One Care Contract Addendum

In September 2014, MassHealth, the Centers for Medicaid & Medicare Services (CMS), and the One Care plans executed changes to the One Care three-way contract (i.e., executed a contract addendum). The changes established risk corridors for Demonstration Years 2 and 3, and adjusted the Medicare coding intensity factor.

  • Risk Corridors: Risk corridors are a form of financial risk sharing and protection against financial losses and gains. Risk corridors in One Care are meant to lessen the financial risk One Care plans take on as they provide coordinated services to One Care enrollees. They also allow the Commonwealth and CMS to share in savings the One Care plans may achieve. The original three-way contract established risk corridors for the first year of the Demonstration; MassHealth and CMS amended the three-way contract to include risk corridors for the second and third years.
  • Coding Intensity: CMS revised the coding intensity factor for 2014 and 2015, which will result in an increased capitation payment from Medicare to the One Care plans. Coding intensity is an adjustment that CMS applies to the Medicare payment rate to offset the differences in coding practices between Medicare fee-for-services and managed care (i.e., Medicare Advantage).

The Massachusetts One Care contract addendum is posted below.

Duals Demonstration (One Care) CY2014 Payment Rates to Integrated Care Organizations (ICOs)

MassHealth, in conjunction with the Centers for Medicare and Medicaid Services (CMS), is releasing the final Medicaid and Medicare components of the CY 2014 rates for the Massachusetts Demonstration to Integrate Care for Dual Eligible Individuals (One Care). Effective January 1, 2014, these rates will replace the Demonstration rates included in the CY 2013 rate report. Included in this report are final CY 2014 Medicaid rates and Medicare county base rates and information supporting the estimation of risk adjusted Medicare components of the rate.

Duals Demonstration CY2013 Payment Rates to Integrated Care Organizations (ICOs) — Revised August 2013

MassHealth, in conjunction with the Centers for Medicare and Medicaid Services (CMS), is releasing final CY2013 rates for the Massachusetts Demonstration to Integrate Care for Dual Eligible Individuals. This report includes updates to the previously posted May 15, 2013 report. Compared to the May 15, 2013 Rate Report this document includes updates related to: start date; savings percentages; risk corridors; the default rate; the impact of sequestration; administrative expense update to the MassHealth component; and other minor clarifications. The MassHealth component of the rates is now final.

Contracts with One Care Plans

On July 16, 2013, MassHealth and CMS announced that we have signed contracts with three health plans to participate in One Care: MassHealth plus Medicare - Commonwealth Care Alliance (CCA), Fallon Total Care (FTC), and Network Health. We are excited to be working with these organizations. They have shown a high degree of collaboration, innovativeness, and commitment to serving our members under this new integrated model. They also have strong experience providing quality services to MassHealth members and persons with complex care needs:

  • CCA; FTC’s parent company, Fallon Community Health Plan (FCHP); and Network Health’s parent company, Tufts Health Plan; all currently offer integrated Medicare and MassHealth plans to dual-eligible individuals age 65 and older through the Senior Care Options program.
  • Network Health and FCHP have served thousands of MassHealth members with disabilities as MassHealth Managed Care Organizations.
  • CCA received the highest rating from CMS in the last two years for quality and performance by a Medicare Advantage Special Needs Plan for people in Massachusetts aged 65 or over.
  • FCHP and Network Health were ranked the #1 and #3 Medicaid health plans in the National Committee for Quality Assurance’s (NCQA’s) 2012-2013 Health Insurance Plan Rankings for Medicaid Plans.

Below is a chart of the plans’ expected service areas for Demonstration Year 1. With this geographic coverage, more than 90,000 individuals will have one or more One Care plans servicing their area. The chart below shows which counties will have one, two or three One Care plans, as well as counties that do not currently have a plan. As previously stated, there will be auto-assignment only in counties with two or more plans serving the full county. Where there is only one plan in a county, that plan would receive self-selected enrollments only. One Care will not be offered in counties without a plan.




Network Health

Number of Plans

Auto Assignment?




































































X (partial)

















The Readiness Review process is still ongoing. All plans will have to demonstrate full readiness, including adequate provider networks, in each county they wish to serve, before they will be permitted to accept enrollments. Based on our reviews to date, we are confident that we are on target to begin enrollments effective October 1.

Read the EOHHS Press Release on One Care.

The final Massachusetts One Care contract is posted below.

