CommonwealthCare

Commonwealth Care / MMCO Key Contract Terms – Contract Year 2009

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Summary

• In December, 2007, the Connector began a bid process to establish the capitation rates for FY 2009

• In addition to new capitation rates and risk sharing provisions, staff negotiated a number of language revisions to the current contract

• This was the first comprehensive bid process since initial bidding in Sept. 2006

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Key Contractual Goals

• Ensure continued development of strong care and utilization management programs

• Strengthen program integrity

• Simplify plan type choices to meet the needs of enrollees

• Continue to refine program to be more commercial-like, especially at higher income levels– Open enrollment process and member choice

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FY09 Specific Contract Changes

• Provision for a full contract review and a claims and care management audit

• Provision regarding exclusivity arrangements between MMCOs and Providers

• MMCOs must make best efforts to provide member orientation to the health plan and to encourage the completion of an HRA (Health Risk Assessment)

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FY09 Specific Contract Changes (continued)

• Interim sanctions for a contract breach– Allows Connector to impose penalties, including

financial, that are less severe than contract termination

• Elimination of Plan Type IV (the lower co-pay/higher premium option available to members >200-300% of poverty)

• Newly agreed-upon capitation rates and risk-sharing provisions previously discussed with the Board

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FY09 Specific Contract Changes

• Quarterly interim settlement provision for Plan Type I only

• Co-pay accumulator must be implemented by July 1, 2008

• Allows health plan to track co-pays across services (pharmacy and all others) for the purpose of calculating Member Out-of-Pocket Maximums

• DoI-approved licensure requirements with specific timelines identified

CommonwealthCare

Open EnrollmentApril 2008

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Open Enrollment

• About to embark on first open enrollment where members will be experiencing a change in their premiums due to bid process

• During open enrollment (and for a lengthy period after that time) members can change their plan for any reason

• Extensive information and support will be provided to members to facilitate this process

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Lowest Cost Commonwealth Care Health Plan SFY09

Annual Gross Income Range Lowest Cost Plan*

Starting Point End Point (FPL%) FY08 FY09Change

from 2008

$0 $15,612 (150%) $0 $0 $0

$15,613 $20,808 (200%) $35 $39 +$4

$20,809 $26,016 (250%) $70 $77 +$7

$26,017 $31,212 (300%) $105 $116 +$11

* If member chooses a health plan other than the lowest cost plan they will pay: - Incomes 100 – 150%: 50% of cost difference (for FY09 only) - Incomes above 150% FPL: 100% of cost difference

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Enrollee Contributions

• Premium-paying members will have a range of experiences – Based on current MCO, plan type and service area, there

will be decreases as well as increases

• Based on premium paying member’s plan selection as of March 1, 2008:– 34% of members will see no change– 18% will pay less– 22% will pay less than $5.00 more– 15% will pay less than $50.00 more– 11% will pay more than $50.00

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Implementation

• Staff are working very closely with the plans and vendors to ensure a smooth transition

• Focused on two key areas:– Network Capacity (PCPs & Specialists)– Ensuring continuity of coverage & care– Working with plans on how to best

manage possible continuity of care issues

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Open Enrollment 2008

• May 1 – June 13 • Any Commonwealth Care member who

lives in an area that offers more than one health plan can change their health plan for any reason by: – Completing the Open Enrollment Health Plan

Change Request form or – Calling the Commonwealth Care Customer

Service Center (1-877-MA-ENROL)

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Open Enrollment Materials

• Each premium-paying member will receive a– Letter explaining the process– Notice of the co-pay changes– A form with their plan options (and

costs)– Comparison grid for the plans in their

area

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Methods of Communication

• Invoice Messaging beginning 3/31• MCO Mailings - weeks of 4/21 and 4/28 • Open Enrollment Packets – week of 4/28• Website 4/11

– Open enrollment page• Emails 4/11

– ‘Blasting’ to CommCare distribution list• April Presentations

– Staff will be going statewide to discuss the program changes and member options

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Member Support

• Call Center is adding additional staff both in Boston and the overflow center

• Specific call scripts are being drafted that focus on– Helping the PT4s transition to PT3– Explaining why there are cost differentials

between plans– Guidance understanding the cost changes (co-

pays and enrollee contribution)

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Member Support

• Members in PT2A who fail to pay their premiums will be disenrolled to the lowest cost plan in their region

• Plan Type 4 conversions– No action required by the member unless they

want to change their health plan– If no action is taken, member will automatically

transition to the same health plan in PT3

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Member Support con’t

• Members will also be allowed an additional 60 days (July and August) to change plans – Implementing this one-time process to

facilitate changes and support members– Provides members the opportunity to stay with

their existing provider should they want to complete a course of treatment

– Will be developing the specifics around the process over the next few weeks

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Plan Management

• Will be watching outcomes of open enrollment closely

• Working with plans on resolution of issues (and will make sure they don’t become systematic)

• Contract language will support changes– Access, wait times, ratios– Supports existing network expansion (in those

areas where appropriate)– Stop exclusive provider contracts

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Caseload Activity

• We have completed the second month of redetermination closings– Starting to analyze the data from this

initial group– Experience is similar to the prior months