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A Future Option – Virtual PACE
WHCA/WiCALApril, 2013
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US Births 1933-2009(Source: National Center for Health Statistics)
US Births (Thousands)
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2039 2013
78 = Avg NH Age
2026 2013
LTCYrs
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20,000
40,000
60,000
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120,000
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Births (Wisconsin) 1933-2009(Source: Wisconsin Office of Health Information)
Births…
3
20132039
78 = Avg NH Age
2026 2013
LTCYrs
0
10
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60
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90
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
U.S. Life Expectancy(Years)
(Source: Centers for Disease Control & Prevention)
4
5
(Source: CDCP)
43%
11%4%
9%
33%
NFS
ICF/MR
HHS
PCS
HCBS
57%
15%
3%
7%
18%
NFS
ICF/MR
HHS
PCS
HCBS
2011 US LTC Expenditures(Source: Eljay Report, Dec. 2011 -- CMS-37, 2010-11)
2000
2011
Shift
$70B
$118B
(+28%)
(+21%)
(+210%)
(+133%)
(+70%)
6
7
370
380
390
400
410
420
430
1995
1996
1997
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2010
NHs in Wisconsin
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20,000
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40,000
50,000
60,000
1995
1996
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2001
2002
2003
2004
2005
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2007
2008
2009
2010
NH Beds in Wisconsin
80.0
82.0
84.0
86.0
88.0
90.0
92.0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
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2008
2009
2010
WI NH Occupancy Rate
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
NH Residents in Wisconsin
(Source: Health, United States, 2011)
($70.00)
($60.00)
($50.00)
($40.00)
($30.00)
($20.00)
($10.00)
$0.00
NH
NY
NJ
WI
DE
MA
SD
MN
WA
PA
NH NY NJ WI DE MA SD MN WA PA$(40.00)
$(35.00)
$(30.00)
$(25.00)
$(20.00)
$(15.00)
$(10.00)
$(5.00)
$-
WI
NY
NJ
WA
MA
WY
PA IL
MN
UT
WI NY NJ WA MA WY PA IL MN UT
Medicaid $$ Shortfall of NH Per-Diem(Source: Eljay Report, Dec. 2012, for AHCA)
$147
$220
$205
$159
$193
$161
$199
$117
$164
$162
$179
$221
$199
$156
$208
$199
$126
$169
$181
$208
2009 2012
8
Combined Medicare/Medicaid Shortfall (AHCA-MedPAC 2011)
Payer Avg Rate Days (M) Rev (B) Gain(Loss) Net (Billions)
Medicare $441.44 67.4 $29.70 18.10% $5.39
Medicaid $171.5 325.5 $55.80 -9.60% ($5.36)
Net $0.03
% of Rev 0.03%
Combined Medicare/Medicaid Shortfall (AHCA-MedPAC, 2012)Payer Avg Rate Days (M) Rev (B) Gain(Loss) Net (Billions)
Medicare $467.09 68.6 $32.06 14.60% $4.68Medicaid $178.68 321.7 $57.49 -12.50% ($7.19)
Net ($2.51)% of Rev -2.8%
General Sustainability Model(Source: Eljay Reports, Dec. 2011, 2012)
2009
2012
9
(1.8:1)
Life Expectancy (system failures)
Demographics (aging imbalance)
Lifestyle (health-risk behaviors)
Technology (medical-industrial cures)
Facilities (salaries, room-board)
Pharmacy (users, frequency, costs)
Benefits (consumer demand)
Utilization (wrong care-wrong time)
Futile Care (end-of-life treatment)
Administration (complexities)
Fraud & Abuse (misappropriation)
10
IntegratedConsolidated
Diversified11
AdminCntr
NH1
NH2
NH3
NH4
NH5
NH6HHA
PT/OT
SocSrv
NH
AdminCntrClinic
PhyGrp
Hospital
PT/OT
PCW
AdminCntr
SocSrv
AltnLiving
NursingHome
HHA
Clinic
NH• MD
• RN• SW• Dietician
ICO• CC
Network
• NP
12
• Member• Family
ICT
&/or
13
MedicalHome
HomeHealth
RN PCWPT/OT
PrivateHome
CBRF RCAC
Community Caregiving
PrivateHome
PrivateHome
PrivateHome
Adult Community
AdultFam Hm
Community Engagement
Sub-acuteCare Activity
Center
AdvancedCare Center
(nursing home)AssistedLiving(Other)
Encourage nursing homes to become medicalhomes for frail-age citizens.
