BMC Healthnet Plan and Accountable Care Organizations Frequently

BMC HealthNet Plan and Accountable Care Organizations

Frequently Asked Questions

1 What are Accountable Care Organizations?

2 What is an Accountable Care Organization (ACO)?

ACOs are provider-led organizations that coordinate care, have an enhanced role for primary care, and are rewarded for value – improving total cost of care and outcomes – not volume

The primary focus is on improving patient outcomes by:  Promoting healthy behaviors  Expanding population health management programs  Improving data exchange between payers and providers

3 What is an Accountable Care Organization (ACO)?

ACOs are designed to help patients manage their illnesses and reduce health care costs by preventing unnecessary or duplicative testing, reducing preventable admissions to the hospital and reducing emergency department utilization.

ACOs are “accountable” for managing the health of a population of patients/members. Performance is measured using identified quality metrics and reductions in the total cost of care.

4 What is an Accountable Care Organization?

MassHealth Members have three types of health plan options: • Accountable Care Organizations – Accountable Care Partnership Plans (Model A) – Primary Care ACOs (Model B) – MCO-administered ACO (Model C)

• Managed Care Organizations Effective March 1, 2018, MassHealth contracts with only two MCOs: BMCHP and Tufts Health Public Plans.

• Primary Care Clinician Plan

Why are we moving to an ACO for Medicaid (MassHealth) enrollees?

The Affordable Care Act encouraged the development of ACOs, and states across the country are implementing them for governmental programs like Medicare and Medicaid and under commercially insured health plans.

In Massachusetts, transitioning to ACOs is expected to improve patient care and coordination for our most vulnerable patients while also helping to control MassHealth costs, which have grown to over 40% of the State budget.

6 Model A: Accountable Care Partnership Plan (ACPP)

An ACPP has an exclusive group of PCPs from whom all members receive their primary care.

Partnership Plans are paid a capitated rate for attributed members and are at risk for savings and losses beyond the capitation rate.

Partnership Plans must meet all of MassHealth’s requirements for managed care organizations, including capital reserves and other financial considerations. But it also must meet the requirements for ACO, including provider-led governance and Health Policy Commission (HPC) ACO certification.

7 Model A: Accountable Care Partnership Plan

These are the MassHealth (Model A) APCCs: MCO or ACO name Name of Plan affiliated with Plan BMC HealthNet Community Alliance BMC HealthNet Plan BMC HealthNet Mercy Alliance BMC HealthNet Plan BMC HealthNet Signature Alliance BMC HealthNet Plan BMC HealthNet Southcoast Alliance BMC HealthNet Plan Berkshire Health Collaborative Fallon Health Fallon 365 Care Fallon Health Wellforce Care Plan Fallon Health BeHealthy Partnership Health New England Merrimack Valley Health Partnership Neighborhood Health Plan Tufts Together with Atrius Health Tufts Health Plan

Tufts Together with Boston Children’s ACO Tufts Health Plan Tufts Together with BIDCO Tufts Health Plan Tufts Together with CHA Tufts Health Plan Tufts Together with CMACO Tufts Health Plan

8 Model B: Primary Care ACO

A Primary Care ACO contracts directly with MassHealth and has an exclusive group of Primary Care Clinicians (PCCs) from whom all members receive their primary care.

Unlike a managed care organization or the ACPP, Primary Care ACOs are not paid a capitation to provide services. Instead, their attributed members receive care from MassHealth’s fee-for-service network providers.

The Primary Care ACO is accountable through shared savings and losses based on the Total Cost of Care (TCOC) and quality performance.

9 Model B: Primary Care ACO

These are the MassHealth (Model B) Primary Care ACOs:

Name of Plan MCO or ACO name affiliated with Plan

Community Care Cooperative (C3) Community Care Cooperative

Partners HealthCare Choice Partners Health Care

Steward Health Choice Steward

10 Model C: Managed Care Organization (MCO) Administered ACO

• An MCO-administered ACO is part of the primary care network for one or more MassHealth MCOs. A MassHealth MCO may contract with one or more MCO-administered ACOs. • Each MCO-administered ACO has an exclusive group of participating PCPs. Members attributed to an MCO-administered ACO receive their care from their MCO’s network, which is paid for directly by the MCO. • MCO-administered ACOs are accountable to their MCOs through shared savings and losses payments. • MassHealth must approve the financial arrangements and the associated requirements in the contracts between an MCO- administered ACO and its MCOs to be eligible for DSRIP (Delivery System Reform Initiative Payments).

