One Care: MassHealth plus Medicare

Program Location: 
Boston, MA
Payer Type: 
Partner Organizations: 
Massachusetts Health and Human Services
Network Health
Commonwealth Care Alliance (CCA)

Reported Outcomes


One Care: MassHealth plus Medicare is designed to improve coordination of services provided to dual eligibles ages 21-64; the majority of whom have extremely complex medical care needs. The One Care program also offers services that are personalized to an individual’s needs and preferences; focus on independent living and community-based supports; improve functional and health outcomes for individuals; and help reduce undesirable cost-drivers such as potentially unnecessary emergency room use, readmissions, facility-based care, and unmanaged chronic diseases. MassHealth's initiative to integrate care and financing for Dual Eligible adults ages 21-64 is a fundamental component of a broader effort in Massachusetts to transform its health care system by restructuring how care is delivered and how providers are reimbursed. The state has requested CMS to incorporate the One Care demonstration into the 1115 waiver, which would then extend the time frame of the demonstration through June 30, 2019

Massachusetts' reform efforts include initiatives to develop patient-centered medical homes, bundled payments, accountable care organizations (ACOs), and pending state legislation to promote a multi-payer transition to the use of ACOs and alternative payment methodologies. Through these initiatives, Massachusetts seeks to ensure access to appropriate services, integrate comprehensive services at the person level, improve care coordination across the health care and long term support delivery systems, and create payment systems that hold providers accountable for the care they deliver. Massachusetts aims to reward quality care, improve health outcomes, and more effectively spend health care dollars.


Payment Model: 

As part of this initiative, CMS and the Commonwealth will test a new Medicare and Medicaid payment methodology designed to support Participating Plans in serving Medicare- Medicaid Enrollees in the Demonstration. Participating Plans will have full accountability for managing the integrated blended capitated payment to best meet the needs of Enrollees according to Individualized Care Plans developed using a person-centered planning process. For more information on the payment model, review Appendix 6 in the approved CMS contract. 

Fewer ED / Hospital Visits: 
  • Beneficiaries in the demonstration group experienced a small decline in the number of preventable ED visits per 1,000 eligible months from the baseline to the demonstration period (146.9 to 134.2 visits). 
  • Beneficiaries who were enrolled in the demonstration had fewer preventable ED visits per 1,000 eligible months than those who did not enroll (116.1 to 130.2 visits, respectively). 

Last updated March 2019
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