SCO (Senior Care Options), is sometimes referred to as "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 the Senior Care Options 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. Specific Senior Care Options plans that eligible seniors may choose are referred to as “SCO Plans” throughout this Q&A.
1. What do SCO Plans cover?
SCO Plans cover all the services the member currently receives under MassHealth and/or Medicare (if applicable). SCO Plans also cover 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 covered in the health-care plan.
2. What are the criteria for becoming a member of an SCO Plan?
To become a SCO Plan 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 Plan.
3. 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 a SCO Plan?
Once a MassHealth member enrolls in a SCO Plan, payment for services is made only by the SCO Plan. You can continue to provide services to your patients who enroll in a SCO if you are in the SCO Plan’s network of providers. You do not need to be in a SCO network to be paid for providing emergency services to a SCO Enrollee.
4. How can I determine if a patient is enrolled in a SCO Plan?
When you verify a MassHealth member's eligibility through EVS (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 Plan name): xxx-xxx-xxxx." SCO plans provide health plan cards to all enrolled members.
5. If I treat a SCO Plan member for an emergency, how do I get paid?
Emergency services provided to a SCO Plan member will be paid by the SCO Plan. The SCO Plan member's authorized representative or provider must notify the SCO Plan of the emergency as soon as possible.
6. If I do not have a contract with the member's SCO Plan, other than emergencies, are there any circumstances when I would be paid for services provided to a SCO Plan member?
In some circumstances, the SCO Plan will authorize specific services from a non-contracted or out-of-network provider. For example, a SCO Plan may authorize and pay for health-care services delivered by a non-contracted provider if a contracted provider was not available to treat the SCO Plan member or if the member is temporarily out of the SCO Plan’s service area.
7. 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.
8. Will all MassHealth members aged 65 or older be required to join a SCO Plan?
No. Enrollment in a SCO Plan is voluntary but enrollment in a SCO Plan does offer seniors a variety of benefits such as individualized, managed, and supportive care services to assist them with their health care.
9. Are SCO Plans available statewide to MassHealth members?
SCO Plans are currently available throughout Massachusetts except for certain locations in the Berkshires and the Islands. We hope to make the option available to these areas in the near future.
10. Do SCO Plans replace MassHealth as the secondary insurer when a member has Medicare Parts A and B? Do SCO Plans replace crossover claims?
SCO Plans provide and pay for all of the services covered by Medicare Parts A and B and MassHealth Standard. There is no primary or secondary insurer. There are no fee-for-service payments, service exclusions, or crossover claims.
11. How will Medicare Part D affect SCO Plan patients?
It is not necessary for SCO Plan members to sign up for Medicare Part D, as the SCO Plan they belong to provides coverage of all drugs and pharmacy services covered under Medicare Part D. If a SCO Plan member signs up for Medicare Part D, they will be disenrolled from the SCO Plan they are currently enrolled in.