DEVAL L. PATRICK
Governor

JOHN W.  POLANOWICZ
Secretary

KRISTIN L. THORN
Acting Medicaid Director

October 3, 2013

The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid

One Ashburton Place Boston, MA  02108

Dennis Heaphy, Implementation Council Co-Chair Disability Policy Consortium
89 South Street, Suite 203
Boston, MA 02111 Dear Dennis,
Thank you for your recent letter regarding Implementation Council (IC} priorities and the Early Indicators proposal. I appreciate your thoughtful comments and your dedication to continuing the dialogue that is essential to the IC-MassHealth relationship as we execute implementation of the One Care
demonstration project. Our dialogue takes on a new dimension now that One Care is a live program. From here forward, MassHealth, CMS, and the One Care Plans are making decisions in real-time. It is against this new backdrop that I offer the following observations in response to your letter. This is an exciting time for all of us, and I look forward to harnessing the spirit and substance of the IC's input as we move forward at a redoubled pace to achieve program success and ensure One Care members' access to quality, comprehensive, whole-person care that is consistently delivered in a culturally competent, person-centered manner.

1.	Overarching Objectives

In the three monitoring-related objectives the workgroup identified, we recognize the IC's strong investment in our common goal of promoting effective care and protecting consumers. As a premise for the new objectives, your letter noted that the reduced scope of One Care implicates increased opportunities for monitoring. It is certainly the case that the program configuration we landed on will likely be more manageable in some respects than the scope originally envisioned. At the same time, however, the program as deployed retains the elements, goals, requirements, and oversight mechanisms of the original concept. Monitoring implementation consequently demands the same complexity in systems platforms and functions, the same number of data elements, and the same functionality in consumer feedback and grievance avenues as the original program concept. For that reason, we anticipate that development of the monitoring aspects of One Care will not be significantly simplified. With that in mind, please find below my recommendations to reframe the three overarching objectives articulated in your letter, with an eye toward broadening the focus somewhat to maximize the benefit of the IC's expertise. Please consider what follows through that lens, and be assured that

MassHealth shares the IC's expectation of systemic transparency, meaningful monitoring, and constructive communication within and among One Care contractually-obligated parties and stakeholders.

Regarding transparency and information sharing- MassHealth is committed to ensuring a robust and transparent monitoring process as set out in the Memorandum of Understanding (MOU) and Three-Way Contract. Over the course of the One Care demonstration, the data will facilitate ongoing identification of program trends that will inform our collective evaluation of program strengths and problems. To help inform the IC's consideration of program data trends, we will provide an updated, user-friendly
reporting spreadsheet so IC members are well-acquainted with the underlying quantitative and qualitative data elements that comprise the overall contractual reporting requirements (reporting requirements are already publically available in the Three-Way Contract).

In addition, as discussed at the August IC meeting, the IC will have access to supplemental data collected and reported by the One Care ombudsman, SHINE, and MassHealth customer service. The elements of that "dashboard" are still being finalized and will incorporate the IC's input.

Regarding supporting the commitments of IC members - We hope that IC participation in monitoring review at the trends level will relieve pressure on IC members to receive and digest massive amounts of data, and thereby allow for deeper IC engagement in several core monitoring-related areas. Specifically, we ask that the IC renew its focus and efforts on the objectives and scope in the documents issued by MassHealth describing the role of the IC:

•	Advising EOHHS;
•	Soliciting input from stakeholders;
•	Examining ICO (Plan) quality;
•	.   Reviewing issues raised through the grievances and appeals process and ombudsman reports;
•	Examining access to services (medical, behavioral health, and LTSS); and
•	Participating in the development of public education and outreach campaigns.

With the IC's action and input on these aspects of implementation, One Care will be in the best position to succeed at the program and member levels.

Regarding consumer involvement in One Care monitoring processes - As discussed at the September 20'' IC meeting, the commitment IC members made to individually engage in specific outreach activities in their communities and among their peers exemplifies the incredible resource that the IC represents. Council members are encouraged to not only disseminate information about the opportunity One Care presents for eligible populations, but also to educate consumers about the importance of
communicating their experiences with One Care-whether they enroll, opt-out, cancel, or switch plans-through the IC, the ombudsman, SHINE, or MassHealth customer service. Garnering a critical volume of qualitative data and narrative feedback on One Care will be invaluable in the monitoring process, as it will layer whole-person experiences on to the body of data collected through required reporting.