Encourage development of day activitycenters for an integrated community.
Encourage vent providers to also develop in-house dialysis capacity.
Accelerate certification of nursing homes ashome health agency providers.
Allow nursing homes to be certified ashospice facilities at Medicare fee schedule.
Add a nursing home consumer benefit toimprove mobility, self-care or socialization.
14
Develop “Acute-RUGs” rate for acute-episode care within the nursing home.
Transfer pharmacy from Part A RUGs to PartD stabilizing nursing home pharmacy costs.
Introduce multiple reimbursement levels tothe current vent program for expansion.
Eliminate bad debt from unpaid co-payments following day 20.
Eliminate occupancy penalty on Medicaidrates resulting from relocations.
Offer a P4P program based on new fundsrather than redistribution of existing funds.
15
Increase Internet-based patient connectivitywith family members.
Accept Medicare cost report withsupplemental schedules as Medicaid report.
Survey high-performing homes every 3 years,more often for low-performing homes.
Establish standards for 3rd party assessmentof patient relocation candidacy.
Configure ICO assessments and plans tocurrent nursing home forms.
Modify the standard and process foranomalous incident reporting.
Integrate and simplify regulatoryenvironment with the duals demo initiative.
16
Develop a “0%-Interest” investment fund forexpansion of nursing home infrastructure.
Add incentives for nursing homes to upgradeacute care and condition-stabilizingequipment.
Create incentives for nursing homes to providehome and community based waiver services.
Restore portion of the NH assessment to NHs tofacilitate business model transitions.
Introduce statutory zoning reform statewide toallow expanded community livingarrangements.
17
o Community activity center o Intensive care units/equipment
o Medical clinic offices o Alternative living arrangements
DLTC Expected Results (CMS Submission, 3/12)
Reduced hospitalizations (5-15%) Increased CC/PCP services (5-15%) Reduced ER costs 2-6% DLTC savings goal: $1.6M-$7.5M (Base: Yr1-$1.2B, Yr3-$1.3B)($973MM Medicaid spent on NH Care for 17,400 WI Residents – WI Plan Y12)
Opportunities for Improvement
15% LTC-Res in-hospital ~6 Mo (Grabowski, 2007)
60% of all Potentially Avoidable Hospitalizations ≥ 65 7.7:10 ≥ 65 were NH PAHs (Ouslander, 2010)
40% NH ER visits preventable (NCHS, 2010, 48% Bowman, 2001)
57% NH ER visits hospitalized (HCUP, 2004, 67% Jensen, 2009)
55% NH Hospitalizations with no Advance Directive
• Falls (36%) • Heart (19%) • Pneumonia (12%) •Other (33%)
18
• Respiratory (30%) • Cardiovascular (18%) • Falls (15%) •Other (37%)
1
2
Medicare & Medicaid Policies
Patient and/or Family Preferences
Absence of Advanced Care Plans
Absence of Medical Personnel in NH
Absence of Diagnostics/Pharmaceuticals
Limited Resources of EDs
Absence of Community Based Options
Fear of Regulatory Sanctions
Fear of Litigation(LTQA, 2012)
19
ACSCs
PAHs
1
2
Ambulatory CareSensitive Conditions
COPD CHF Diabetes
Hypertension Ulcer Urinary Infection
Dehydration Malnutrition Pneumonia
Influenza ENT Infection Seizure
Leading NH Hospitalizationsby ACSC
Percent
Pneumonia 32.8%
Urinary Track Infection 14.2%
Congestive Heart Failure 11.6%
Dehydration 10.3%
Falls/Trauma 9.4%
COPD, Asthma 6.0%
Skin Ulcers/Cellulitis 4.9%
