Provider Manual

Overview of the Senior Care Options Program

What Is The Senior Care Options Program?

The Senior Care Options (SCO) Program is a comprehensive health plan that covers all the services reimbursable under Medicare and Medicaid (MassHealth), and potentially additional benefits, through one organization, Commonwealth Care Alliance, and its preferred network of providers. SCOs were created through a partnership between the Centers for Medicare and Medicaid Services (CMS) and the Commonwealth of Massachusetts/EOHHS. This governmental partnership resulted in a first-in-the-nation Memorandum of Understanding that allowed joint collaboration of the two public payor sources, to deliver and coordinate all components of Medicare and Medicaid health care benefits. This allows the SCO program to offer a comprehensive array of health care and social services.

Key objectives of the SCO program:

Improve the quality and coordination of care provided to seniors
Expand member access to covered services
Maximize member satisfaction with services provided
Increase the cost effectiveness of care
Reduce the likelihood that hospitalizations or nursing home placements will be required
Provide services to individuals across a wide range of health care statuses
Provide alternatives to traditional health care services

Why Would An Elder Be Interested In Enrolling in SCO?

The purpose of the SCO program is to help elders remain as independent as possible by improving the ability to access the most appropriate and necessary services required according to an individual's need. The SCO program allows for a primary care physician (PCP) and/or primary care team (PCT) to coordinate a comprehensive range of health and health-related services that best suits a person's health care needs. SCO PCPs are dedicated to providing a personalized approach to health care so that members, their families, and our network of providers are able to work together efficiently and effectively.

Commonwealth Care Alliance contracts with community health centers and medical group practices that have demonstrated experience with, and a particular commitment to, the populations we serve.

What Are Some Unique Features Of Our SCO Program?

The SCO Program offers important and exciting benefits, including:

An Individualized Care of Care to address a member to address a member's specific care needs
The ability to receive health care and support services in one's community
Comprehensive health care services, including pharmacy, in-home services and long term care supports when the PCP/PCT determines they are needed
Flexibility to remain at home with needed care and supports rather than be admitted (unnecessarily) to a hospital or nursing home
Caring professionals to help ensure that all those involved in providing care are working together as a team to maintain a member's health
24 hour/7 day a week access to a clinician with knowledge about a member's care
Active involvement in care decisions by members and their families

Members have the convenience of a single point contact for any health related problems or questions as well as access to care 24 hours a day, 7 days a week.

Senior Care Options Program Eligibility Requirements

Eligibility

Potential members must be:

At least 65 years old
A Massachusetts resident living in Commonwealth Care Alliance's service area
Enrolled in MassHealth Standard or be dually eligible for Medicare and MassHealth (Medicaid)
Willing to choose a primary care physician (PCP) from Commonwealth Care Alliance's contracted network of physicians
Willing to be assessed by the primary care team (PCT) prior to enrollment

Who Is Ineligible For SCO Enrollment

Individuals with End Stage Renal Disease (ESRD) diagnosis, prior to becoming a Commonwealth Care Alliance member
Residents of an Intermediate Care Facility (ICF) for the mentally retarded
Inpatients in a chronic disease or rehabilitation hospital

Enrollment and Disenrollment

Enrollment

Enrollment in Commonwealth Care Alliance's SCO Program is voluntary. Enrollment is effective on the first calendar day of the month following of the approval of the member's enrollment.

Disenrollment

Disenrollment is effective on the first calendar day of the month following the month in which the notice was received. Until the effective date of disenrollment, the member is required to continue to use Commonwealth Care Alliance's services and obtain all services through Commonwealth Care Alliance and its contracted network of providers and facilities.

Voluntary Disenrollment

Members can voluntarily disenroll any month of the year. Requests for voluntary disenrollment are taken verbally and/or in writing. Verbal requests are recorded in the member database.

In cases where a disenrollment request is due to service and/or quality issues, Commonwealth Care Alliance notifies the member of the right to grieve and/or to appeal any adverse determinations that may have affected the member's decision to disenroll.

Commonwealth Care Alliance's staff, providers, or delegates shall not inappropriately request or encourage a member to disenroll.

Involuntary Disenrollment

Commonwealth Care Alliance will do everything possible to avoid involuntary disenrollment for a member. However, it will be necessary for Commonwealth Care Alliance to terminate benefits if:

The member loses MassHealth eligibility. Benefits will cease on the first day of the following month that a member is no longer eligible for MassHealth
The member remains outside the service area for more than six consecutive months
The Commonwealth Care Alliance program agreement with CMS and MassHealth is not renewed or is terminated
The member is disruptive, abusive, or uncooperative to an extent that membership in Commonwealth Care Alliance's program seriously jeopardizes the provider's safety or the safety of others. Disenrollment on this basis is subject to prior approval by CMS and MassHealth
The member commits fraud or allows another person to use his/her Commonwealth Care Alliance membership card to obtain services

Note: Membership cannot be cancelled due to the status of the member's health.

Provider Notification of New Enrollment

Commonwealth Care Alliance sends each of its primary care sites (PCS) a membership report within the first seven days of enrollment.

The membership report identifies:

New members who have chosen the practice as their primary care site
Existing members with rating category changes
Member disenrollments

Additionally a membership roster is sent as an accompaniment with financial information to each of the PCS by the 15th of each month.

To ensure proper reimbursement, providers are encouraged to monitor the membership rosters carefully. Enrollments are effective the first calendar day of the month.

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Last Updated 1/1/12

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