2.	Immediate  Priorities

We absolutely agree that it is critical to identify an immediate priorities timeline for IC actions for approval at the next IC meeting. Now that One Care has moved past the planning phase and in to active operation, we request targeted IC input moving forward. I would suggest that the priorities should reflect the current and on-deck phases of One Care implementation. Based on issues that the IC discussed at the September 20'h meeting, and with an eye toward the moving parts of One Care that we need focused 1.C input on, I propose the following ng short-term, Council-level priorities timeline for your consideration:

When	IC Task/ Action

Before October IC meeting: At October IC meeting:

Before November IC meeting: At November IC meeting:

Before December IC meeting: At December IC meeting:
•	
Identify IC reps for the Early Indicators Project (EIP) Workgroup
-	Done, thank you -
•	Commit to short-term priorities timeline
•	Member report-back on outreach activities, discussion
•	Agenda topics for discussion:
-	self-enrollment and opt-out numbers update
-	auto-enrollment process
-	introduce the EIP Workgroup
•	Continued IC member outreach and community  listening
•	Member report-back and discussion
•	EIP Workgroup update to Council:
-	Focus group #1 update
-	Survey #1 update
•	Organize around development of the Work Plan*
•	Continued IC member outreach and community  listening
•	Member report-back and discussion
•	EIP Workgroup update to Council:
-	Focus group #1 update
-	Survey #1 update
•Work Plan update:
- 2014 Work Plan proposal

*	Based on MassHealth's IC solicitation documents and CMS funding requirements, the IC is required to develop a Work Plan and submit an annual report.

The IC's committing to a schedule of immediate priorities and actions would be tremendously valuable at this early phase of implementation. Doing so also represents a valuable first step toward the creation of a work plan that is part of the IC's scope of work. At this point in time, as One Care shifts from a plan to an operational program, the need for a structured IC work plan cannot be overstated. We look forward to a specific, structured, meaningful, and achievable work plan for the coming year.

To maximize the value of the work plan as well as the IC's impact, please consider creating a work plan that identifies substantive IC actions on a timeline that reflects One Care's programmatic phases (for example, self-enrollment, passive enrollment, beginning of effective coverage, deadlines for Initial Assessments, care transitions/continuity of care, early member feedback, early provider feedback, evaluating outreach strategy going forward, etc.). In this vein, MassHealth will provide a prospective

programmatic timeline that flags areas of need and specific opportunities for IC review and input. We will identify specific requests for actions where we can prospectively anticipate a need. It is our hope that this will be helpful in creating the work plan.

3.	Response to Enumerated Points

I.	Monitoring- With One Care already open for enrollment and coverage having started this week, time is of the essence in moving forward with the Early Indicators Project (EIP}. We agree that a work group on Early Indicators would be beneficial at this time to expedite the discussions and decision­ making needed to deploy the project and begin collecting data on members' early experiences in/with One Care. Thank you for your identification of IC members to participate in this work group. As alluded to in your letter, the EIP Workgroup will serve as the forum for IC representatives to forward specific suggestions from the IC on methods of research and other monitoring-related matters.

Below are responses to some of the enumerated issues in your letter:

o	The proposed dashboard includes 14 early warning indicator factors. Some of them are further refined into multiple sub-categories to get a better picture of the specific member experience. Specific suggestions by EIP Workgroup members for additional factors may be incorporated, but keep in mind that we need a set of key indicators-there is a limit to how meaningful the dashboard can be with too many data points.
o	EIP Workgroup suggestions for methodologies that increase opportunities for face-to-face surveys and focus groups will be incorporated in the research framework where feasible.
o	The IC was convened to apply the expertise of people with disabilities to the implementation process. Additional IC suggestions regarding target populations for and manner of delivery of surveys and focus groups should be forwarded to the EIP Workgroup for discussion.
o	Timely EIP Workgroup and IC suggestions will be incorporated in the research framework where feasible.
o	As discussed at the September 20'h IC meeting, data reporting requirements are listed in full
in the publically-available Three-Way Contract. In response to IC request, MassHealth is developing a streamlined, user-friendly format for ease of review by IC members that will include timeframes for availability of data elements. For the original list, please refer to the Three-Way Contract.
o	One Care Utilization data can be compared to historic utilization data. It is unclear at this juncture precisely how that data will be used over the relatively short timeframe of the demonstration project.
o	There are legal/administrative safeguards in place that protect member data that sometimes slow down the response time on data requests. Also, as mentioned previously, some data elements, even if collected, are not supported by an automated reporting mechanism. Finally, MassHealth plans ahead for anticipated data needs so that we can manage our agency resources efficiently. New requests may simply exceed our staffing capacity.
o	
o	As a government agency, MassHealth is responsible for direct monitoring across all of its programs to ensure quality, cost-effectiveness, fairness, and program integrity. MassHealth is obligated to perform program monitoring of One Care under the MOU and Three-Way Contract. Many of these requirements arise from federal and state laws and regulations.
The state's monitoring role is also an essential element of good governance. MassHealth's direct monitoring provides the agency information necessary to improve the program and achieve greater efficiencies and superior programmatic outcomes. MassHealth will not and cannot abdicate this role to any other party.

