Overview of the Virginia Medicaid Program

Karen E. KimseyDeputy Director of Complex Care and ServicesTammy J. WhitlockDirector, Division of Integrated Care & Complex ServicesVirginia Department of Medical Assistance Services

VAPCP Fall ConferenceOctober 3, 2013

Commonwealth Coordinated Care and Future Medicaid Reforms

http://dmasva.dmas.virginia.gov

Department of Medical Assistance ServicesOverviewMedicaid Overview

Review of Medicaid Reforms : Phase 1

Implementation of a New Behavioral Health Services Administrator

Virginias Program: Commonwealth Coordinated Care

Future Reforms: Opportunities for Your Input

Virginia Medicaid: Enrollment v. Spending

The historical 30% of enrollment responsible for 70% of expenditures is true . But it is even more drastic than than that. The 7% of enrollment receiving long-term care services is responsible for almost 35% of expenditures.3Virginia Medicaid ExpendituresTop Expenditure Drivers:Enrollment Growth: Now provide coverage to over 400,000 more members than 10 years ago (80% increase)

Growth in the U.S. cost of health careGrowth in Specific Services: Significant growth in expenditures for Home & Community Based LTC services and Community Behavioral Health servicesNotes: Average annual growth FY02-FY12 = 8% FY11 expenditures reflect 13 capitation payments and 53 weekly remittances done to maximize federal match under ARRA4Composition of Virginia Medicaid Expenditures SFY 2012Notes: Long-Term Care ServicesMedicalServicesEnrollment Just shy of 1 million beneficiaries5Virginia Medicaid Expenditures Long Term Care ServicesNotes: Average annual growth total Long Term Care services 8%Average annual growth Institutional services 4%Average annual growth Community-Based services 14%Proportion of Long Term Care services paid through Community-Based care has increase from 30% in FY02 to 51% in FY12

Improve Service Delivery

Service delivery should be efficient, cost effective, and provide quality services.Improve Administration

DMAS should be accountable, streamlined, and transparent.Increase Beneficiary Engagement

Individuals should be engaged in, responsible for, and active participants in their health care.

Goals of Medicaid Reform Administrative SimplificationThe ability to set agreed upon parameters between Virginia and CMS in order to give Virginia expedited flexibility to implement innovative pilots and demonstrations

Streamlining operating authority of the Virginia Medicaid program through 1115 waiver authority Including all Medicaid populations (including individuals receiving long-term services and supports) into a managed, coordinated delivery system

CMS is very receptive to this reform effort.

Meaningful Market Based and Value Driven Reforms

Commercial-like Reform of the Virginia Medicaid Benefit PackageDelivery System Reforms Building on innovations and variations in regional delivery systems to test options beyond traditional health plans; andLeveraging tight, high quality, provider networks.

Payment and Reimbursement Reforms Bundling payments for select services and procedures; Linking incentives to increased primary care utilization and quality metrics; and Using the Commonwealths broad purchasing power to align state contracts: state employee health plan, QHP with the exchange, Medicaid, FAMIS, etc.

7Working with CMS to Implement Reforms in VirginiaKey CMS Approvals/SupportMedicare-Medicaid Enrollee (dual eligible) Financial AlignmentSignificant Reforms to the Managed Care Organization ContractsFast Tracking Reviews of Eligibility and Enrollment ChangesAdditional Required Medicaid Reforms

Two Key Questions:What Reforms Can be Implemented with the Existing Medicaid Population under Current Authority? What Reforms Can be Implemented with the Existing Medicaid Population that Require Additional CMS Authority or Waivers? (e.g., Bed Hold Days for congregate residential placements)

Virginia Must Implement Medicaid Reform in Three PhasesPhase 1: Advancing Current Reforms

Dual Eligible DemonstrationEnhanced Program IntegrityFoster CareNew Eligibility and Enrollment SystemBehavioral Health Veterans

Virginias Dual Eligible Demonstration: Commonwealth Coordinated CareDemonstration beginning January 1, 2014 and running through December 31, 2017Will provide high-quality, person-centered care for Medicare-Medicaid beneficiaries that is focused on their needs and preferences Blends Medicares and Medicaids services and financing to streamline care and eliminate cost shifting

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

12The Problem for the U.S. & VirginiaMedicare and Medicaid are not designed to work together resulting in an inefficient, more costly delivery system

At the national level, we are spending 39% of Medicaid funds on 15% of the Medicaid population

Individuals and providers have to navigate two complex systems of support

The Solution: Commonwealth Coordinated CareProvides high-quality, person-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences

Blends Medicares and Medicaids services and financing to streamline care and eliminate cost shifting

Creates one accountable entity 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

Commonwealth Coordinated CareWho is Eligible?Full benefit Medicare-Medicaid Enrollees including but not limited to: Participants in the Elderly and Disabled with Consumer Direction Waiver; andResidents of nursing facilities