Other 10.8%
(CMS, 2011)
20
Chronicity
PredictorsProbable Predictors
of Transfer Risk
Mobility Score (MDS 3.0, Sec G) p<.05 (+)
Chronic Conditions (MDS 3.0) p<.001 (+)
RN Hours/Resident Day P<.01 (-)
Current 6-Mo History p<.01 (+)
No. of NH Lab Tests p<.01 (-)
No. Chronic Conditions Odds for Hosp Admit for ACSC
1 7.49x
2 18.10x
3 36.43x
≥ 4 98.52x
3
4
(Wolff, 02)
21
(Intrator, 07)
Availability of physician on-site 3 days/wk
Exam by PCP or extender ≤ 24-hrs w/ COC
Availability of lab tests ≤ 3-hrs
NP working in the NH
Availability of RN to provide care
Ability of NH to provide therapy Intravenous
Respiratory
Ability of NH to perform pulse oximetry
Family counseling (AD & POC)(Ouslander, 2009)
22
To ensure daily contact with Member
To eliminate duplicative functions
Feature PCP and/or NP presence to Member
Integrate data streams
Waive 3-day inpatient stay requirement
Improve custodial level of care
Create “quick-response” care elements
Connect alternative care resources
Integrate care (medical, pharmacy & social)
23
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CY 2013 CY 2014 CY 2015Medicaid Service Costs
Inpatient Hospital 27.20 27.48 27.75Emergency Room 0.36 0.39 0.42Outpatient Hospital 6.98 7.33 7.70Nursing Home 4,162.14 72% 4,370.25 73% 4,588.76 73%Physician and Clinic 11.68 12.03 12.39Mental Health 0.82 0.84 0.87DME/DMS 15.65 16.28 16.93Rx 10.48 10.59 10.69Home Care 0.35 0.37 0.39Lab and Radiology 2.56 2.64 2.72Therapy 1.53 1.58 1.63Dental 10.30 10.61 10.93Transportation 5.91 6.09 6.27All Other 32.14 33.11 34.10Subtotal Medicaid 4,288.12 4,499.58 4,721.54
Medicare Service Costs
Inpatient Hospital 454.35 458.89 463.48Emergency Room 8.79 9.40 10.06Outpatient Hospital 213.85 224.54 235.77Carrier 272.26 289.96 308.81DMERC 28.24 29.36 30.54Home Health 2.97 3.12 3.28Hospice 55.13 58.71 62.53Skilled Nursing Facility 425.63 10:1 446.92 10:1 469.26 10:1
Subtotal Medicare 1,461.22 1,520.91 1,583.72Total PMPM 5,749.34 3:1 6,020.48 3:1 6,305.26 3:1
(Test 2)$973MM
x 1.35÷ 17.4K
÷ 126,291
(Test 1)1.8:1
(Test 3)WPP =$1.6KPMPM
$-
$50
$100
$150
$200
$250
$300
$350
$400
$450
$500
1
10
19
28
37
46
55
64
73
82
91
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361
Current ICO-1 ICO-2
25
$10K (HOSP)
90Days
90Days
45Days
45Days
∆(1-2) = $15,360/Yr ($10,000-Hosp, $5,360-NH)
$10K (HOSP)
$10K (HOSP)
ICTDecision
ICTDecision
ICTDecision
POSSIBLE ICO CARE PATTERN FOR NH RESIDENT Q(EXAMPLE)
70Days
= Compress Cost ∆ = Compress LOC
∆(1-3) = $22,370/Yr ($10,000-Hosp, $12,370-NH)
ICTDecision
$10K (HOSP)
50Days
12
3
1 2 3
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Background, Status & Next Steps
Virtual PACE
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Medicare-Medicaid Coordination Office(MMCO)
• A CMS office established by the Affordable CareAct (ACA)
• Sometimes referred to as the “Duals Office”
• Three focuses
o Program Alignment
o Data and Analytics
o Models and Demonstrations
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Complex and Acuity Population
• Complex needs and higher costs – national data shows:
o 43% have mental or cognitive impairment
o 60% have multiple chronic conditions
o More likely to be low income or live in an institutionthan other Medicare beneficiaries
o In 2006, dual eligible individuals were 16% of Medicareenrollees & accounted for 27% of costs.