II.	Financing and Financial Data

With respect to your questions on One Care financing and financial data, please refer to the informational presentation MassHealth delivered to the IC on this topic at the April IC meeting. While MassHealth is available to answer specific IC questions regarding rates, risk-sharing, risk corridors, etc., we see this area as generally outside the IC's scope of work, and feel that future IC meeting presentation opportunities are a limited resource best allocated to implementation issues where timely IC input can realistically be incorporated. The following provides a brief summary relating to the financing and financial data matters in which your letter expressed specific interest:

o	CMS leads the demonstration rate-setting process.
o	Rating categories were influenced by historic data on utilization and expenditures across the eligible population.
o	Under the MOU and Three-Way Contract, rates are effective the first of each calendar year of the demonstration. The rate-setting mechanism is unlikely to change significantly, if at all. In the event that major changes occur, CMS will steer the development of new parameters.
o	In the event that risk corridors are triggered, EOHHS and the Plans will not finalize. reconciliation of payments until at least six months after the end of the calendar year during which the trigger occurred (thus, mid-2015 at the earliest). We cannot predict at this time what the effect on the program will be of a risk corridor trigger scenario.
o	Yes, comparing expenditures within and across rating categories to historic spending for this population of dually-eligible members will be a major prong of evaluating overall program effectiveness.

Ill. Understanding/Comparing the Three One Care Plans

These questions go to the heart of evaluating the global consumer experience in One Care and relate to the elements the One Care Plans were required to demonstrate on-the-ground capacity for in final readiness review prior to being cleared for marketing and enrollment in September. For example, each Plan had to demonstrate network adequacy (measured by numbers, type, and accessibility of practitioners) and functional processes to receive enrollments, among numerous other requirements.

o	While the Plans' marketing strategies may vary, all must be conducted within the parameters of CMS marketing guidelines, which are designed to ensure fair and equal
treatment of all consumers. Plans' marketing materials and activities are being monitored by an independent CMS contractor to ensure compliance with marketing regulations and ensure consumer protections.
o	Service continuity is addressed in the Three-Way Contract by a strict requirement that Plans cover new enrollees' appointments, treatment, and services for 90 days while the initial assessment is conducted, the Care Team is assembled, and the Personal Care Plan is designed and implemented. (Part D continuity requirements apply to the pharmacy benefit.)
o	Under the Three-Way Contract, Plans must conduct a comprehensive initial assessment within 90 days of a member's effective date of enrollment. The assessment tool must cover specific domains and special considerations as may be relevant for the member in the creation of his or her Individualized Care Plan (ICP), including domains to help identify LTSS needs, if any. For example, the assessment tool must cover:
•	Immediate needs and current services;
•	Functional status, AOL and IADL limitations, and choices about daily routines;
•	Personal goals and barriers; accessibility requirements;
•	Home environment considerations;
•	Employment status and interest;
•	Informal caregiver supports;
•	Social supports;
•	Food security and nutrition; and
•	Wellness and exercise.
4.	Response to Appendix

I suggest reserving many of the specific items in your letter and its appendix for discussion with the IC and within the EIP Workgroup, to be convened shortly. Again, thank you for the vigorous involvement of the IC in the launching of One Care and in monitoring and directing it toward success. I look forward to continuing to work together to deliver the finest integrated care plan in the nation for people with disabilities. I trust you will share this response to your letter with other members of the IC.

Sincerely,

Robin Callahan
Deputy Medicaid Director MassHealth