Age 21 and Over

Live in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)

Who is Not Eligible?Individuals not eligible include those in:The ID, DD, Day Support, Alzheimer's Technology Assisted HCBS WaiversMH/ID facilitiesICF/IDsPACE (although they can opt in)Long Stay HospitalsThe Money Follows the Person (MFP) program

Virginias Strategies to Address Needs Enhanced Care ManagementDMAS working with Stakeholders to design care management, including expectations, levels of care management, how to best manage care for subpopulations (e.g., chronic conditions, dementia, behavioral health needs, etc.), how to structure transition programs in hospitals and NFsBehavioral Health Homes for individuals with SMI with MCOs partnering with the CSBs (Could also be ID)Encouraging MCOs to link/sub-contract with different providers for care coordination (e.g., CSBs, adult day care centers, NFs)

Virginias Strategies to Address NeedsDevelop strong consumer protections (e.g., external ombudsman, grievances and appeals)Ensure individuals only have to make one call to receive all their Medicaid and Medicare funded services 24/7 help linesProvide access to disease & chronic care management services that could improve overall health conditions and/or slow down declineDevelop strong quality improvement programs, measures and monitoringUse existing community systems to strengthen services and supportsRate Development; method for applying savings adjustments

Approximately 78,600 Medicare-Medicaid Enrollees

Medicare-Medicaid Enrollees in Virginia eligible for Commonwealth Coordinated Care Region Nursing FacilityEDCD WavierCommunity Non-waiverTotalCentral VA4,4303,76216,13524,327Northern VA1,9351,76612,95216,653Tidewater3,0312,49212,57518,098Charlottesville1,4778424,4276,747Roanoke2,8331,3558,58312,771Total13,70610,21754,67278,59620Proposed enrollment process21Eligible Populations

Enrollment and Disenrollment Process and Timeframes:Opt-in only period;Passive enrollment;Two enrollment phases, based on regionsOffering opt out provisions before and after enrollmentDeveloping enrollment algorithms to connect individuals with MCOs based on past enrollment and provider networks, to extent feasible

Benefits for VirginiaEliminate cost shifting between Medicare and Medicaid and achieve cost savings for States and CMSReduce avoidable, duplicative or unnecessary servicesStreamline administrative burden with a single set of appeals, auditing and marketing rules, and quality reporting measuresPromotes and measures improvements in quality of life and health outcomesSlows the rate of both Medicare and Medicaid cost growth

Covered ServicesAll services covered now by Medicaid and Medicare will be covered including:Pharmacy (Part D and those OTC covered by Medicaid)Nursing home servicesEDCD Waiver services (including CD services)PPL will be acting as the fiscal agent for all health plans

Carved Out ServicesTargeted Case ManagementEmergency DentalBenefits for Individuals and FamiliesOne system of coordinated carePerson-centered service coordination and case managementOne ID card for all care24 hour/7 days a week, toll free number for assistanceDisease and chronic care management (if applicable)Health plans may add supplemental/enhanced services, such as dental care, vision and hearingOne appeals processConsumer protections (180 day service auth honored, keep physician even if out of network) No co-pays (except w/Part D or pt. pay for LTC services)

Benefits for ProvidersOne card for each memberMay participate with multiple Medicare/Medicaid Plans but will not have multiple authorization and payment processes between Medicaid and MedicareInitial authorization periods will be honored for up to 6 months; also members can stay with physicians for that period of time if they arent in the health plans networkCentralized appeal process

Outreach and Education26Stakeholder engagementDedicated websiteTrainings to providers and local agenciesEducational materials such as presentations, toolkits, fact sheets, FAQs, public service announcements Working with community partners to educate and informPartnering with Virginia Insurance Counseling Assistance program (VICAP) counselors and Virginias Long-Term Care Ombudsman Program

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In the coming weeks.29Continued negotiation with three health plans (readiness reviews, rate setting, determining network adequacy)

Development of the three-way contract between CMS, Virginia and the health plans

Continued outreach and education to all stakeholders

Another Key Step Toward Medicaid Reform: Implementation of a Behavioral Health Services AdministratorThe contract was awarded to Magellan Health Services and in May 2013 and will be implemented December 1, 2013.

