Coverage Changes Coming to SCO and One Care
Coverage Changes Coming to SCO and One Care
CMS policy updates will affect eligibility, covered services, and authorizations starting January 1, 2026.
Important Coverage Changes Coming to SCO and One Care: What Providers Need to Do Now
CMS policy updates will affect eligibility, covered services, and authorizations starting January 1, 2026.
Beginning January 1, 2026, major changes to Senior Care Options (SCO) and One Care will impact eligibility, service coverage, and payment pathways. Providers should review caseloads now to avoid service disruptions and reimbursement delays.
Effective date: January 1, 2026
Overview
In July, the Centers for Medicare & Medicaid Services (CMS) updated SCO eligibility rules, requiring beneficiaries to have Medicare Parts A and B and MassHealth Standard coverage to qualify for SCO. Separately, the CMS demonstration allowing One Care plans to cover certain non-medical services will end on January 1, 2026.
Below is a summary of what providers need to know and act on now.
Senior Care Options (SCO) Changes
Effective January 1, 2026:
- SCO plans will no longer pay for services for members who are not enrolled in both MassHealth Standard and Medicare Parts A and B.
- MassHealth-covered services will be provided and reimbursed directly through MassHealth.
- Non-MassHealth services (e.g., home care, laundry, chore) may be accessed through the Frail Elder Waiver/ASAP Home Care Program, if the individual is eligible.
- Services will require individual assessment and authorization by Aging Services Access Points (ASAPs).
One Care Changes
Effective January 1, 2026, the following services will no longer be covered by One Care plans:
- Adult Companion
- Chore
- Home Delivered Meals
- Personal Care
- Homemaker
- Laundry
Additional notes:
- One Care members receiving these services should have been notified by their plans.
- One Care plans remain responsible for payment for covered services during the transition.
- Providers with authorization questions should contact their contracted One Care plan or the ASAP, as applicable.
- There are three One Care plans in Massachusetts; Commonwealth Care Alliance (CCA) covers the largest share of members.
CCA-Specific Transition Updates
- CCA is reassessing affected One Care members to identify alternative service options.
- Members who have not yet been reassessed will receive continuity-of-care authorizations through March 31, 2026.
- These authorizations should be issued before January 1, 2026, and agencies will receive updated authorizations directly.
- During the continuity period, CCA will evaluate options such as PCA or GAFC.
- Providers currently serving affected members should receive direct notice from CCA regarding service discontinuation or transition plans.
Provider Action Steps
To prevent gaps in care and billing delays, providers should take these steps now:
- Review your SCO and One Care caseloads for members who may be affected.
- Verify eligibility (MassHealth Standard + Medicare A/B for SCO) and confirm payer pathways.
- Confirm authorizations and document changes with contracted plans and ASAPs.
- Communicate early with patients/families as transitions are identified.
Proactive coordination, documentation, and communication will be essential to maintain continuity of care and ensure timely reimbursement as these changes take effect.
Note: This summary is intended for operational planning and should be used alongside plan communications and MassHealth guidance as updates are issued.