11 Model C: MCO Administered ACO

At this time, Lahey Health is the only Model C ACO

12 BMC HealthNet Plan’s ACO Alliances: PCP Considerations

13 BMC HealthNet Plan has formed ACPP alliances with these health care entities

BMCHP BMCHP BMCHP BMCHP Community Signature Mercy Southcoast Alliance Alliance Alliance Alliance

14 Can primary care providers be in More than one ACO?

Primary care providers may enroll only in one ACO.

Non-PCP (specialists, facilities, ancillary services etc.) participation is not limited by ACO participation.

There is no need for a new contract for non-PCP services. Providers will remain contracted under their current MCO Agreement.

15 How will patients/members be affected?

16 What are the benefits and protections for members who are being shifted to the new ACO model?

The core covered benefits will be the same for both ACO and MCO members. There may, however, be additional services or programs offered by each ACO.

ACO members have the same protections and rights under the ACO program as they currently have under the MCO program.

17 What are the benefits and protections for members who are being shifted to the new ACO model?

The ACO model is expected to improve quality and patient experience by: • Integrating the full spectrum of care, including medical care, behavioral health and long-term services and supports (LTSS) • Providing clinical and community based support for populations with behavioral health and long-term health care needs • Shifting incentives to hold providers accountable for quality and total cost of care for their MassHealth patients • Allowing for innovative ways of addressing social determinants of health • Expanding access to substance use disorder treatment, including treatment for co-occurring disorders

18 Does the ACO follow MassHealth FPL guidelines for member eligibility or new guidelines?

The determination of MassHealth eligibility, which is defined by the Affordable Care Act requirements and guidelines, remains MassHealth’s sole responsibility.

Neither the ACO nor BMC HealthNet Plan is responsible for member eligibility determinations.

Will providers be able to verify eligibility and benefits on the existing BMC HealthNet Plan website?

Yes. We will continue to use the same member eligibility verification system.

20 Will members receive new member ID cards? Will the ID card indicate their new ACO?

Yes. All ACO members will receive a new ACO member ID Card. Their assigned ACO will be indicated on the new ID card.

Here is a sample of the card’s front and back:

What will the new member IDs look like for our ACO members?

ACO member IDs will have new number sequencing according to the ACO they are assigned to, as shown below:

ACO Prefix ID Numbering Scheme (note: the 00 is the suffix for all subscribers and will be on the ID card)

BACO 2 2#########00

MERCY 3 3#########00

SIGNATURE 4 4#########00

SOUTHCOAST 5 5#########00

When will members be notified of changes to their existing enrollments?

• The MassHealth ACO program operational start date/member enrollment effective date is March 1, 2018. • MassHealth began mailing special assignment* letters and enrollment guides to members from November 13, 2017 to December 22, 2017. • The member notices instruct members of their option to change their ACO Special Assignment by letting MassHealth know before March 1, 2018. • After March 1, 2018, members will have a ‘Plan Selection Period’ until May 31, 2018 to try out their assigned ACO plan, and can change their ACO for any reason. • As of June 1, 2018, members will be in a ‘Fixed Enrollment Period’ for the duration of the contract year. *See slide 25 for special assignment description

When will members be notified of changes to their existing enrollments?

Certain exceptions to the “fixed enrollment” will apply based on members who experience certain designated situations (e.g., member moves out of Massachusetts, member’s PCP leaves the ACO).

In addition, certain members (e.g., children under age 1 and members in DCYF custody) do not have a Fixed Enrollment Period and can change their health plan any time of the year.

Members must go directly to MassHealth to request a change in their health plan enrollment or a change in their ACO.

24 What is “special assignment”?

Special assignment is based on keeping members with their current PCP to the extent possible.

Members whose PCPs are joining an ACO will be “special assigned” to the ACO that the member’s PCP joined.

25 What is “Auto Assignment”?

Auto-assignment is when BMC HealthNet Plan assigns the member to a PCP.

A member will be auto-assigned a PCP if one of the following is true: • The member cannot be “special assigned” to a PCP • The member has not proactively chosen to enroll in an ACO, MCO or the Primary Care Clinician (PCC) plan • The member is in an MCO that is not available to members after January 1, 2018.

(continued)

26 What is “Auto Assignment”? (continued)

Auto-assignment in Rate Year 2018 will be apportioned among/across ACOs and MCOs based on the value that an entity delivers to members and the Commonwealth; value will be reflected by factors such as the following:

• An entity’s administrative per-member-per-month rate • An entity’s network variance factor, which informs the capitation rate or total cost of care benchmark for the entity prior to risk adjustment • EOHHS’s determination that the entity meets a threshold of compliance and quality performance

27 Member Assignment Scenarios:

Special Letter ID PCP Movement Assignment Logic Message

MassHealth PCP joins Model A Special Assignment Member follows Your current PCP has joined a Partnership Plan Model A PCP to Model A ACO. You will be enrolled in this ACO and 1 continue receiving care from your PCP. Please contact MassHealth if you’d like to make a different choice.