The contract with Magellan fulfills the directive to improve several program areas including: The coordination of care for individuals receiving behavioral health services with acute and primary services andThe value of behavioral health services purchased by the Commonwealth of Virginia

www.dmas.virginia.gov30Covered ServicesNon-Traditional & TraditionalEPSDT In-Home Behavioral Services

Community Mental Health Rehabilitation Services (includes Intensive In Home, Therapeutic Day Treatment, and Mental Health Supports)

Targeted Case Management

Treatment Foster Care Case Management

Residential Treatment (Levels A, B & C)

Substance Abuse Services

Inpatient and Outpatient Psychiatric Services (such as individual, group and family therapy)31Services NOT CoveredInpatient and outpatient psychiatric services for members enrolled in a Managed Care Organization are excluded

Behavioral health services for individuals enrolled in the Commonwealth Care Coordination Demonstration (except for MH and Substance Abuse Case Management)

www.dmas.virginia.gov32BH Services Covered by Magellan33FFSMedallion IICCC ProgramInpatientxOutpatientxCMHRSxX carved outMH/SA Case Mgmt.xX-carved outX-carved outBenefits to Members & ProvidersCentralized call center to provide eligibility, benefits, referral and appeal information Provider recruitment, issue resolution, network management, and training Quality Assurance, Improvement and Outcomes programService authorizationMember outreach, education and issue resolutionClaims processing and reimbursement of behavioral health services that are currently carved out of managed care34Virginia Must Implement Medicaid Reform in Three PhasesPhase 2: Improvements in Current Managed Care and FFS programsCommercial like benefit packages and service limitsCost sharing and wellnessCoordinate Behavioral Health ServicesLimited Provider Networks and Medical HomesQuality Payment IncentivesManaged Care Data ImprovementsStandardization of Administrative ProcessesHealth Information ExchangeAgency Administration SimplificationParameters to Test Pilots

Virginia Must Implement Medicaid Reform in Three PhasesPhase 3: Coordinated Long Term Care

Move remaining populations and waivers into cost effective and coordinated delivery models

Report due to 2014 General Assembly on design and implementation plansStatus of Phase 1 ReformsTitleProgressTimeline/Target DateDual Eligible Demonstration Pilot6th State in the Nation to have signed MOU with CMS July 2013 - Negotiations started with selected health plansAugust 2013 - Readiness Reviews startSeptember/October 2013 -Contracting, RatesMarch 2014 Regional phased-in enrollment begins Enhanced Program Integrity

OngoingFoster Care Enrollment into MCOsSeptember 2013 Begin expansion to Central, Tidewater, and Northern VirginiaSpring 2014 Rest of the state

Status of Phase 1 ReformsTitleProgressTimeline/Target DateEligibility and Enrollment SystemOctober 2013 New VaCMS eligibility system goes live for new Medicaid/FAMIS; Begin taking Medicaid/FAMIS applications based on new financial requirements MAGIJanuary 1, 2014 - Eligibility based on MAGI rules required to beginAccess to Veterans Benefits for Medicaid RecipientsOngoingIntegrity and Quality of Medicaid Funded Behavioral Health Services

December 2013 Implementation of strengthened regulations and a new Behavioral Health Services Administrator (Magellan) Status of Phase 2 ReformsTitleProgressTimeline/Target DateCommercial Like Benefit Package

July 2014 for MCOs and FFSCost Sharing and Wellness

July 2014 for MCOs and FFSLimited Provider Networks and Medical Homes

July 2014 for FFS

July 2013 for MCOsQuality Payment and Incentives

July 2013 (for MCOs) Program implemented to establish the baseline targetSFY 2015 quality withholds begin

Parameters to Test Innovative PilotsJuly 2014 for MCOs and FFSStatus of Phase 3 ReformsTitleProgressTimeline/Target DateMedicare-Medicaid (Duals) Enrollees Demonstration

January 2014ID/DD Waiver RedesignOctober 2013 - First Phase of DBHDs Study completedJuly 2014 ID/DD Waiver Renewal Due/ Redesign

All HCBC Waiver Enrollees in Managed Care for Medical Needs (waiver services remain out) October 2014PACE Program for ID/DD or other Pilot Programs (Health Homes)Beginning July 2015Status of Phase 3 ReformsTitleProgressTimeline/Target DateAll Inclusive Coordinated Care for HCBC Waiver Clients, now including all HCBC waiver servicesJuly 2016Complete Medicare-Medicaid (Duals) Coordinated Care across the State, including children

July 2018 Questions?42 EMILY OSL CARR Director, Office of Coordinated Care

Email: ccc@dmas.virginia.govChart10.550.030.10.070.180.070.210.020.080.350.330.01

ChildrenPregnant Women & Family PlanningCaretaker AdultsLong-Term CareNon Long-Term CareQMB55%21%8%7%35%33%7%

Sheet1ChildrenPregnant Women & Family PlanningCaretaker AdultsLong-Term CareNon Long-Term CareQMBEnrollment57%3%10%6%18%6%Expenditures23%2%9%37%28%1%65%To resize chart data range, drag lower right corner of range.ChildrenPregnant Women & Family PlanningCaretaker AdultsLong-Term CareNon Long-Term CareQMBColumn1Enrollment55%3%10%7%18%7%100%Expenditures21%2%8%35%33%1%100%