o In 2007, dual eligibles were 15% of Medicaid enrollees& accounted for 39% of costs.
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Medicare & Medicaid Misalignments
• Served by separate systems with different requirements &incentives that sometimes conflict:
• Examples:o Different coverage standards for overlapping benefits
o Misaligned appeals & grievance systems
o Differing incentive for upstream service utilization
o Incongruent provider network access requirements
MMCO Fact Sheet: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
MMCO Grant
• The MMCO awarded grants to fifteen stateso design integrated care demonstrations for dual eligible individuals.
• Wisconsin was awarded one of these grants in April 2011.o Grant funds awarded for the purpose of designing a state specific
integrated model of care to serve dually eligible individuals.
o Proposal parameters were to develop a cost and qualitative effectivemodel of care coordination and funding.
• 12 months of Program Planning Data and analysis
Stakeholder input
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
What did Wisconsin Propose?
• Submission in April 2012
• Integrated funding of Medicare & Medicaid
• Managed Care model
o Integrated Care Organizations (ICOs) to coordinate care
• Passive enrollment of FFS Nursing home residentson Medicaid stay, in participating nursing homesin service areas of the demonstration.
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Why focus on nursing home residents?
o FFS Institutional Least coordination in FFS; greater opportunity to improve care
High cost population & high acuity
Specific misalignments can be targeted
o Home & Community Based Services (HCBS) Existing programs already provide some level of coordination
Avoid disrupting current delivery systems
o Community Non-Waiver Not in institution or receiving HCBS; otherwise heterogeneous
Uncertain if costs of care coordination in capitated programwould outweigh potential savings
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Targeted Population for Virtual PACE?
• Full dual-eligible members of Medicare andMedicaid;
• Age 18 and over;
• Residing in a participating nursing home; and
receiving nursing home services via Medicaid fee-for-service funding.
While the target population is people residing in a nursinghome, the enrollment is retained if individuals relocate to acommunity setting
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Virtual PACE Enrollment
• Wisconsin proposed to passively enroll eligibleindividuals with an option to opt-out any month afterenrollment.
• Individuals in participating nursing homes will bepassively enrolled if they:
o Are not in Medicare Advantage or Medicaid managed care
o Do not have employer-sponsored or other supplementalinsurance or subsidies
o Have not elected hospice benefit at time of enrollment• Nursing home residents excluded from passive enrollment may voluntarily enroll, if
they meet the eligibility criteria, but will not be passively enrolled
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
DemonstrationArea
• Three year demonstration
• “Roll-out period”: 18 months forimplementation in new areas
• No new counties or NHs maybe added later.
• Includes counties insoutheastern, southern, andnortheastern Wisconsin.
• Approximately 10,000individuals eligible for passiveenrollment in these areas
• Estimated NH participation of150 to 200 by end of roll-outperiod
• Estimated enrollment between5,500 and 6,000 enrollees by endof roll-out period
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
How many people does this include?
• 2010 Data: Approximately 120,000 full dualeligible individuals statewide
• Virtual PACE targets a subset of dual eligiblesresiding in nursing homes
o 2010: About 17,000 in any given month who wouldhave met Virtual PACE passive enrollment criteria.
o Projected passive enrollment eligible residents indemonstration regions in 2013: 10,000.
o Roughly estimated enrollment accounting for nursinghome participation and resident opt-out: 5,500-6,000 bythe end of the 18-month roll-out period.