One Care Plan Readiness Update

MassHealth and CMS are pleased to announce that three plans are moving into the final phase of readiness review and contracting for One Care: MassHealth plus Medicare. Commonwealth Care Alliance, Fallon Total Care, and Network Health have completed their submissions for the desk review and provider networks, and are preparing for the final site visit components of the readiness review. The desk review and the plans’ provider network analysis are currently in process. We have finalized the 2013 capitated payment rates and will begin systems testing with all plans the second week in July.

We continue to work toward a One Care start date of October 1, beginning with a period of self-selected enrollment. The first wave of auto-assignment is tentatively scheduled to take effect on January 1, 2014.

MassHealth will be kicking off a broad public awareness and outreach effort in mid-July to ensure that consumers, their families, providers, and other community-based organizations are informed about One Care and prepared for the enrollment process this fall.

We look forward to One Care becoming a reality, in partnership with a solid group of plans that will ensure access to enhanced care coordination and quality for MassHealth members.

RFR for One Care Ombudsman

On June 27, the Executive Office of Health and Human Services (EOHHS) issued a Request for Responses (RFR) from qualified entities to provide Ombudsman services for One Care: MassHealth plus Medicare. EOHHS recognizes the importance of potential Enrollees, their families, caregivers, and advocates having accessible avenues of support and assistance, and the need for strong oversight of One Care throughout its implementation. To serve this function EOHHS will select a qualified contractor to provide Ombudsman services for One Care.

The RFR provides details about the qualifications, responsibilities, and requirements for bidders, and information on how to submit responses. Responses to the RFR are due to MassHealth by 4:00 PM (EDT), July 29, 2013.

Update – The deadline for responses has been extended to August 9, 2013. Please see the amendment that is posted on Comm-PASS for additional details.

If you have any questions regarding this procurement, please contact the Procurement Coordinator Lisa Wong at Lisa.D.Wong@State.MA.US.

The RFR is available on the state procurement website COMBUYS ( as Document Number 13CBEHSOMBUDSMANSVCSRFR.

One Care Timeline Update

A revised timeline for the implementation of One Care is provided below. These changes have been agreed to by MassHealth and CMS following careful consideration of the time needed to achieve key milestones before enrollment of members into One Care plans begins.

Key dates in the revised timeline include:

Work StreamExpected DateEntityAction
Readiness ReviewMid-JunePlansOne Care plans resubmit provider networks
OutreachJulyMAPublic awareness campaign begins
ContractMid-JulyCMS, MA and PlansThree-way contracts signed
ImplementationAugustMA and PlansMassHealth and plan implementation readiness activities
OutreachSeptember 1MASelf-selection letters sent to individuals in target population. Outreach to potential enrollees begins.
MarketingSeptember 1PlansPlan marketing begins
ImplementationOctober 1AllOne Care start date, self-selection enrollments only
ImplementationNovember 1MA60 day notice sent to first auto-assignment group (individuals in C1 and F1 rating categories)
ImplementationJanuary 1, 2014PlansEffective date for first wave of auto-assignment
  • 2nd wave of auto-assignment effective tentatively April 1, 2014
  • Possible 3rd wave of auto-assignment tentatively July 1, 2014

MassHealth thanks all stakeholders for continuing to work with us on this important initiative.

Duals Demonstration CY2013 Payment Rates to Integrated Care Organizations (ICOs)

MassHealth, in conjunction with the Centers for Medicare and Medicaid Services (CMS), has released final payment rates for ICOs for calendar year 2013 (CY2013). The general principles of the rate development process for the Demonstration are outlined in the Memorandum of Understanding (MOU) between CMS and the Commonwealth of Massachusetts. Included in this report are final Medicare county base rates, information supporting the estimation of risk-adjusted Medicare components of the rate, details related to the development of the MassHealth portion of the rate, and some information supplemental to the July 2012 MassHealth Data Book to support comparisons of projected spending on the target population to the rates. The MassHealth component of the rate remains subject to final review and approval by CMS.

Duals Demonstration Timeline

After careful consideration, MassHealth and CMS have agreed to certain changes in key dates for the Duals Demonstration implementation. This is to ensure that there is sufficient time for all critical implementation milestones to be achieved before any member is enrolled into an ICO, including robust public awareness and targeted outreach efforts so that individuals have a meaningful opportunity to learn about the Demonstration and select an ICO prior to the auto-assignment process.

For implementation to be successful, all Demonstration stakeholders need certainty around the timeline. MassHealth is committed to working with all stakeholders to accomplish the implementation steps needed to support a date of July 1, 2013 for the first self-selected enrollments to become effective.

