http://www.dmas.virginia.gov

Karen Kimsey and Tammy WhitlockComplex Care and Services

Virginia Department of Medical Assistance Services DMAS Announcement to Interested Plans

June 2, 2015

Proposed Initiatives for Medicaid Managed Long-Term Services and Supports (MLTSS)

Department of Medical Assistance Services

Agenda

2

Welcome

Medicaid Reform Initiatives

General Assembly Directives

Current Program Models

Medicaid Long Term Care Services

Future Managed Care Initiatives

o Medicaid Managed Care for Individuals Eligible for CCC but Not Enrolled

o Managed Long-Term Services and Supports

Next Steps

Questions

Phase 3Move Forward with Coordination of LTSS

Phase 2Implement Innovations in Service Delivery, Administration, &

Beneficiary Engagement

Phase 1Advance Reforms In-Progress

Moving Forward with Medicaid Reform Initiatives

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CURRENT STATUS OF PHASE 3 REFORMS (MIRC)Title Status

ID/DD Waiver Redesign

• October 2013 - First Phase of DBHDs Study completed• 5 Subgroups created and to provide recommendations for design• Based upon recommendations, plan is to amend current waivers• Amended waivers would be renamed - Community Living Waiver, Family

and Individual Supports Waiver, and Building Independence waiver. All waivers would serve both ID and DD populations

All non-dual EDCD waiver enrollees in Managed Care for medical needs

• In combination with the acute and long-term care (ALTC) Phase 1 program, this initiative became known as the health and acute care project (HAP)

• Individuals enrolled in Medallion 3 (M3) who subsequently enroll into one of 5 home and community based care waivers (excludes Tech Waiver) maintain their enrollment in M3 for acute and primary care services.

• In December 2014, DMAS transitioned individuals in the EDCD waiver, who were otherwise eligible for managed care, i.e., did not meet any managed care exclusions, into one of the Medallion 3.0 health plans for acute and primary care services. (Included approximately 2,700 EDCD individuals).

• As of May 1, 2015 8,010 HCBS individuals are enrolled in Medallion 3 for their acute and primary services; their long-term services and supports are paid through fee-for-service.

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Progressing

PHASE 3 REFORMS REMAINING. . .

Title Status

All inclusive Coordinated Care for LTC Beneficiaries (coordinated delivery for all LTSS)

Original Goal - By Summer 2016• Complete the transition of all non-dual waiver recipients in the six

home and community based care waivers and their community long term care services into coordinated care networks. (HAP for remaining waivers.)

Complete Statewide Commonwealth Coordinated Care by July 2018

Original Goal – By July 2018• Implemented the voluntary duals demonstration program in

March 2014; completed regional phases of automatic assignment phase in November 2014; currently operating in 103 of 134 localities; provides choice of at least 2 health plans per locality except for a few localities. Focus at this time is on quality evaluation, monitoring , oversight.

• Approximately 25K individuals are enrolled in CCC as of March 2015 and another 37K are eligible but not enrolled.

• July 2018- After the Commonwealth Coordinated Care (Duals) demonstration is completed, upon CMS approval expand statewide with all the remaining dual populations and all their medical, behavioral, and long term care services.

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VA General Assembly Directives

Beginning in 2011 and continuing in the 2015 session, the Virginia General Assembly has directed DMAS to continue with reform efforts to transition fee-for-service (FFS) populations into managed care so the Commonwealth can take advantage of the benefits of managed care as a delivery model, including:

(1) increased access due to larger and more comprehensive provider networks and network management;

(2) accountability;

(3) administrative benefits DMAS has not been able to replicate (care management, nurse and other call lines, maternity and education programs);

(4) budget predictability through capitated payments;

(5) focused quality improvement programs; and,

(6) tighter and more complex medical management. 6

VA General Assembly Directives

The 2015 Appropriations Act – Item 301.TTT, directs DMAS to seek reforms to include all remaining Medicaid populations and services, including long-term care and home- and community-based waiver services into cost-effective, managed and coordinated delivery systems.

