Overview of the Virginia Medicaid Program

http://dmasva.dmas.virginia.govDepartment of Medical Assistance Services

Virginia Association of Area Agencies on Aging Emily Osl CarrDirector, Office of Coordinated Care October 17, 20131OverviewCurrent structure of Medicare/Medicaid

History of Integrated Care in Virginia

Commonwealth Coordinated Care (CCC)

2

2Medicare-Medicaid Enrollees?Receive both full benefit Medicare and Medicaid coverage58.8% age 65 or older41.2% under age 65Often have multiple, complex health care needs.

Over 9 million Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees)

3Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from 2006-2011. February 2013.

3Who are Medicare-Medicaid enrollees?Individuals who have a unique set of circumstances, care and support needs, options and opportunities under a coordinated care system

Individuals who receive full benefit Medicare and Medicaid coverage

4

Medicare and Medicaid today5Medicare and Medicaid are not designed to work together resulting in an inefficient, more costly delivery systemCosts of serving individuals on Medicare and Medicaid are rising exponentially Each program has its own set of rules, regulations, requirements and coverage

*We cant afford to continue to support rising costs without intervention*

Medicare and Medicaid todayThe costs of serving these individuals are rising exponentially:

1K. Young, et al. Medicaids Role for Dual Eligible Beneficiaries. Kaiser Commission on Medicaid and the Uninsured, April 2012.At the national level; spending 40% of Medicaid funds on 15% of the Medicaid population1In Virginia; spending 33% of Medicaid funds on 19% of the Medicaid population267

Who pays for what services in Virginia? MEDICAREHospital carePhysician & ancillary servicesSkilled nursing facility (SNF) care (up to 100 days)Home health careHospicePrescription drugsDurable medical equipmentMEDICAIDHospital once Medicare benefits exhaustedHome- and community-based services (HCBS)Nursing facility (once Medicare benefits exhausted)Optional services: personal care, select home health care, rehabilitative services, some behavioral healthSome prescription drugs not covered by MedicareDurable medical equipment not covered by Medicare

88What does care look like for Medicare-Medicaid enrollees now?WITHOUT COORDINATED CARE INDIVIDUALS MAY HAVE:Three ID cards: Medicare, Medicaid, and prescription drugsThree different sets of benefitsMultiple providers with limited means of coordination Health care decisions that are not coordinated and not made from the person-centered perspective 99Challenges for IndividualsUnderstanding two programsConfusion with billingMultiple insurance cardsNot knowing who to call with questionsFrustration over delays, getting care and supportLack of holistic care

10

Fragmented

Not Coordinated

Complicated

Difficult to Navigate

Not Focused on the Individual

Gaps in CareWhat Does the Medicare-Medicaid Benefit Look Like Now?Like navigating a traffic circle.11History of Integrated Care in Virginia2006: DMAS released the Blueprint for the Integration of Acute and Long Term Care Services2009: DMAS planned to launch VALTC; however, due to budget constraints, provider resistance, and other limitations, did not move forward with initiative2010: DMAS applied for CMS State Demonstrations to Integrate Care for Dual Eligible Individuals and was not one of the 15 states accepted2011 & 2012: Legislature directed DMAS to develop and implement a care coordination model for Medicare-Medicaid enrollees2011: DMAS sent Letter of Intent to participate in CMS Financial Alignment Demonstration2014: Virginia to launch Commonwealth Coordinated Care

12Developed rates in 2008 that were not sufficient to interest plans (only Medicaid $)

No state plan personal care services

Stringent Long-Term Care Criteria: 4 ADLs plus medical nursing need

Lack of reimbursed care coordination included in the Elderly or Disabled waiver

12

Virginias Solution: Commonwealth Coordinated Care Beginning January 2014, Virginia is rolling out a new initiative called Commonwealth Coordinated Care or CCC.Provides high-quality, person-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences Blends Medicare and Medicaid services and financing to streamline care and eliminate cost shifting

13

Creates a single program to coordinate delivery of primary, preventive, acute, behavioral, and long term services and supportsPromotes the use of home and community based behavioral and long term services and supportsSupports improved transitions between acute and long term facilities

