§ 9F — Duals demonstration; review of request for financial solvency

[Text of section added by 2012, 118, Sec. 25. See also, Section 9F added by 2012, 224, Sec. 117.]

Section 9F. (a) The secretary of health and human services may establish, subject to appropriation, all required federal approvals and agreements and the availability of federal financial participation a demonstration to integrate care for dual eligible individuals program, hereinafter referred to as the duals demonstration, for residents, aged 21 to 64 at the time of enrollment, who are dually eligible for benefits under MassHealth Standard or CommonHealth and Medicare under Title XVIII of the Social Security Act and do not have any additional comprehensive health coverage. Under the duals demonstration, the executive office, jointly with the Centers for Medicare and Medicaid Services, shall contract with dual eligible integrated care organizations, hereinafter referred to as ICOs, to provide integrated, comprehensive Medicaid and Medicare services, including medical, behavioral health and long-term support services for a prospective blended payment from the executive office and the Centers for Medicare and Medicaid Services.

(b) Notwithstanding any general or special law to the contrary, the secretary of health and human services may review a request for financial solvency certification by a care delivery organization based in the commonwealth applying to serve as a Medicare plan caring for residents who are dually eligible for Medicare and Medicaid. Upon determination that appropriate financial standards, which may be the standards already in place for organizations with contracts pursuant to this section, have been met, the secretary shall so certify to the centers for Medicare and Medicaid services. Said secretary may require the requesting organization to pay a reasonable certification fee.

(c) No contract to provide ICO services under this section shall constitute the business of insurance and no such plan shall be subject to chapters 175 to 176O, inclusive. Nothing in this subsection shall affect the legal status or obligations under said chapters 175 to 176O, inclusive, of any entity otherwise constituting or conducting the business of insurance for any other purpose.

[Text of section added by 2012, 224, Sec. 117. See also, Section 9F added by 2012, 118, Sec. 25.]

Section 9F. (a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

''Dual eligible'', or ''dually eligible person'', any person age 21 or older and under age 65 who is enrolled in both Medicare and MassHealth.

''Integrated care organization'' or ''ICO'', a comprehensive network of medical, health care and long-term services and supports providers that integrates all components of care, either directly or through subcontracts and has been contracted with by the executive office of health and human services and designated an ICO to provide services to dually eligible individuals under this section.

(b) Members of the MassHealth dual eligible pilot program on ICOs or any successor program integrating care for dual eligible persons shall be provided an independent community care coordinator by the ICO or successor organization, who shall be a participant in the member's care team. The community care coordinator shall assist in the development of a long-term support and services care plan. The community care coordinator shall:

(1) participate in initial and ongoing assessments of the health and functional status of the member, including determining appropriateness for long-term care support and services, either in the form of institutional or community-based care plans and related service packages necessary to improve or maintain enrollee health and functional status;

(2) arrange and, with the agreement of the member and the care team, coordinate appropriate institutional and community long-term supports and services, including assistance with the activities of daily living and instrumental activities of daily living, housing, home-delivered meals, transportation and, under specific conditions or circumstances established by the ICO or successor organization, authorize a range and amount of community-based services; and

(3) monitor the appropriate provision and functional outcomes of community long-term care services, according to the service plan as deemed appropriate by the member and the care team; and track member satisfaction and the appropriate provision and functional outcomes of community long-term care services, according to the service plan as deemed appropriate by the member and the care team.

(c) The ICO or successor organization shall not have a direct or indirect financial ownership interest in an entity that serves as an independent care coordinator. Providers of institutional or community based long-term services and supports on a compensated basis shall not function as an independent care coordinator; provided, however, that the secretary may grant a waiver of this restriction upon a finding that public necessity and convenience require such a waiver. For the purposes of this section, an organization compensated to provide only evaluation, assessment, coordination, skills training, peer supports and fiscal intermediary services shall not be considered a provider of long term services and supports.