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Fee For ServiceServes certain coverage groups and is also the delivery system for most long-

term services and supports (LTSS); often results in fragmented care

coordination

Commonwealth Coordinated Care (CCC)

Serves certain full-benefit adult duals (age 21 and older) ; fully integrated

model ; includes CCC eligible nursing facility and EDCD Waiver participants

Program of All-Inclusive Care for the Elderly (PACE)

Serves adults age 55 and older who meet nursing facility criteria; fully

integrated system of care; community alternative to nursing facility care

Medallion 3.0Serves pregnant women, children, adults

(caretakers) and ABD without LTSS through a coordinated delivery model;

excludes LTSS

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Current DMAS Service Models

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Composition of Virginia Medicaid Expenditures SFY 2014

46%

Dental2%Medicare Premiums

6%Indigent Care

5%

Behavioral Health Services

9%

33%

Nurs-ing

Facil-ity,

ICF/ID44%

Waivers

56%

Long-Term Care Expenditures

Managed Care Fee-For-Service

$2.4b

$1.2b

Medical Services by Delivery Type

Long-Term Care

ServicesMedicalServices

VA’s HCBS Waivers/Alternative Institutional Placements

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WaiverAlternate Institutional Placement

Alzheimer’s Assisted Living Nursing Facility

EDCD Nursing Facility

Developmentally Disabled Intermediate Care Facility for Individuals with Intellectual Disabilities

Intellectual DisabilityIntermediate Care Facility for Individuals with Intellectual Disabilities

Day SupportIntermediate Care Facility for Individuals with Intellectual Disabilities

Technology Assisted Specialized Care in Nursing Facility for Adult / Hospital for children

Waiver program service descriptions and eligibility criteria may be found on the DMAS website

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Virginia Medicaid Expenditures Long Term Care Services

FY

04

FY

05

FY

06

FY

07

FY

08

FY

09

FY

10

FY

11

FY

12

FY

13

FY

14

$.0

$.5

$1.0

$1.5

$2.0

$2.5

$3.0

Community-Based

Institutional

Long-Term Care

$b

illio

ns

Notes: Average annual growth total Long Term Care services – 7%Average annual growth Institutional services– 3%Average annual growth Community-Based services– 13%Proportion of Long Term Care services paid through Community-Based care has increase from 32% in FY04 to 55% in FY14

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Virginia Medicaid HCBS Waivers – Enrollment and Wait List Information

Notes: *Enrollment for the HCBS Waivers as of March 2015 and is subject to frequent change**This is the same waiting list for servicesSource: Virginia MMIS, Databases

Slot/Wait List Summary Enrollment * Waiting List

EDCD 30,460 N/A

MR/ID 10,017 4,941**

DD 909 807

Tech 293 N/A

Day Support 276 4,941 **

Alzheimer’s 56 N/A

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Proposed Future MLTSS Initiatives

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Managed Long-Term Services and Supports Future

Coordinated system of care that focuses on improving access, quality, and efficiencyo Provides greater flexibility to serve individuals

before they have higher needso Improves qualityo Improves efficiency in the systemo Includes value based purchasing models o Better manages and reduces expenditures

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To move 107,000 individuals into

mandatory managed care

model(s) to improve their lives

The Plan

Those Eligible for CCC but

Who are Not Enrolled

(Approximately 37K)

Duals Excluded From the CCC

Demo(Approximately 50K)

Medicaid Only Individuals

Receiving LTSS(Approximately 20K)

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Populations to Transition from FFS to Managed Care

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Phased Implementation

Phase 1 – Managed

Medicaid for individuals

eligible for CCC but not enrolled

Mid 2016

• Transition approximately 37,000 CCC eligible individuals who have chosen not to participate in CCC into a mandatory managed care program for Medicaid services.

• Includes Medicaid primary and acute, LTSS, and behavioral services coordinated by a CCC health plan (Anthem, Humana and Virginia Premier).

Proposed

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Phase 1: Managed Medicaid Enrollment for CCC Opt-Outs

Key strategy is to replace the current fee-for-service structure with managed care, for Medicaid services for individuals that opt-out of CCC

Improves continuity of careo Allows the health plans to provide care coordination on a continuous basis versus

brief periods of opt-in/opt-out enrollment elections

o Better care coordination could lead to better health outcomes

o Allows the member to see the program benefits (coordinated care, value added services, enhanced benefits, 24 hour nurse line, etc.)

