Slide 1: One Care Implementation Council Meeting
Executive Office of Health & Human Services
MassHealth Demonstration to Integrate Care for Dual Eligibles
April 12, 2022, 10:00 AM – 12:00 PM
Virtual Meeting via Zoom
Slide 2: Agenda
1.	Denials
2.	2019-2021 Disenrollment
3.	One Care Contract
Slide 3: Clear Denials
•	Plans must:
o	Provide out-of-network access for any covered service they cannot provide in-network (Section 2.7.1.9.1)
o	Support members to identify providers that are accessible/can provide reasonable accommodations to meet the member’s needs, and/or identifying alternate arrangements to support the member’s access to care
o	Provide access to covered services, including alternatives to meet needs when necessary
•	Provider availability is an issue beyond One Care, and has been exacerbated in many areas by the pandemic.

•	Denials should not be issued for these reasons*:
o	No providers of covered service in network
o	Accessible provider not available, not able to provide reasonable accommodations
o	Provider not available timely

*If you have specific case examples of these types of denials, please send them to our team.
Slide 4: Updating Denial Notice Template
•	MassHealth is working with CMS to propose updates to the Integrated Denial Notice template One Care plans use to:
o	Improve clarity, especially for modifications
o	Provide additional details of request
o	More clearly specify rationale for any denials/modifications, including clarifying scope of service considered
o	Describe rationale for changes to previously authorized services or items
•	We appreciate the Council’s suggestions and feedback, and welcome further discussion for improving member communications.
Slide 5: One Care Total Disenrollment For All Rating Categories 2019-2021
Note: the following information is shown in a bar chart on this slide.

One Care Total Disenrollments
Voluntary vs. Involuntary
2019-2021

2019
Voluntary		1,646 (23%)
Involuntary	5,551 (77%)
Average One Care Members Per Year	24,207
Annual Total Disenrollment as % of Average Enrollment	30%

2020
Voluntary		1,211 (32%)
Involuntary	2,573 (68%)
Average One Care Members Per Year	28,204
Annual Total Disenrollment as % of Average Enrollment	13%

2021
Voluntary		1,767 (40%)
Involuntary	2,618 (60%)
Average One Care Members Per Year	31,949
Annual Total Disenrollment as % of Average Enrollment	14%

Slide footnote:
Note: Maintenance of Effort (MOE) protections from the federal Public Health Emergency significantly reduced involuntary disenrollments in 2020 and 2021. Voluntary disenrollment numbers may include some individuals who would have been subject to involuntary disenrollment if enrollments were not protected during these periods.
Slide 6: One Care Voluntary Disenrollment For All Rating Categories 2019-2021
Note: the following information is shown in a bar chart on this slide.

One Care Voluntary Disenrollments
By Disenrollment Reason, 2019-2021

2019
Transfer to MassHealth FFS/Other	1,204 (73%)
Transfer to SCO	128 (8%)
Transfer to Medicare Advantage	233 (14%)
Other	81 (5%)
Total:	1,646
Average One Care Members Per Year	24,207
Annual Voluntary Disenrollment %	7%

2020
Transfer to MassHealth FFS/Other	892 (74%)
Transfer to SCO	136 (11%)
Transfer to Medicare Advantage	109 (9%)
Other	74 (6%)
Total:	1,211
Average One Care Members Per Year	28,204
Annual Voluntary Disenrollment %	4%

2021
Transfer to MassHealth FFS/Other	1,316 (74%)
Transfer to SCO	299 (17%)
Transfer to Medicare Advantage	106 (6%)
Other	46 (3%)
Total:	1,767
Average One Care Members Per Year	31,949
Annual Voluntary Disenrollment %	6%

Slide footnote:
Note: Maintenance of Effort (MOE) protections from the federal Public Health Emergency significantly reduced involuntary disenrollments in 2020 and 2021. Voluntary disenrollment numbers may include some individuals who would have been subject to involuntary disenrollment if enrollments were not protected during these periods.

Slide 7: One Care Voluntary Disenrollment Rating Categories C1, 2019-2021
C1 : Community Tier 1 Community Other
Note: the following information is shown in a bar chart on this slide.

One Care Voluntary Disenrollments
Rating Categories C1, By Disenrollment Reason, 2019-2021

2019
Transfer to MassHealth FFS/Other	328 (78%)
Transfer to SCO	28 (7%)
Transfer to Medicare Advantage	45 (11%)
Other	19 (5%)
Total:	420
Average C1 Members Per Year	3,813
Annual Voluntary Disenrollment %	11%

2020
Transfer to MassHealth FFS/Other	233 (75%)
Transfer to SCO	23 (8%)
Transfer to Medicare Advantage	34 (11%)
Other	18 (6%)
Total:	298
Average C1 Members Per Year	4,289
Annual Voluntary Disenrollment %	7%

2021
Transfer to MassHealth FFS/Other	250 (72%)
Transfer to SCO	70 (20%)
Transfer to Medicare Advantage	18 (5%)
Other	<11 (<3%)
Total:	349
Average C1 Members Per Year	4,957
Annual Voluntary Disenrollment %	7%

Slide footnote:
Note: Maintenance of Effort (MOE) protections from the federal Public Health Emergency significantly reduced involuntary disenrollments in 2020 and 2021. Voluntary disenrollment numbers may include some individuals who would have been subject to involuntary disenrollment if enrollments were not protected during these periods.
Slide 8: One Care Voluntary Disenrollment Rating Categories C2, 2019-2021
C2 – Community Tier 2 –High BH Community Need

Note: the following information is shown in a bar chart on this slide.