Virginias Solution: Commonwealth Coordinated Care

14

Benefits for VirginiaEliminates cost shiftingAchieves savings Slows the rate of Medicaid cost growth for VirginiaReduces duplicative or unnecessary servicesStreamlines administrative burden Single set of quality reporting measures, appeals and auditingPromotes and measures improvements in quality of life and health outcomes

15

Benefits for Individuals and FamiliesPerson-centered service coordination/case management

One ID card for all care

One 24/7 toll free phone number for assistance

Behavioral health homes for individuals with Serious Mental Illness (SMI)

A unified appeals process

16

Health Plans17DMAS is in the process of negotiations with health plans to provide Commonwealth Coordinated Care Plans will be finalized this fallCurrently negotiating with 3 plansHealthkeepersHumanaVirginia Premier

Behavioral Health Homes18DMAS estimates there are over 17,000 dual eligible individuals with SMI in VirginiaOne of the unique features of the CCC is the opportunity for health plans to develop behavioral health homes.Behavioral health homes are a team-based services delivery model that provides comprehensive and continuous care to patients, including care management, with the goal of maximizing health outcomes.

Behavioral Health Home19Examples of the types of providers in the health plan network include but are not limited to the following: PsychiatristsClinical psychologistsLicensed clinical social workersOutpatient substance abuse treatment providersResidential substance abuse treatment providers for pregnant women

Behavioral Health Homes20Expected outcomes for the health homes are:Reduced use of the ER for routine careRegular use of preventive strategiesReduced hospitalizations and re-admissionsCoordinated prescribing and medication managementCrisis prevention and avoidance

Who is eligible for CCC? Full benefit Medicare-Medicaid Enrollees (entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits) Participants in the Elderly or Disabled with Consumer Direction WaiverResidents of nursing facilities Age 21 and OverLive in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)

21

21

Virginias Service Regions22

Approximately 78,600 Medicare-Medicaid Enrollees

Who is eligible for CCC? Region Nursing FacilityEDCD WavierCommunity Non-waiverTotalCentral VA4,4303,76216,13524,327Northern VA1,9351,76612,95216,653Tidewater3,0312,49212,57518,098Charlottesville1,4778424,4276,747Roanoke2,8331,3558,58312,771Total13,70610,21754,67278,5962323Who is not eligible for CCC?Individuals not eligible include those in:ID, DD, Day Support, Alzheimer's, Technology Assisted HCBS WaiversMH/ID facilitiesICF/IDsPACE (although they can opt in)Long Stay HospitalsMoney Follows the Person (MFP) program Hospice

24EnrollmentEnrollment will be in two phases:The first phase is called voluntary enrollment where an individual proactively enrolls in the program The second phase is called passive enrollment (also known as automatic enrollment) where the individual is automatically enrolled into the CCC program

25

Intelligent AssignmentFor passive enrollment (automatic enrollment) where individuals dont specify a specific health plan, DMAS has developed an intelligent assignment algorithm that assigns an individual to a specific health plan based on several factorsThe process considers beneficiaries prior enrollment in health plans and providers

26

Intelligent AssignmentThe pre-assignment process will specifically consider the following:Individuals in a nursing facility will be pre-assigned to a health plan that includes that nursing facility in its network Individuals on the EDCD waiver will be pre-assigned to a health plan that includes the individuals current adult day health care27

Intelligent AssignmentIf more than one health plans network includes the nursing facility or adult day provider used by an individual, they will be assigned to the health plan with which he/she was previously assigned in the past six (6)months.If the individual has no history with the health plans available under CCC, he/she will be assigned to a health plan in which their provider participates.28

Intelligent AssignmentMost importantly, if an individual is unhappy with the health plan chosen for them, he/she may request reassignment to another health plan.29

Commonwealth Coordinated Care Enrollment TimelineCentral Virginia/Richmond and Tidewater areas:Early 2014: Voluntary enrollment beginsMarch 2014: Coverage beginsMay 2014: Automatic enrollment begins July 2014: Coverage for those automatically enrolled begins

Northern Virginia, Roanoke, Charlottesville areas:May 2014: Voluntary enrollment beginsJune 2014: Coverage beginsA