- What is SCO?
- What does SCO cover?
- What are the criteria for becoming a member of SCO?
- I am a MassHealth-participating provider. I have patients who have both MassHealth and Medicare (also known as "dually eligible members"). Can I continue to treat them if they enroll in SCO?
- How can I determine if a patient is enrolled in SCO?
- If I treat a SCO member for an emergency, how do I get paid?
- If I do not have a contract with the member's senior care organization, other than emergencies, are there any circumstances when I would be paid for services provided to a SCO member?
- How can I become a contracted provider with a senior care organization?
- Will all MassHealth members aged 65 or older be required to join the SCO program?
- Is SCO available statewide to MassHealth members?
- Does SCO replace MassHealth as the secondary insurer when a member has Medicare Parts A and B? Does SCO replace crossover claims?
- How will Medicare Part D affect SCO patients?
1. What is SCO?
SCO is an abbreviation for Senior Care Options. It is sometimes also used as an abbreviation for a "senior care organization." A senior care organization is a qualified contractor selected to provide services to MassHealth members aged 65 or older who have chosen to participate in Senior Care Options. Under this program, senior care organizations provide a fully integrated geriatric model of care. Senior care organizations authorize, deliver, and coordinate all services currently covered by Medicare and Medicaid, including primary, acute, and specialty care; community and institutional long-term care; behavioral health; medical transportation; and drugs.
2. What does SCO cover?
SCO covers all the services the member currently receives under MassHealth and/or Medicare (if applicable). SCO also covers all health and personal care services including, primary care and specialty physician visits, regular preventive services, prescription drugs (under the member's Medicare prescription drug coverage), emergency care, inpatient hospitalization, mental health and substance abuse treatment services, nursing facility care, transportation for medical care, and other services in the health-care plan.
3. What are the criteria for becoming a member of SCO?
- To become a SCO member the senior must be:
- aged 65 or older;
- covered by MassHealth Standard alone or MassHealth Standard and Medicare,
- residing at home or in a long-term care facility; and
- residing within a geographic area serviced by a SCO organization.
4. I am a MassHealth-participating provider. I have patients who have both MassHealth and Medicare (also known as "dually eligible members"). Can I continue to treat them if they enroll in SCO?
Yes. However, once a MassHealth member enrolls in SCO, payment for services is made only by the senior care organization. To be paid by a senior care organization for nonemergency services, you must join its network of providers.
5. How can I determine if a patient is enrolled in SCO?
When you verify a MassHealth member's eligibility through REVS (Recipient Eligibility Verification System), you will receive the following message: "Senior Care Options. Payment limited to SCO. Authorization needed for all services except emergencies. Call (senior care organization name): xxx-xxx-xxxx."
6.If I treat a SCO member for an emergency, how do I get paid?
Emergency services provided to a SCO member will be paid by the senior care organization. The SCO member's authorized representative, or provider must notify the senior care organization of the emergency as soon as possible.
7. If I do not have a contract with the member's senior care organization, other than emergencies, are there any circumstances when I would be paid for services provided to a SCO member?
In some circumstances, the senior care organization will authorize specific services from a noncontracted or out-of-network provider. For example, a SCO may authorize and pay for health-care services delivered by a noncontracted provider if a contracted provider was not available to treat the SCO member or if the member is temporarily out of the senior care organization's service area.
8. How can I become a contracted provider with a senior care organization?
To contract with a senior care organization, you must contact the organization directly. If you are interested in contracting with a senior care organization, you can call the SCO Unit. The SCO representative can give you the latest contact information for each of the senior care organizations.
9. Will all MassHealth members aged 65 or older be required to join the SCO program?
No. Enrollment in SCO is voluntary but does offer seniors a variety of benefits such as individualized, managed, and supportive care services to assist them with their health care.
10. Is SCO available statewide to MassHealth members?
SCO is currently available throughout Massachusetts except for certain locations in the Berkshires and Cape Cod. We hope to make the option available to these areas in the near future.
11. Does SCO replace MassHealth as the secondary insurer when a member has Medicare Parts A and B? Does SCO replace crossover claims?
SCO provides all of the services covered by Medicare Parts A and B and MassHealth Standard. It is funded by capitation payments to senior care organizations by both Medicare and MassHealth. There is no primary or secondary insurer. There are no fee-for-service payments, service exclusions, or crossover claims.
12. How will Medicare Part D affect SCO patients?
If a SCO member signs up for Medicare Part D, they will be disenrolled from the senior care organization they are currently enrolled in. SCO members should know that it is not necessary to sign up for Medicare Part D, as the senior care organization they belong to provides coverage of drugs and pharmacy services.
This information is provided by MassHealth.