One Care Voluntary Disenrollments
Rating Categories C2, By Disenrollment Reason, 2019-2021

2019
Transfer to MassHealth FFS/Other	328 (70%)
Transfer to SCO	26 (6%)
Transfer to Medicare Advantage	84 (18%)
Other	29 (6%)
Total:	467
Average C2 Members Per Year	8,309
Annual Voluntary Disenrollment %	6%

2020
Transfer to MassHealth FFS/Other	262 (76%)
Transfer to SCO	33 (10%)
Transfer to Medicare Advantage	37 (11%)
Other	12 (3%)
Total:	344
Average C2 Members Per Year	9,470
Annual Voluntary Disenrollment %	4%

2021
Transfer to MassHealth FFS/Other	378 (78%)
Transfer to SCO	56 (12%)
Transfer to Medicare Advantage	34 (7%)
Other	14 (3%)
Total:	482
Average C2 Members Per Year	10,334
Annual Voluntary Disenrollment %	5%

Slide footnote:
Note: Maintenance of Effort (MOE) protections from the federal Public Health Emergency significantly reduced involuntary disenrollments in 2020 and 2021. Voluntary disenrollment numbers may include some individuals who would have been subject to involuntary disenrollment if enrollments were not protected during these periods.
Slide 9: One Care Voluntary Disenrollment Rating Categories C3, 2019-2021
C3 – Community Tier 3 – High LTSS Community Need

Note: the following information is shown in a bar chart on this slide.

One Care Voluntary Disenrollments
Rating Categories C3, By Disenrollment Reason, 2019-2021

2019
Transfer to MassHealth FFS/Other	519 (72%)
Transfer to SCO	73 (10%)
Transfer to Medicare Advantage	103 (14%)
Other	29 (4%)
Total:	724
Average C3 Members Per Year	11,906
Annual Voluntary Disenrollment %	6%

2020
Transfer to MassHealth FFS/Other	391 (71%)
Transfer to SCO	79 (14%)
Transfer to Medicare Advantage	38 (7%)
Other	40 (7%)
Total:	548
Average C3 Members Per Year	14,230
Annual Voluntary Disenrollment %	4%

2021
Transfer to MassHealth FFS/Other	673 (73%)
Transfer to SCO	172 (19%)
Transfer to Medicare Advantage	54 (6%)
Other	23 (2%)
Total:	922
Average C3 Members Per Year	16,390
Annual Voluntary Disenrollment %	6%

Slide footnote:
Note: Maintenance of Effort (MOE) protections from the federal Public Health Emergency significantly reduced involuntary disenrollments in 2020 and 2021. Voluntary disenrollment numbers may include some individuals who would have been subject to involuntary disenrollment if enrollments were not protected during these periods.
Slide 10: One Care Three-way Contract
•	The new Three-way Contract for 2022 to implement procurement under the current demo terms has been posted to the One Care Administrative Webpage at the following link:
o	One Care Three-Way Contract and Memorandum of Understanding (MOU) | Mass.gov
o	Effective for 1/1/22; effectively replaces current Contract; will operate for at least 1 year under current Demo, which was extended through 12/31/22
Slide 11: APPENDIX
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Slide 12: One Care Rating Category Definitions
•	F1 – Facility-based Care
Individuals identified as having a long-term facility stay of more than 90 days 
•	C3 – Community Tier 3 – High LTSS Community Need
Individuals who have a daily skilled need; two or more Activities of Daily Living (ADL) limitations AND three days of skilled nursing need; and individuals with 4 or more ADL limitations - In CY2014, C3 split into two subsets: C3B: for C3 individuals with certain diagnoses (e.g., quadriplegia, ALS, Muscular Dystrophy and Respirator dependence) leading to costs considerably above the average for current C3 C3A: for remaining C3 individuals 
•	C2 – Community Tier 2 – Community High Behavioral Health
Individuals who have a chronic and ongoing Behavioral Health diagnosis that indicates a high level of service need - In CY2014, C2 split into two subsets C2B: for C2 individuals with co-occurring diagnoses of substance abuse and serious mental illness C2A: for remaining C2 individuals 
•	C1 – Community Tier 1 – Community Other
Individuals in the community who do not meet F1, C2 or C3 criteria
Slide 13: One Care MassHealth + Medicare
Bringing your care together

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