Three-Month Rule) 6 Status Changes 7 Demographic Changes 7 Rate Cell Changes for Community Members 7 Rate Cell Changes for Institutionalized Members 7 Disenrollment 7 Involuntary Disenrollment 8 Admissions and Discharges from Nursing Facilities 8 Short-Term Admissions 8 Long-Term Admissions 8 Discharges 8 MassHealth Capitation Payments 9 Monthly Payment Cycle 9 Financial Reconciliation 9 Patient-Paid Amount 9 Payment Confirmations - HIPAA 820 Transaction 9 SCO MDS Submissions 10 MDS 2.0 10 Management Reports 11 Key MassHealth SCO Contacts 11 MassHealth Senior Care Options Program The MassHealth Senior Care Options (SCO) program is a comprehensive health plan that covers all of the services reimbursable under Medicare and MassHealth through a senior care organization and its network of providers. The SCO program offers MassHealth Standard members aged 65 or older quality health care that combines health services with social support services. By coordinating care and specialized geriatric support services, along with respite care for families and caregivers, SCO offers advantages for eligible MassHealth members over traditional fee-for-service care. Receiving Care Under SCO Members enrolled in SCO have 24-hour access to care and active involvement in decisions about their health care. SCO members have a primary care physician (PCP) who is affiliated with the senior care organization. The member's PCP and a team of nurses, specialists, and a geriatric support services coordinator work with the member (and family members or caregivers, if applicable) to develop a plan of care to specifically address the needs of the member. SCO Enrollment Senior care organizations are responsible for verifying potential members’ eligibility for MassHealth by checking the MassHealth Eligibility Verification System (EVS). The EVS User Manual is accessible on the MassHealth Web site at www.mass.gov/masshealth/newmmis. Click on Read Updated Billing Guides, Companion Guides, and Other Publications. Senior care organizations are also responsible for checking EVS monthly to ensure that members enrolled in SCO have not lost their MassHealth eligibility, thereby becoming ineligible for SCO. Potential SCO members who are not MassHealth members should be referred to the MassHealth Enrollment Center serving their area. For more information on enrollment centers, see the “MassHealth Enrollment Centers” section of this guide, or refer to Appendix B of your MassHealth provider manual at the MassHealth Web site www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then on Provider Library. Now click on MassHealth Provider Manual Appendices or go to www.mass.gov/masshealthpubs. Eligibility for SCO Enrollment Enrollment in this managed care program is voluntary and open to MassHealth Standard members who meet the following criteria: * are aged 65 or older; * reside in a geographic area serviced by a senior care organization; * live at home or in a long-term-care facility (The member cannot be an inpatient at a chronic or rehabilitation hospital or reside in an intermediate care facility for the mentally retarded.); * are not subject to a six-month deductible period under MassHealth regulations at 130 CMR 520.028; * are not diagnosed with end-stage renal disease (ESRD). Enrollment Requirements The MassHealth member must choose to enroll in SCO voluntarily and * live in the geographic area served by the senior care organization; * agree to receive all services from the senior care organization, except in the case of an emergency or when traveling temporarily out of the service area; * select a primary care physician; and * agree to assist his/her primary care physician or primary care team in developing an individualized plan of care. The MassHealth member is not eligible to enroll in SCO if: * diagnosed with end-stage renal disease (ESRD); * subject to a six-month deductible period under 130 CMR 520.028 (spenddown) * residents of an intermediate care facility for the mentally retarded; or * inpatient in a chronic disease or rehabilitation hospital. Note: A potential SCO member may be receiving services from the Department of Developmental Services (DDS). Before enrolling the member, the senior care organization, must contact the member’s DDS service coordinator to determine whether SCO enrollment is appropriate. Call 617-624-7779 for information about DDS services. Enrollment Processing The Provider Online Service Center (POSC) is accessible via the EOHHS Virtual Gateway. This portal allows the electronic enrollment and disenrollment of members without submitting paper enrollment forms. However, the MassHealth SCO enrollment form must be completed by the member, or his or her eligibility representative and retained by the senior care organization. The senior care organization must keep the original MassHealth SCO enrollment form or an electronic image on file while the member is an active participant, and for six years following the member’s disenrollment from the senior care organization. All enrollment forms are subject to review by MassHealth and the Centers for Medicare & Medicaid (CMS) at any time. The senior care organization must complete standard HIPAA signature forms and keep them in the Centralized Enrollee Record (CER) so that the senior care organization knows who has the authority to receive information and to participate in health-care decisions on the member’s behalf. Initial Enrollment The senior care organization must check the Eligibility Verification System (EVS) to determine the member’s MassHealth eligibility status. A prospective SCO member must have active MassHealth Standard to enroll. The member or the member’s eligibility representative must