Key dates in the revised timeline include:

ICO Selection AnnouncementNovember 2, 2012
Readiness ReviewNovember 2012 – March/April 2013
3-Way ContractsMarch/April 2013
Learning CollaborativesMarch 2013 – Ongoing
Implementation Activities 
      Stakeholder Workgroups: Quality, Notices, Outreach, Admin. SimplificationDecember 2012 – Ongoing
      Implementation CouncilFebruary 2012 – Ongoing
      OmbudspersonMay 2013 – Ongoing
Public Awareness CampaignApril 2013 - Ongoing
Member Outreach Activities
(Members can begin to select ICOs for effective date July 1, 2013)
May 2013 – Ongoing
Self-Selected Enrollments BeginJuly 1, 2013
Auto-assignments Effective
(Members notified at least 60 days prior to the effective date)
October 1, 2013; January 1, 2014

Duals Demonstration Implementation Pathway

Through the Duals Demonstration proposal, RFR and MOU processes, which have featured significant stakeholder engagement, many fundamental aspects of the Demonstration have been solidified. However, MassHealth and CMS continue to develop certain Demonstration components. In letters and other communications, stakeholders continue to raise important questions on a variety of topics — from payment rates and quality measures to ensuring an ongoing consumer voice.

As the Demonstration now moves from a design phase toward implementation with selected ICOs, there will be additional opportunities for CMS, MassHealth and stakeholders to work together on addressing and resolving outstanding issues. The Issue-Response Document posted below outlines a number of issues that stakeholders have raised in the past several months and provides responses from MassHealth. For each issue and response, also noted is the mechanism(s) by which MassHealth anticipates addressing the issue; the mechanisms for approaching these issues may change as MassHealth gains more experience with the Demonstration. Please see the Issue-Response Document for additional details.

MassHealth remains confident that our experience in building new programs, coupled with the strong engagement we have had and continue to have with stakeholders, will lead to successful implementation of this Demonstration.

Notice of Opportunity to Participate in the Duals Demonstration Implementation Council

The Executive Office of Health and Human Services (EOHHS) is seeking individuals to serve on the Implementation Council for the Massachusetts State Demonstration to Integrate Care for Dual Eligible Individuals (Duals Demonstration).

EOHHS wishes to establish and consult a working committee to operate during the Duals Demonstration. The Implementation Council will play a key role in monitoring access to healthcare and compliance with the Americans with Disabilities Act (ADA), tracking quality of services, providing support and input to EOHHS, and promoting accountability and transparency. The Implementation Council will develop a work plan and meeting agendas. The roles and responsibilities will likely include advising EOHHS; soliciting input from stakeholders; examining ICO quality, reviewing issues raised through the grievances and appeals process and ombudsperson reports, examining access to services (medical, behavioral health, and LTSS), and participating in the development of public education and outreach campaigns.

EOHHS anticipates that the Implementation Council will meet monthly or bimonthly and will hold meetings across Massachusetts from January 2013 through December 2016.

EOHHS seeks individuals, including MassHealth members with disabilities and their family members or guardians, representatives of community-based organizations, representatives of consumer advocacy organizations, union representatives, and providers, representing the diverse communities affected by the Duals Demonstration, to serve on this Implementation Council. At least half of all Implementation Council members will be MassHealth members with disabilities or family members or guardians of MassHealth members with disabilities.

Members are expected to be available to devote the time needed to perform the roles and responsibilities of the Implementation Council, review all meeting materials in advance of meetings, attend and participate in all meetings, participate in the development of work plan deliverables, and provide advice and guidance to EOHHS. Members should possess strong analytic skills, critical reading skills, good interpersonal and communication skills, be a resident of Massachusetts, and not be employed by an Integrated Care Organization.

Interested individuals should submit a completed nomination form and letter of reference by December 17 at 5:00 PM. The nomination form and a frequently asked questions (FAQ) document are available online at under Related Information. Email or call Geraldine Sobkowicz at 617-573-1678 if you need the form and FAQ sent to you or would like to request a reasonable accommodation, which may include the information in an alternative format.