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Virtual PACE Goals
• Integrate Medicare and Medicaid
• Eliminate artificial barriers and treatment patterns
o By aligning financial and regulatory arrangements
• Improve outcomes for individuals by incentivizing:
o Effective and timely primary care
o Stronger coordination of care transitions
o More flexible service delivery
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Key Stakeholders/ Contributions
• Stakeholder AdvisoryCommittee
• Divisional AdvisoryCommittee
• CountlessDepartmental ContextExperts
• PwC
• HP
• Ombudsman
• Nursing HomeAssociations
• ICOs (Health Plans)
• CMS
• Medicare and Part DContext Experts
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Next Steps for Virtual PACE
oMOU
Rate Method Negotiations
oICO Certification
oThree-way contract
oImplementation Planning
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Implementation Planning
• Grant Application Due April 10th, 2013 Enrollee Outreach and Education
Provider and Community Stakeholder Involvement
Monitoring and Support Structure
IT infrastructure
Reporting & Measuring Systems
• Then on to…
o Ready, Enroll and Monitor!
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Challenges
• Balancing the incentives of all stakeholders
• CMS
o systems & subgroups
• Wisconsin’s current spectrum of services
• Changing thinking
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Medicare Medicaid Combined 2013 PMPM
Medicare Service Categories yr 2013 yr2013
Emergency Room $ 9.23 $ 0.31 $ 9.54
Home Health $ 7.94 $ 0.78 $ 8.72
Outpatient Hospital $ 226.11 $ 7.56 $ 233.67
DMERC $ 30.03 $ 15.66 $ 45.69
Carrier $ 265.32 $ 16.53 $ 281.85
Inpatient Hospital $ 380.15 $ 20.33 $ 400.48
other $ 27.35 $ 27.35
Hospice $ 238.75 $ 44.62 $ 283.37
Subtotal $ 1,157.53 $ 133.14 $ 1,290.67
Skilled Nursing Facility $ 362.08 $ 4,148.51 $ 4,510.59
Total $ 1,519.61 $ 4,281.65 $ 5,801.26
IncentivesWhere’s the Money?
17
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
A Seat at the Table
• Shape the Initiativeswith DHS, ICOs andCMS
• SubcontractOpportunities
o Care CoordinationFlexibility
o Authorization &Decisional Refinements
o Payment Rates
18
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Flexibility & Opportunity Exhaustion?
• IDT Structure
• Assessments
• Care Planning
• Payment Rates
19
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Share your Ideas
Contribute your expertise
Virtual PACE 101 Division of Long Term Care
Wisconsin Department of Health Services
Additional Information
DHS Virtual PACE website:http://www.dhs.wisconsin.gov/virtualPACE/
MMCO website:https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/
Project Director:
Deborah Rathermel at [email protected]
608-267-3712
Virtual PACE Frequently Asked Questions
Page 1 of 7
The purpose of this material is to provide answers to key questions about Virtual PACE program.
The FAQ will be posted on the Virtual PACE website and it is anticipated that the document will
be viewed by a variety of stakeholders as an informational reference. This FAQ, however, is not
intended to serve as an educational material for potential enrollees.
Feedback will be solicited at our ongoing stakeholder forums. Reviewers are also encouraged to
submit comments to Dalia Stonys (Virtual PACE Team Lead for topic area).
1. What is Virtual PACE?
Virtual PACE is a proposed demonstration program that aims to:
fully integrate the two major public-payer systems, improving the delivery and financing
of primary, acute, mental health, and long-term care services;
eliminate artificial barriers and treatment patterns resulting from differing, and sometimes
competing, regulatory and financing arrangements; and
improve the physical, mental health, and long-term care outcomes for Wisconsin’s most
vulnerable citizens by creating incentives for better and more timely delivery of primary
care, stronger management of care transitions, and more flexible service delivery.
2. What is the target population for Virtual PACE?
Virtual PACE’s target population is people who are:
full dual-eligible members of Medicare and Medicaid;
age 18 and over;
residing in a participating nursing home; and
receiving nursing home services via Medicaid fee-for-service funding.