complete the MassHealth Senior Care Options enrollment form and select a primary care physician. If a member needs assistance completing the application, an Enrollee Service Representative (ESR) from the senior care organization may help the member complete the form. Initial Enrollment (cont.) After confirming the prospective member’s eligibility for MassHealth, the senior care organization may request enrollment immediately for members by enrolling via POSC. In order to have a member approved for Community Alzheimer’s/dementia or chronic mental illness (AD/CMI) and Community nursing home certifiable (NHC) rate cells, the senior care organization must submit the electronic Minimum Data Set – Home Care (MDS-HC). The Request for Service form must be completed with all submissions. For institutional members, submit a copy of MDS 2.0 with all initial enrollment requests. As MDS 2.0 is not available in an electronic format, provide via CD to the SCO Operations Unit. You must post an institutional member’s Management Minutes Category (MMC) on the Provider Online Service Center when the initial enrollment request is received. Enrollment requests will be denied for institutional members until the MMC data is posted in the system. This information is submitted directly to MassHealth by nursing facilities. Enrollment Confirmations - HIPAA 834 Transaction Enrollment confirmations are posted daily and are available for download from the Provider Online Service Center. In addition to the daily enrollment confirmations, a monthly 834 file is available for download. The monthly 834 file contains details of all members for which a monthly capitation payment is being made. For more information on the HIPAA 834 transaction, refer to the 834 Companion Guide available on the MassHealth Web site at www.mass.gov/masshealth. Submission of Enrollments and Disenrollments The senior care organization may process new member enrollments and disenrollments through the last business day of the month. All enrollment effective dates are the first of the month following enrollment. All disenrollment effective dates are the last day of the month in which the disenrollment is requested. Note: The cut-off may vary month to month and is determined by the MassHealth production schedule. The senior care organization must check with the SCO Operations Unit monthly to determine the cut-off time for processing. Retroactive enrollment disenrollment dates are not generally permitted. However, individual consideration will be given on a case-by-case basis. All member enrollment information is considered protected health information (PHI) under HIPAA. If any member information is faxed, the fax cover sheet must indicate that PHI is included. The senior care organization must call the SCO Operations Unit in advance whenever PHI is being faxed. Automatic Enrollment Adjustments Other state agencies or MassHealth units may change MassHealth member eligibility or demographic data. As these changes may affect a member’s rate cell, automatic enrollment adjustments are batch processed through NewMMIS. NewMMIS verifies and edits enrollment information on a daily and monthly basis. SCO enrollment status and rate cells will be affected by the following conditions: * change of address from Boston or out of Boston; * addition or termination of Medicare Part A, Part B, or both; * change in Management Minutes Category (MMC); * admission or discharge to a nursing facility (including the three-month rule described in the Rate Cells section of this guide); and * loss of MassHealth eligibility. MassHealth Enrollment Centers The MassHealth Enrollment Center locations are listed below. For more information, refer to Appendix B of your MassHealth provider manual at the MassHealth Web site www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then on Provider Library. Now click on MassHealth Provider Manual Appendices or go to www.mass.gov/masshealthpubs. 45-47 Spruce Street Chelsea, MA 02150 Phone: 1-888-665-9993 333 Bridge Street Springfield, MA 01103 Phone: 1-888-665-9993 MassHealth Enrollment Centers (cont.) 21 Spring Street Suite 4 Taunton, MA 02780 Phone: 1-888-665-9993 367 East Street Tewksbury, MA 01876 Phone: 1-888-665-9993 Rating Categories SCO members are assigned rating categories based on the following criteria: Medicaid and Medicare eligibility, region of residence (Boston/Non-Boston), clinical status, and setting of care. SCO members who have Medicaid and Medicare Part A and B are dually eligible and SCO members without Medicare, or only Medicare Part A or B are Medicaid only. There are three community rating categories, as follows: * Well; * Alzheimer’s/dementia or chronic mental illness (AD/CMI); and * Nursing home certifiable (NHC). There are three institutional rating categories, based on the member’s Management Minutes Category (MMC), as follows: * Tier 1, MMC Level H, J, or K; * Tier 2, MMC Level L, M, N, P, R, or S; and * Tier 3, MMC Level T. Rating categories are designated by the following NewMMIS Rate cells. These codes appear on management reports the senior care organization receives from MassHealth. The rating category regions are found on the Capitation Payment Report. Eligibility Region NewMMIS Rating Category Rate Cells Dually eligible Boston CWD Community Well Dually eligible Non-Boston CWD Community Well Medicaid only Boston CWM Community Well Medicaid only Non-Boston CWM Community Well Dually eligible Boston CAD Community AD/CMI Dually eligible Non-Boston CAD Community AD/CMI Medicaid only Boston CAM Community AD/CMI Medicaid only Non-Boston CAM Community AD/CMI Dually eligible Boston CND Community NHC Dually eligible Non-Boston CND Community NHC Medicaid only Boston