MassHealth PCP joins Model B Special Assignment Member follows Your current PCP has joined a Primary Care PCP to Model B ACO. You will be enrolled in this ACO and Model B 2 continue receiving care from your PCP. Please contact MassHealth if you’d like to make a different choice.

MassHealth PCP joins Model C Special Assignment Member is Your current PCP has joined an MCO. You will be enrolled in this MCO and continue Model C 3 enrolled in an MCO, and MCO receiving care from your PCP. Please contact MassHealth if you’d like to make a is informed of different choice. PCP affiliation

Use auto- Your MCO is leaving MassHealth. You will MassHealth AE MCO is no longer available and PCP did not Auto Assignment assignment automatically be enrolled in a new health join an ACO algorithm to plan beginning on 3/1/18. Please contact place member MassHealth if you would like to make a different choice.

MassHealth Other PCP movements No Member is Your plan selection period is beginning Plan enrollment assigned a new on 3/1/18. Please contact MassHealth if Selection change PCP if needed you’d like to change plans. Period

Under what circumstances are members allowed to receive care from providers outside of their ACO?

Members may receive care outside of their ACO in the following situations:

• Members will have a PCP in the ACO and must use that PCP for all primary care. • The PCP will make efforts to direct members to specialists and other providers within the ACO or with whom there is an established relationship. • However, members may go to any contracted specialist/other provider within the BMC HealthNet Plan network – subject to the specialist/provider obtaining a prior authorization for the service, if applicable.

Under what circumstances are members allowed to receive care from providers outside of their ACO?

• If the care needed by the member is not available within the ACO or within BMC HealthNet Plan’s contracted provider network, we may authorize the member to see an out-of-network (non-contracted) provider.

• Members may go to any provider (in-network or out-of-network) for emergency services (within the U.S. and its territories) or urgent care.

• At the time new members join the ACO, they may be authorized for a limited time to continue to see a provider who has been delivering services to them. This could be a provider within or out of the BMC HealthNet Plan statewide network. This is referred to as Continuity of Care. It applies, for example, to pregnant members or those needing continuing care for chronic conditions.

30 Can patients sign up for an ACO plan on BMC HealthNet Plan’s website?

No. Members must go directly to MassHealth to sign up for an ACO Plan. To change health plans or get more information, they can go to: Online resources: – Learn more about your health plan options at masshealthchoices.com – Change your health plan at mass.gov/masshealth – Read about health plans at mass.gov/masshealth in the Enrollment Guide Mail or fax: – Fill out the enrollment form in the Enrollment Guide and mail or fax it to: MassHealth Program P.O. Box 120045 Boston, MA 02112-0045 Fax 617-988-8903

Can patients sign up for an ACO plan on BMC HealthNet Plan’s website or what’s the location/s?

In person: • Attend one of the enrollment events where MassHealth customer service representatives will be on hand to help • Talk to a Certified Application Counselor or Navigator who can also help with your application. To make an appointment go to mahealthconnector.org/help-center . Then click the “Find an Enrollment Assister” button. • Visit a MassHealth Enrollment Center (MEC) to ask in person. See the Member Booklet for a list of MEC addresses.

By phone: • Call: 1-800-841-2900 (TTY: 1-800-497-4648).

32 To what extent is a provider able to assist a patient in deciding what ACO to join?

Members should be directed to MassHealth for ACO guidance; however, it is appropriate for you, as the PCP, to make the patient aware of your ACO affiliation.

Will there be anyone reviewing patient panels to ensure that patients are assigned to the correct PCP?

BMC HealthNet Plan provides panel reports at least monthly, but the report can be requested on demand. Providers should review their panel reports on a regular basis to confirm accuracy and inform us of any discrepancies.

33 Provider Network, Prior Authorization and Out-of-Network Utilization

BMC HealthNet Plan’s provider network

Members will have a PCP in the ACO and must use that PCP for all primary care.

BMC HealthNet Plan’s full network of contracted facilities, specialists and ancillary services is available to ACO members.

35 Does being in an ACO affect the insurance types I accept for MassHealth patients?

If MassHealth patients have a PCP at your site, they will be auto- assigned or will need to elect to be in an ACO to maintain their patient/PCP relationship.