While the target population is people residing in a nursing home, the enrollment is retained if
individuals relocate to a community setting.
3. How many individuals are eligible for the Virtual PACE demonstration?
Based on the last six months of 2011, there are approximately 15,500 individuals eligible for the
Virtual PACE demonstration out of a total of 124,000 Medicare-Medicaid enrollees in Wisconsin.
Initially, the program will be limited to 18 months long implementation and will cover counties in
southern, southeastern, and northeastern Wisconsin, where approximately 10,000 individuals are
eligible for the demonstration. It is estimated that during this period the demonstration would
include between 150 and 200 participating nursing homes and between 5,500 and 6,000 enrollees.
Virtual PACE Frequently Asked Questions
Page 2 of 7
4. Who is running the Virtual PACE program?
The Department of Health Services (DHS), which is the Wisconsin state agency that oversees
Wisconsin’s Medicaid programs and long term care services, and the Centers for Medicare and
Medicaid Services (CMS), which is the federal agency that oversees Medicare and Medicaid, will
oversee the demonstration. DHS and CMS will enter into a Memorandum of Understanding
(MOU) that will provide the government authority to operate the program. The MOU will also
describe the program and how it will be run. DHS and CMS will contract with health plans called
Integrated Care Organizations (ICOs), and each of the three parties (DHS, CMS, and the ICO) will
sign one contract that will include all requirements for ICOs providing integrated care in the
demonstration.
5. When will the program start?
Development and implementation of the program is a joint effort of CMS and DHS. These
agencies are working diligently to finish development and start implementation in 2013.
6. Is Virtual PACE going to cost more money for taxpayers?
No. The demonstration is required to be budget neutral and/or save money while maintaining
and/or improving quality of the health care services. This requirement will be achieved by better
coordinating care and increased utilization of preventative care, not by reducing the scope of
covered services.
7. How much will it cost to be enrolled in the Virtual PACE?
The membership in the Virtual PACE is free.
8. What services Virtual PACE program is going to cover?
The Virtual PACE program in Wisconsin is a comprehensive, integrated, and coordinated
managed care plan that includes all services covered by Medicare, Medicaid, and the Long Term
Care Waiver plans. Coverage for enrollees in the Virtual PACE demonstration will include
Medicaid and Medicare (Parts A, B, and D) services; and the ICOs will also provide Long Term
Care Waiver services for individuals who relocate from the nursing home to a community setting.
Services provided by the nursing home as part of the nursing home benefit will be enhanced by the
addition of the Interdisciplinary Team and its services associated with care coordination and
provision.
Virtual PACE Frequently Asked Questions
Page 3 of 7
9. How will care be coordinated under the Virtual PACE demonstration?
The Interdisciplinary Team (IDT) will provide each Virtual PACE enrollee with person-centered,
integrated care coordination for all services related to the enrollee’s care plan. The IDT will center
its care coordination on the member’s values, strengths, personal support and care network, and
broadly-defined support and care needs. This team will have the authority and responsibility to
develop, monitor, measure, and modify the member’s care plan.
10. Who will be on the Interdisciplinary Team (IDT)?
The IDT will, at a minimum, include the member and a care coordinator; it may also include
additional persons with specialized expertise for assessment, consultation, ongoing coordination
efforts, and other assistance as needed, depending on the enrollee’s preferences and needs. The
IDT will complement nursing home staff and will make available a range of care expertise
appropriate to the acuity and complexity of the enrollee. This may include paraprofessionals, peer
specialists, care coordinators and social workers, mental health and psychiatric specialists, nurses,
nurse practitioners, pharmacists, physician assistants, and medical practitioners, including those
with diagnosis and target group-specific expertise. The IDT may be employees of the health plan,
the nursing home, or subcontracted providers. Preservation of enrollees’ valued and long-standing
relationships with specific service providers will be explicitly encouraged and supported.