CNM Community NHC Medicaid only Non-Boston CNM Community NHC Dually eligible Boston TND Transition to NF Dually eligible Non-Boston TND Transition to NF Medicaid only Boston TNM Transition to NF Medicaid only Non-Boston TNM Transition to NF Dually eligible Statewide I1D Institutional Tier 1 Medicaid only Statewide I1M Institutional Tier 1 Dually eligible Statewide I2D Institutional Tier 2 Medicaid only Statewide I2M Institutional Tier 2 Dually eligible Statewide I3D Institutional Tier 3 Medicaid only Statewide I3M Institutional Tier 3 Dually eligible Statewide TCD Transition to Community Medicaid only Statewide TCM Transition to Community Transition to Community Transitional Rating Categories (Three-Month Rule) If a SCO member moves from the community to an institutional setting or from an institutional setting to the community, transitional rating categories are assigned for the three months following the admission to or discharge from the nursing facility. For example, if a community NHC member with a rating category of CND was admitted to a nursing facility on October 25, 2012, the CND rating category would automatically change as of October 31, 2012. A transitional rating category of TND would automatically be assigned as of November 1, 2012. If the member remained in the nursing facility for more than three months, the TND category would automatically transition as of January 31, 2013. An institutional rating category, determined by the member’s Management Minutes Category (MMC), would be assigned as of February 01, 2013. Status Changes Demographic Changes The senior care organization must inform members to report their change of address to the MassHealth Enrollment Center. If members are receiving MassHealth through SSI, the member must report the change in address to the local Social Security Administration office. MassHealth cannot change SSI member address records. Note: The most common reason MassHealth members lose their eligibility is unreported address changes, because financial redetermination forms do not reach the members and are not completed as required. Rate Cell Changes for Community Members The senior care organization must submit an MDS-HC when there is a significant change in a community member’s clinical status that may change the member’s rate cell. Submit an MDS-HC to make the following changes: * well to AD/CMI or NHC; * AD/CMI to NHC; * NHC or AD/CMI to well; and * NHC to AD/CMI Rate Cell Changes for Institutionalized Members The nursing facility must submit a new MMQ, and post the appropriate MMC on the Provider Online Service Center before an institutional rate cell can change. The facility must also submit an MDS 2.0 to support changes in institutional rate cells. All members with an intuitional rating category (tier 1, tier 2, or tier 3) who do not have a level of care/MMC score will automatically be placed back into a community well rate. Disenrollment Include a disenrollment reason with all SCO disenrollment requests. On the disenrollment panel, enter a disenrollment reason from the list below. If the reason for disenrollment is death of the member, enter the date of death. * Moved out of service area * Provider network unacceptable * Dissatisfied with health care * Dissatisfied with appeal decision * Death (date of death is required) * Transportation problem * Difficulty contacting doctor * Problem receiving emergency treatment * Language barrier * Poor access for disabled members Disenrollment (cont.) * Takes too long to get appointment * Dissatisfaction with specialty care * Health care needs changed * Did not meet clinical needs requirements * Improperly enrolled * Fair hearing appeal decision Involuntary Disenrollment Involuntary disenrollment requests must be preapproved. You must present a detailed explanation with all applicable documentation to the MassHealth SCO Operations Unit before entering the disenrollment transaction. If a member loses his or her MassHealth eligibility, capitation payments will be stopped. Senior care organizations may help members regain their eligibility by contacting the applicable MassHealth Enrollment Center. The Monthly Member Lost Eligibility report described in the Management Reports section of this document identifies members who have lost their eligibility. Admissions and Discharges from Nursing Facilities Whenever a SCO community member is admitted to or discharged from a nursing facility, the senior care organization or contracted nursing facility must submit the SC-1 form (Status Change for a Member in a Nursing Facility, Chronic Disease and Rehabilitation Inpatient Hospital, or Rest Home) to the appropriate MassHealth Enrollment Center with “SCO Member” clearly indicated on the form. If the SC-1 is not clearly indicated as “SCO Member,” the MassHealth Enrollment Center cannot process the status change. Short-Term Admissions If the admission to the nursing facility is short term the SC-1 is not required. Long-Term Admissions If the admission is long term the contracted Nursing Facility submits an SC-1 to the MassHealth Enrollment Center and completes an MMQ on the Member. Discharges When a Member is discharged from a Nursing Facility the SCO must confirm with the contracted facility that an SC-1 has been submitted to the MEC indicating the member has been discharged. MassHealth Capitation Payments Monthly capitation is a prospective dollar payment per member per month that MassHealth pays to a Senior Care Organization to cover a specified set of services and administrative costs. Monthly Payment Cycle Capitation Payment Run 1st week of each month (Monthly 8200 and 8201 reports are generated for SCO Providers) MMIS Financial Cycle 2nd week of each month