Some patients may choose a different health plan product other than ACO and will have a PCP not affiliated with us.

For example: If you’re a PCP for a patient with a different MassHealth health plan product, the patient will be re-enrolled by the State in our ACO this fall so they will continue to see you for primary care.

36 Does being in an ACO change my patient panel or practice patterns?

You will continue to provide primary care to a panel of patients. Your panel may change in the beginning due to some patients under age 65 choosing to be part of the ACO while others may choose to join a different MassHealth health plan product.

Patients will be able to make changes to their PCP/ACO for 90 days following their enrollment. After the 90 days, individuals generally cannot change health plans until the Plan Selection Period for the following year. Therefore, during the first year of the ACO, your MassHealth patient panel should not change significantly after June 2018.

37 Can a PCP practice as a PCP at another ACO? (e.g., Mattapan and Signature)

No. PCPs may belong only to one ACO.

Can a PCP practice at multiple health centers within the ACO? (e.g., Mattapan and Codman)

Yes. A PCP can practice at multiple sites or health centers within the ACO; however, they should only see their primary members at PCPs affiliated or assigned primary site.

What about urgent care or walk-in care?

If a site has an established Urgent Care Center, it can see any member, but the urgent care must be separate and apart from the primary care practice. Members should be encouraged to see their PCPs whenever possible.

If no providers in the BMC HealthNet Plan network can deliver a particular service, will an authorization be provided for outside network providers?

Yes. If a member requires services that cannot be provided by a BMC HealthNet Plan-contracted provider, we will (if medically necessary) authorize the member to see an out of network (non-contracted) provider.

If there is no qualified/appropriate specialist in the entire BMC HealthNet Plan provider network, we may (if medically necessary) authorize the member to see an out-of-network (non-contracted) provider.

If a patient is seen outside the ACO network, will the patient be fully responsible for costs or will BMC HealthNet Plan pay for those services?

• If the patient receives care outside of the ACO but within the BMC HealthNet Plan statewide network, the network provider will be paid at the BMC HealthNet Plan-contracted rate and the member will not be responsible for costs related to this care except for any applicable cost sharing (e.g., copays). (Note: Currently for MassHealth there are no member copays for any services or supplies, except for pharmacy). • If the patient receives authorized care from an out-of-network provider, BMC HealthNet Plan usually pays the provider the MassHealth fee-for- service rate, except in certain cases where payment is negotiated with the out-of-network provider. • If the patient receives unauthorized care from an out-of-network provider, the patient may be responsible for the costs of those services.

40 What services need referrals (if any) and/or prior authorization? Where can patients and providers find this information?

BMC HealthNet Plan does not require referrals.

We do, however, have prior authorization requirements for select services that are outlined in the Prior Authorization (PA) Matrix and the prior authorization lookup tools at: bmchp.org/providers/authorizations/check-service

What services need referrals (if any) and authorizations? Where can patients and providers find this information (BMC HealthNet Plan website or other)?

Prior Authorization is required for the following services: • Inpatient care (non-emergent) • Select outpatient procedures • High end outpatient radiology • Home health care • Durable medical equipment, prosthetics, orthotics and supplies • Physical, occupational and speech therapy (outpatient) • Genetic testing • Transplants • Select behavioral health services • All non-emergent out of network services

42 Boston Medical Center redirection process

In an effort to drive as much care as possible to Boston Medical Center (BMC), prior authorization is required for specialists affiliated with the following facilities, which are within the general geography of BMC: • Beth Israel Deaconess Medical Center (all locations) • Steward Carney Hospital • Steward St. Elizabeth’s Medical Center • Tufts Medical Center

Prior Authorization to see a specialist affiliated with one of these hospitals will be granted only when: • The specialty care you need is not available from a specialist affiliated with Boston Medical Center, or • The PCP and specialist are both affiliated with one the facilities identified above.

43 Continuation of care

Upon enrollment into an MCO or Partnership Plan ACO, all new members are eligible for a 30-day continuity of care period. During this time, new members may continue to see their current providers (including network providers) for medically necessary services for at least 30 days after the effective date of enrollment with the new plan.

This includes members who, at the time of their enrollment, are pregnant, have significant health care needs or complex medical conditions, have autism spectrum disorder, are receiving services such as dialysis, home health, chemotherapy and/or radiation, are hospitalized, have received treatment for behavioral health or substance use disorder, or have received prior authorization for services.