11. Will Part D coverage or protections change under the Virtual PACE demonstration?
No. The Medicare Part D formularies, protected classes, appeals, enrollee rights and protections,
and oversight mechanisms will remain the same under the Virtual PACE demonstration.
12. How will enrollment work for the Virtual PACE demonstration?
Eligible individuals will be automatically enrolled in Virtual PACE, unless they choose otherwise.
This is called passive enrollment. Enrollment will be phased in starting with participating nursing
homes in the southeastern region of the state and then expanding to additional counties over the
demonstration timeline. Individuals will be able to opt out at any time.
Prior to enrollment, enrollees, their families, their support systems, and community stakeholders
will be engaged in outreach and education activities designed to fully explain the program design,
allow everyone to provide input, alleviate any concerns, and support informed decisions. Virtual
PACE will notify beneficiaries of their enrollment at least 60 days before it is to take effect and
instruct them how to receive more information about the program or opt out of the demonstration.
Individuals who are voluntarily eligible will not be automatically enrolled and will be informed
about the Virtual PACE program through existing ADRC outreach and options counseling venues.
Virtual PACE Frequently Asked Questions
Page 4 of 7
13. Who will be eligible for voluntary enrollment in Virtual PACE?
Voluntary enrollment eligible individuals will not be automatically enrolled and will receive
options counseling with an Aging and Disability Resource Centers if they choose to enroll in
Virtual PACE. Individuals will be designated as voluntarily eligible if they are Medicare-Medicaid
enrollees who otherwise meet the Virtual PACE eligibility criteria but who:
are already enrolled in a Medicare Managed Care Plan, Medicaid Managed Care program
(Family Care, Family Care Partnership, PACE, SSI Managed Care), IRIS, or the
CIP/COP/Children’s Waiver program—these individuals would need to disenroll from their
current coordinated care program before enrolling in Virtual PACE; or
have elected their Medicare hospice benefit prior to Virtual PACE automatic enrollment; or
have private Medigap supplemental policies, employer-sponsored insurance, or are retirees
with an employer/union paid a Part D drug subsidy by Medicare—enrollment in Virtual PACE
could affect their benefit(s).
14. How will the Centers for Medicare & Medicaid Services (CMS) and the Wisconsin
Department of Health Services (DHS) ensure that enrollees understand their choices?
CMS and DHS will work together to engage enrollees, their families, their support systems, and
community stakeholders in outreach and education activities designed to fully explain the program
design, allow everyone to provide input, alleviate any concerns, and support informed decisions.
DHS will work with advocates to develop easily understandable, member-targeted educational
materials that are linguistically and culturally appropriate for the demonstration population.
Eligible individuals residing in participating nursing homes will receive educational materials to
inform them about their benefits, rights, and choices. Virtual PACE will notify beneficiaries of
their enrollment at least 60 days before it is to take effect and instruct them about how to receive
more information about the program or opt out of the demonstration. A help line will assist
individuals with immediate questions or concerns and provide guidance about available options.
Educational materials and enrollment notifications will also be mailed to each enrollee’s power of
attorney or guardian.
15. How often can enrollees change ICOs?
Enrollees may change ICOs (if alternative ICOs are available in their service area) or opt out of
the demonstration at any time. Changes and disenrollments will be effective the first day of the
following month.
16. Where can enrollees get questions answered about the Virtual PACE demonstration?
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Participating ICOs will employ customer service representatives who can answer inquiries and
respond to complaints and concerns. Customer service standards will be no less robust than the
combined Medicare and Medicaid standards. In addition, CMS and DHS will provide sufficient
call center and customer service representatives to address questions and concerns, such as 1-800-
MEDICARE and existing State customer service resources. CMS and DHS will also leverage and
support existing resources to assist beneficiaries and their caregivers, including community based
organizations, State Health Insurance Programs, and Aging and Disability Resource Centers. The
ICOs, CMS, and DHS will work to ensure that the language and cultural competency of customer
service representatives adequately meets the needs of the enrollee population.