Comptroller Processing 2nd week of each month EFT issued End of the 2nd week of each month 820 issued End of the 2nd week of each month Financial Reconciliation On a monthly cycle capitation payments are retrospectively reconciled for three months. Retroactive member enrollment changes that occur three months from the current capitation month will be adjusted automatically. The annual reconciliation cycles are run per request pending MassHealth approval. Patient-Paid Amount Patient-Paid Amount (PPA) is the portion of monthly income that a member in a nursing facility must contribute to the cost of care. When a SCO member transitions to a nursing facility the PPA is reduced from the monthly capitation payment to the senior care organization. The senior care organization is responsible for reconciling the PPA with the appropriate facility. Payment Confirmations - HIPAA 820 Transaction Payment confirmations are posted monthly and are available for download from the Provider Online Service Center in the HIPAA 820 record format. For more information about the HIPAA 820 transaction, refer to the 820 Companion Guide available on the MassHealth Web site at www.mass.gov/masshealth. SCO MDS Submissions Minimum Data Set – Home Care (MDS-HC) is the comprehensive assessment and screening tool used for data submission to MassHealth for most services and programs for elders residing in community settings across the state. A registered nurse must complete the MDS-HC for SCO members in Community NHC and AD/CMI categories, as well as for those individuals transitioning into and out of institutional nursing facility placement. Specialized MDS-HC training is provided regularly by the MassHealth Office of Long Term Services and Supports. Call Virtual Gateway Customer Service at (800) 421-0938 (do they call VG to set up the training?) Submit the MDS-HC with a complete Request for Service form in the following situations: * for initial enrollment requests for those with chronic long-term needs qualifying for AD/CMI and NHC rate cells in the community; * for rate cell changes when a community member experiences a significant long-term change in functional or medical status, or the senior care organization becomes aware of complex service needs; * every 12 months for members evaluated as AD/CMI or NHC. The MDS-HC must be received before the 15th day of the month following 12 full months of continuous payment at the complex rate; * before a planned admission from home or from an acute hospital to a nursing facility for any member who is not evaluated as NHC; and * after discharge from a nursing facility. The MDS-HC must be received before the 15th day of the third month following discharge. MDS 2.0 The MDS 2.0 (Nursing Facility Version) is used for members residing in nursing facilities. It is completed by nursing facility staff for all residents at intervals in compliance with federal and state regulations. As MDS 2.0 is a federal requirement, nursing facility staff are trained in its use by the Massachusetts Department of Public Health. MDS 2.0, along with the Request for Service form, and the current Medication Administration Record from the nursing facility, must be submitted to the SCO Clinical Coordinator in the following situations: * initial enrollment requests for members residing in a nursing facility (not on short-term stays – but who have an LTC segment in the MassHealth system) * rate cell changes when a member is in a nursing facility at the time of request, including o any unplanned admission that occurred before an MDS-HC could be submitted; o when a member meets the MMQ significant change criterion, which is considered a permanent change in condition and results in a payment change; and o to accomplish transition to an institutional tier rate cell, when a member has been at the facility for 90 days; and * before discharge from a nursing facility to establish the correct institutional rating category for transition to community determination. MDS 2.0 (cont.) Include accurate admission, discharge, and assessment dates with all submissions to coincide with other required documentation (e.g., SC-1, and MMC submissions). All medical data submitted via MDS forms is considered current if gathered within 30 days of submission. Determinations are effective for six months. The SCO must request redetermination within 30 days whenever a significant status change occurs. Management Reports Use of the HIPAA 834 and 820 transactions is optional. NewMMIS generates management reports that are available for download from the Provider Online Service Center. These reports include enrollment and payment information that can be used in lieu of the 834 and 820 transactions. The reports are generated monthly at the time capitation payments are calculated. The following is a list of NewMMIS reports. * Monthly New Enrollments * Monthly Disenrollments * Monthly Capitation Payments * Monthly Member Lost Eligibility * Monthly Three Month Rule/Case Mix * SCO Capitation Errors * SCO Quarterly Capitation Payment Key MassHealth SCO Contacts The Coordinated Care Systems Unit, MassHealth Office of Long Term Care, manages the Senior Care Options program. The office is located at One Ashburton Place, 5th Floor, Boston, MA 02108. SCO Director, Coordinated Care Systems 617-222-7466 SCO Assistant Director 617-222-7548 SCO Operations Coordinator 617-222-7418 SCO Enrollment Coordinator 617-222-7527 SCO fax 617-727-9368 Toll-free telephone and TTY lines are available for members. Toll-free telephone number: 1-888-885-0484 TTY number (for people with partial or total hearing loss): 1-888-821-5225 SCO-Guide (Rev. 05/2013) A Guide to the Senior Care Options Program for MassHealth Providers