44 Community Partner Program

45 Principles and Goals of the Community Partner (CP) Program*

• Create opportunity for ACOs and MCOs to leverage the expertise and capabilities of existing community-based organizations serving populations with behavioral health and long term services and supports needs • Invest in infrastructure and capacity to overcome fragmentation among community-based organizations • Improve member experience, continuity and quality of care by holistically engaging members with high behavioral health needs (serious mental illness, serious emotional disturbance, substance abuse disorder) and complex long term services and supports needs • Improve collaboration in order to break down existing silos and deliver integrated care

*Materials from the MassHealth ACO Meeting on CPs and Quality 7.13.17 (continued)

46 Principles and Goals of the Community Partner (CP) Program* (continued)

• Support ACOs and MCOs in achieving their care coordination and care management objectives • Support members with high behavioral health needs, complex long term supports and services needs – and their families – to help them navigate the complex system of behavioral health and long term services and supports care in Massachusetts • Invest in the continued development of behavioral health and long term services and supports infrastructure (e.g., technology, information systems) that is sustainable over time • Support values of Community First, Substance Abuse and Mental Health Services Administration recovery principles, independent living, and cultural competence

*Materials from the MassHealth ACO Meeting on CPs and Quality 7.13.17

47 ACOs and MCOs will contract with community partners for the purposes of integrated care delivery

• MCOs and Accountable Care Partnership Plans must partner with all behavioral health community partners in the service areas in which the ACO or MCO operates and vice-versa.

• MCOs and Accountable Care Partnership Plans must partner with at least two long term services and supports community partners in the service areas in which the ACO or MCO operates.

48 Who will community partners serve?

Behavioral health community partners will serve a population with high behavioral health needs and include: • ACO and MCO-enrolled members age 21 and older with serious mental illness and/or substance use disorder and high service utilization • For members < 21 years of age with serious emotional disturbance, existing Community Service Agencies (CSAs) under the Children’s Behavioral Health Initiative (CBHI) will continue to provide Intensive Care Coordination (ICC) services for such members. • Members 18-20 with substance use disorder diagnosis and high utilization will be eligible for behavioral health community partners supports, if requested. • Members with co-occurring behavioral health and long term services and supports needs will be offered behavioral health community partners supports. Only assignment to a single CP is permitted.

49 Who will community partners serve?

Long term services and supports (LTSS) community partners will serve a population with complex LTSS needs and include:

• ACO and MCO-enrolled members ages three and older • Members with complex LTSS; members with brain injury or cognitive impairments; members with physical disabilities; members with intellectual or developmental disabilities, including Autism; older adults eligible for managed care (up to age 64); and children and youth with LTSS needs

50 What will community partners do for members?

Behavioral health community partners function: comprehensive care management

• Outreach and engagement • Comprehensive assessment and person-centered treatment planning • Care coordination & care management, including across medical, behavioral health and long term services and supports • Care transitions • Medication reconciliation • Health and wellness coaching • Connection to social services and community resources, including flexible services

51 What will community partners do for members?

Long term services and supports (LTSS) community partners functions: LTSS care coordination

• Outreach and engagement • LTSS care planning, including choice counseling • Care team participation • LTSS care coordination • Support for transitions of care • Health and wellness coaching • Connection to social services and community resources, including flexible services

52 How will BMC HealthNet Plan and the ACO manage the community partners relationships?

Behavioral Health Community Long Term Services and Supports Partners Community Partners

Beacon will work with BMC HealthNet BMC HealthNet Plan will hold Plan to contract with the behavioral contracts with long term services health community partners on behalf and supports community partners of the ACO. on behalf of the ACO.

Beacon will lead the development of BMC HealthNet Plan will lead the Exhibit of Documented Processes to development of Exhibit of take place between the ACO and Documented Processes to take community partners. place between ACO and community partners.

53 Who are BMC HealthNet Plan’s clinical vendors?

Beacon Health Strategies • Available 24/7 for members and providers.

Behavioral Health • Manages inpatient and outpatient behavioral health and substance use services, and will be contracting on behalf of the ACO for BH Community Partner services.

• Prior authorization may be required for certain services.

Northwood • Manages durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) network. Durable Medical Equipment, Prosthetics, and Orthotics • Prior authorization is required for all DMEPOS dispensed and billed by a DMEPOS supplier.

EnvisionRx Options • Prior authorization may be required for certain medications.

Pharmacy Benefits

eviCore • Manages outpatient non-emergency high end radiology (MRI, CT, PET, Nuclear Cardiology) High End Radiology • Prior authorization may be required for certain services.

AxisPoint Health • Available 24/7 for members

Nurse Advice Line • An audio health library of recorded information, by topic, can be accessed through the advice line