17. How will CMS and DHS ensure that enrollees receive high-quality care under the
Virtual PACE demonstration?
A primary goal of the Virtual PACE demonstration is to improve care quality by building an
integrated system, reducing CMS/DHS regulatory infrastructure, and improving consumer
medical, mental health and long-term care access and overall satisfaction. CMS and DHS will
develop and conduct a comprehensive performance and quality monitoring process that
incorporates measures from a wide variety of data sources and existing programs, integrates them,
and aligns them as applicable to the demonstration population. ICOs will be required to report on a
set of measures including access and availability, care coordination/transitions, health and well-
being, mental and behavioral health, long-term supports and services, enrollee/caregiver
experience, and screening and prevention.
CMS and DHS will evaluate provider network adequacy for the participating ICOs using the
integrated standards for acute and primary services. CMS and DHS will ensure that all provider
networks meet adequacy requirements to handle the number of enrollees and needs of the target
population.
For enrollees that relocate to the community, Medicaid managed care standards for access to
home- and community-based waiver services will apply. More generalized standards will be
developed as the proportion of relocated individuals increases.
18. Will enrollees be involved in plan governance or operations of the Virtual PACE
demonstration?
Yes. CMS and DHS will require participating ICOs to obtain consumer and community input on
issues of program management and enrollee care through a range of approaches, which may
include enrollee participation on governing boards and quality review bodies. Each participating
ICO must establish at least one consumer advisory committee and a process for that committee to
provide input to the governing board. ICOs must also demonstrate participation of consumers with
disabilities, including enrollees, within their governance structures.
Virtual PACE Frequently Asked Questions
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19. Will there be an evaluation of the Virtual PACE demonstration?
Yes, CMS is funding and managing the evaluation of the Virtual PACE demonstration. CMS has
contracted with an external independent evaluator, RTI International, to measure, monitor, and
evaluate the overall impact of the demonstration, including impacts on Medicare and Medicaid
expenditures and service utilization.
The Virtual PACE demonstration will utilize a pre-post evaluation design that looks at
performance on measures over time. The evaluation will use a comparison group to analyze the
impact of the demonstration.
The evaluation of the demonstration will not affect continuation of services members receive. It is
expected that all necessary service transitions are well planned and communicated to affected
parties with proper notice.
20. How is Virtual PACE different from Family Care and Family Care
Partnership?
Virtual PACE shares features of the Family Care and Family Care Partnership programs, which
mostly stem from the latitude of services provided in these programs. However, as a second-
generation integrated care model, Virtual PACE builds on the experience of these programs and
offers unique opportunities available only through Virtual PACE:
a primary target population of long-term nursing home residents who are dually eligible
and are on the Medicaid paid stay;
enhanced person-centeredness in all health and long-term care decisions;
a flexible Interdisciplinary Team complements and works with nursing home staff in a
synergetic and efficient manner;
greater access to all Medicaid- and Medicare-covered services;
an integrated benefit package with services provided independent from traditional payor source;
improved coordination of the service delivery system and overall accountability;
integration of the care organization’s operational processes and requirements that are
otherwise regulated separately and are administratively burdensome; and
an enrollment process that is seamless with coverage that starts on the same day for all
benefits.
21. Why is it called Virtual PACE?
Virtual PACE borrows its naming convention from the Programs of All-inclusive Care for the
Elderly (PACE), one of the few fully integrated programs. Apart from the integration, Virtual
PACE is a new program in the continuum of long term care programs available in Wisconsin and
differs from PACE in several ways:
care is not exclusively in a day-center setting;
the demonstration is not limited to elderly individuals;
Virtual PACE Frequently Asked Questions
Page 7 of 7
maintaining enrollees’ current providers is encouraged.
22. Where can I find more information about Virtual PACE?
To learn more about the program, please visit Virtual PACE website:
http://www.dhs.wisconsin.gov/virtualpace
Also, you may sign up to receive updates via e-mail:
http://www.dhs.wisconsin.gov/virtualpace/listserv.htm