Readiness Review for Integrated Care Organizations

MassHealth and CMS have developed a tool to facilitate a joint readiness review process for Integrated Care Organizations (ICOs). This “readiness review tool,” posted below, includes criteria that reflect Demonstration design elements and ICO requirements outlined in the Memorandum of Understanding between CMS and the Commonwealth, the Commonwealth’s Request for Responses from Integrated Care Organizations, the CMS Capitated Financial Alignment Application, applicable Medicare and Medicaid regulations, and feedback from Massachusetts stakeholders provided in writing and ongoing public meetings.

The criteria provided in this tool are unique to the Massachusetts demonstration and will be used to ensure that the ICOs are ready to serve dual eligible individuals. The criteria span a range of core areas such as care coordination, systems, organizational structure and provider networks. ICOs will be asked to produce documents for review and participate in site visits by CMS and MassHealth based on this tool.

ICO Selection Announcement

EOHHS has completed the procurement process to select organizations to proceed to contract negotiations to participate as Integrated Care Organizations (ICOs) for the Duals Demonstration. We are excited to announce the following selected organizations:

  • Blue Cross and Blue Shield of Massachusetts HMO Blue Inc. (BCBSMA)
  • Boston Medical Center HealthNet Plan (BMCHP)
  • Commonwealth Care Alliance (CCA)
  • Fallon Total Care, LLC (FTC)
  • Neighborhood Health Plan (NHP)
  • Network Health, LLC

These organizations will now advance to a joint federal and state Readiness Review process. During the Readiness Review period, EOHHS and CMS will require these organizations to demonstrate full readiness and meet operational requirements. An ICO will not be able to accept enrollments without successfully completing the joint Readiness Review, negotiating and executing a three-way contract, and receiving any necessary state and federal approvals.

These organizations were selected for full (F) or partial (P) Massachusetts counties as follows:

BarnstableFF F F
Berkshire F   F
BristolFF F F
Dukes     F
FranklinFFF  F
HampdenFFFF F
HampshireFFFF F
Nantucket     F
NorfolkFFFF F
PlymouthFFPF F
WorcesterF FF F

We look forward to working with the selected organizations and continuing engagement with all stakeholders in implementation activities.

Memorandum of Understanding with CMS

EOHHS and CMS signed a Memorandum of Understanding (MOU) authorizing the Massachusetts Duals Demonstration on August 22, 2012. The MOU signifies CMS’s official approval of the Massachusetts Duals Demonstration.

The MOU and an addendum to the Final Demonstration Proposal are posted below.

RFR for Consumer Consultants

On June 19, MassHealth issued a Request for Responses (RFR) from Integrated Care Organizations (ICOs) to participate in the Demonstration. EOHHS is issuing a separate RFR seeking the advice of up to six MassHealth members who are Consumers of medical services, behavioral health services and/or LTSS (“Consumer Consultants”). The selected Consumer Consultants will form a paid advisory subcommittee that shares its thoughts and expertise with EOHHS throughout the process of reviewing and evaluating the RFR responses that EOHHS receives from organizations seeking to be ICOs.

Details about the qualifications, responsibilities, and requirements for Consumer Consultants are provided in the RFR, along with information on how individuals can submit responses. Individuals who are interested in serving as Consumer Consultants are asked to submit a short written statement, two references, and some other information to EOHHS. The deadline for responses is July 20, 2012 at 4 PM.

The RFR is available below and on the state procurement website COMMBUYS as Document Number 13CBEHSCONSUMERCONSULTANTRFR.

CMS Guidance for Organizations Interested in Serving as Integrated Care Organizations

CMS has issued two documents of relevance to organizations that are interested in serving as Integrated Care Organizations (ICOs) under Duals Demonstration. These documents were distributed on March 30 via HPMS to those organizations who have submitted a Notice of Intent to Apply (NOIA) to participate in this Demonstration. NOIAs were due to CMS by April 2, 2012. Interested organizations must have submitted a NOIA to CMS by April 2, 2012 in order to be eligible to participate in the Demonstration.

One of the documents issued by CMS is guidance on the Medicare portion of the ICO selection process. The guidance summarizes the Medicare requirements for participation, including approval of a medication therapy management program (MTMP); approval of an integrated plan benefit package (IBP), approval of a formulary, approval of a model of care, and other elements. The guidance also provides an update on the mechanism by which States and CMS will jointly review organizations’ marketing and beneficiary notification materials.

The second document released by CMS is the Demonstration application, which all organizations interested in serving as ICOs must complete and submit to CMS via HPMS. Applications may be submitted until May 24, 2012.