Increased enrollment stability could improve health plan viability

Allows DMAS and the CCC Plans to build on existing infrastructure, networks, and relationships

Proposed

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Phase 1 Managed Medicaid for CCC Opt-Outs (Continued)

Design Element CCC with Full Integration CCC with Medicaid Only (New)

Population CCC Opt-Ins CCC Opt-Outs

Services Medicare/Medicaid covered services

Same Medicaid services as CCC; health plan will coordinate benefits with the individual’s Medicare plan

Service Area CCC Demo Regions (http://www.dmas.virginia.gov/Content_pgs/mmfa-imme.aspx

CCC Demo Regions

Health Plans CCC Plans (Anthem, Humana, and Virginia Premier)

CCC Plans

Federal Authority

Dual Demonstration 1932(a) State Plan Amendment

CMS 1915 (b) (c) Waiver

Contract CCC 3 Way Contract New CCC 2 Way Contract

Member Materials

Member handbook and 1 CCC ID Card for Medicare and Medicaid

Member handbook and separate Medicaid Card

Appeals Process Unified Medicare/Medicaid Process

Medicaid process consistent with Federal/State regulations

Proposed

Phased Implementation

Phase 2 – Managed Long Term

Services and SupportsMid 2017

• Transition approximately 70,000 eligible individuals, including duals not eligible for CCC and individuals receiving LTSS (institution or HCBS waiver) into coordinated care.

• Includes primary and acute, LTSS, and behavioral services. The health plans will be selected through a competitive procurement process.

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Proposed

New managed care program for remaining FFS individuals receiving LTSS

Would be the fourth DMAS managed care program in addition to the current Medallion 3.0, PACE, and CCC programs

Serves two general populations: o Duals excluded from the current CCC demonstration program

(children, excluded regions, and select individuals receiving home and community based waiver services)

o Non-duals receiving LTC services in institutions and the 6 home and community based care waivers

Choice of at least 2 plans; participation is mandatoryo The health plans will be selected through a competitive

procurement process

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Phase 2: Managed Medicaid for CCC Excluded Duals and LTSSProposed

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Phase 2 - Managed LTSS Design ElementsDesign Element MLTSS

Eligible Population Duals not eligible for CCC and individuals receiving LTSS

Excluded Populations ICF/ID, limited coverage groups, others are being considered

Included Services Full spectrum of care (primary, acute, long-term, behavioral health, care coordination); integrated model

Excluded Services Very few carve-outs; ID, DD, and DS waiver services, dental, and school services are being considered at this time

Service Area Plan to phase in by region and to operate statewide

Health Plans To be determined through competitive RFP process

Federal Authority 1915 (b) (c) waiver

Contract Fully-capitated risk-based; actuarially sound cap rates Offers value based payment opportunities

Health Plan Requirements

Bureau of Insurance Approval and MCHIP Certification through VDH ; approved or seeking approval by CMS to operate as a Dual SNP

Quality NCQA Accreditation and 1915 (c) waiver quality assurances

Beneficiary Protections Continuity of care, Ombudsman, appeals, others to be determined

Proposed

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Next Steps

MLTSS RFP• Development, Review, • Approval, Post• Evaluation, Award• Contract Execution

Regulatory Authority, Rate and Data Book Development• CMS 1915 (b)(c) Waiver• Regulations Systems Changes

• Requirements, Design, Testing, Implementation

Communication & Outreach• Town- halls,

stakeholder calls, trainings, etc.

AssessMCO, DMAS, Other Contractor systems Readiness• Networks,• Systems• Transition• Etc.

Public Comment

On-Going:• Stakeholder Involvement• Consult with CMS• Consult with Mgmt

Changes and Readiness of Contractors: Enrollment broker, CD Fiscal Employer Agent, BHSA, Service Auth, Dental LogistiCare, etc.

Strategic Planning

Managed Care Contract Signing and Assessment of MCO Contractor Readiness

MLTSS launch is anticipated

mid-year 2017

Proposed

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Stakeholders Are Key(Includes Health Plans)

Stakeholder involvement is crucialo Request for Commento Meetings with Health

Planso Town Hallso Meetings with

Stakeholder Groups (including Advisory Committee)

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Questions and Discussion

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References

CCC Demo Regions – Available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/mmfa-imme.aspx

MLTSS updates will be posted as available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx

Implementing Medicaid Reform in Virginia (Report to the General Assembly of Virginia, January 2014) http://leg2.state.va.us/dls/h&sdocs.nsf/By+Year/HD62014/$file/HD6.pdf