MassHealth and CMS continue to discuss critical aspects of the how the Demonstration will be implemented. The March 30 CMS guidance and Demonstration application represent minimum requirements that organizations interested in serving as ICOs must satisfy. The Request for Responses that MassHealth and CMS expect to jointly issue later this spring will include additional, complementary requirements that reflect MassHealth’s expectations for ICOs and the design process that has proceeded in Massachusetts to date with robust stakeholder input.

Information Session for Entities that May be Interested in Serving as Integrated Care Organizations (ICOs)

The Centers for Medicare & Medicaid Services (CMS) has released technical Guidance for Organizations Interested in Offering Capitated Financial Alignment Demonstration Plans, which will include entities interested in serving as Integrated Care Organizations (ICOs) in Massachusetts’ State Demonstration to Integrate Care for Dual Eligibles. This information includes some important steps that must be completed by prospective ICOs.

This preparation does not obligate you, MassHealth, or CMS to participate in the demonstration. Pending CMS approval of the demonstration, MassHealth and CMS anticipate releasing a Request for Proposals to select the ICOs that will participate.

If you are interested in potentially serving as an ICO in the Massachusetts duals demonstration, it is important that you understand federal ICO requirements. Prospective ICOs will need to complete certain steps to comply with federal requirements before the Massachusetts RFP is released.

On February 1, 2012, representatives from CMS joined MassHealth at an information session to discuss federal requirements and processes with potential ICO participants.

  • February 1, 2012, 2 PM – 4 PM
    One Ashburton Place, 21st Floor
    Boston, MA

Posted below is guidance that CMS distributed. For other materials related to the February 1 meeting, please see Materials from Previous Meetings.

Report on Risk Adjustment for Dual Eligibles by the Massachusetts Medicaid Policy Institute

The Massachusetts Medicaid Policy Institute, a program of the Blue Cross Blue Shield of Massachusetts Foundation, has released a report examining the critical need for risk adjustment in programs serving persons dually eligible for both Medicare and Medicaid, and describing federal and state experience implementing risk adjustment models. The report is available at: Risk Adjustment for Dual Eligibles: Breaking New Ground in Massachusetts.

MMPI hosted a forum on Wednesday, February 29 to provide an overview of the risk adjustment paper and views on this topic from experts and other states. Materials from the event are available under the Open Meetings section of this website.

Letters of Intent regarding CMS Financial Alignment Models

In July 2011, CMS announced that it is offering opportunities to align financing between Medicare and Medicaid to support improvements in care for dual eligible individuals. The two financing options – managed fee for service, and capitated – were detailed in a letter to State Medicaid Directors (see posting below). On September 30, 2011, MassHealth submitted a Letter of Intent to CMS to pursue the capitated, three-way contract model for our initiative to integrate care for dual

Information Session for Entities that May be Interested in Serving as Integrated Care Organizations (ICOs)

 eligibles ages 21-64.

MassHealth also submitted a second Letter of Intent expressing our interest in exploring returning the Senior Care Options (SCO) program to a capitated three-way contract. This will allow for more streamlined financial and administrative processes for the SCOs. SCO is not part of the Duals Demonstration.

Integrating Medicare and Medicaid - Naming Contest

MassHealth is running a contest to name its program to integrate Medicare and Medicaid for dual eligible adults ages 21-64. Additional information about this new program is available at . The name should be easy to say and understand. We need your suggestions!

Here is what we need from you:

  • Name of the program? ex: Health Integration Program
  • Name the organizations that will serve individuals in its program: ex: Health Integration Programs, Health Integration Organizations
  • Why did you choose this name? (optional)
  • How do you say/abbreviate it? ex: HIPs ("hips"), HIOs ("H.I.O.s")

Please send your suggestion (either anonymously or with your name if you want bragging rights!) to no later than September 30, 2011 at 5pm.

Massachusetts Medicaid Policy Institute (MMPI), a program of the Blue Cross Blue Shield of Massachusetts Foundation - Report on Dual Eligibles in Massachusetts

CMS July 8, 2011 (State Medicaid Director) SMD Letter

Downloadable Project Summary with Contact Information

This one pager includes an overview of the project, the website address, and the email address for sharing information and submitting questions. Please download this sheet to share information with your organization or individuals who may be interested. Thank you for helping us to spread the word!

Federal Coordinated Health Care Office RFI: Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare - Published May 16, 2011

Office of Medicaid RFI: Integrating Medicare & Medicaid for Individuals with Dual Eligibility - Released March 18, 2011

This information is provided by the Executive Office of Health and Human Services.

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