Overview of the Virginia Medicaid Program

Kristin Burhop Director, Office of Coordinated CareVirginia Department of Medical Assistance Services

Adult Services CommitteeSeptember 18th, 2013

http://dmasva.dmas.virginia.gov

Department of Medical Assistance Services

Overview2Current structure of Medicare/Medicaid

Opportunities for Coordinated Care in Virginia

Virginias Program: Commonwealth Coordinated Care

Medicare-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.

3Medicare and Medicaid today4Medicare 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 coverageAt the national level we are spending 39% of Medicaid funds on 15% of the population

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

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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

66Who are Medicare-Medicaid Enrollees?7Receive full benefit Medicare and Medicaid coverageMedicare-Medicaid enrollees include:Older adults, including those receiving long term care services and supportsIndividuals with disabilities, including those receiving long term care and supports

Each individual has a unique set of circumstances, care and support needs, options and opportunities under a coordinated care system

Who are Medicare-Medicaid enrollees?8

Source: Hilltop Institute -- MedPac, June 2008; based on data from the 2005 MCBS Cost and Use file *Data from 2003 MCBS http://www.cms.hhs.gov/MCBS/Downloads/CNP_2003_dhsec8.pdf What 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 99

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.10History 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

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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

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13Creates 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

The Solution: Commonwealth Coordinated Care

Who is Eligible?14Full 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 OverLive in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)

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16Approximately 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 VA1,9351,76612,95216,653Tidewater3,0312,49212,57518,098Charlottesville1,4778424,4276,747Roanoke2,8331,3558,58312,771Total13,70610,21754,67278,59616Who is Not Eligible?17Individuals not eligible include those in:The ID, DD, Day Support, Alzheimer's, and Technology Assisted HCBS WaiversMH/ID facilitiesICF/IDsPACE (although they can opt in)Long Stay HospitalsThe Money Follows the Person (MFP) programHospice

Benefits for Virginia18Promotes and measures improvements in quality of life and health outcomesEliminate cost shifting between Medicare and Medicaid and achieve cost savings for States and CMSReduce duplicative or unnecessary servicesStreamline administrative burden with a single set of appeals, auditing and marketing rules, and quality reporting

Benefits for Individuals and Families19One system of coordinated carePerson-centered service coordination and case managementOne ID card for all care24 hour/7 days a week, toll free number for assistanceUnified appeals processFor individuals with Serious Mental Illness (SMI), behavioral health homes will be created in partnership with CSBs

Benefits for Providers20One 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 monthsCentralized appeal process

How are Individuals enrolled?21Eligible individuals identifiedIndividuals will first receive information in Fall 2013Enrollment will be conducted in phasesEnrollment will initially be voluntary, followed by automatic enrollment with ability to opt out anytime

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

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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 factors. The process considers beneficiaries prior enrollment in health plans and providers so enrollees can be served as well as possible.

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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 care or personal care provider in its network24

Intelligent AssignmentIf more than one health plans network includes the nursing facility or adult day provider or personal care 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.25Intelligent AssignmentMost importantly, if an individual is unhappy with the health plan chosen for them, he/she may request reassignment to another health plan.26

Enrollment27Central Virginia/Richmond and Tidewater areas:Voluntary enrollment begins Early 2014Coverage begins March 1, 2014Automatic enrollment begins May 1, 2014Coverage for those automatically enrolled begins July 1, 2014Northern Virginia, Roanoke, Charlottesville areas:Voluntary enrollment begins May 1, 2014Coverage begins June 1, 2014Automatic enrollment begins August 1, 2014Coverage for those automatically enrolled begins October 1, 2014

Health Plans28DMAS 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

Outreach and Education29Outreach and Education by DMAS will include:Stakeholder 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 VICAP counselors and Virginias Long-Term Care Ombudsmen

In the coming weeks.30Continue Readiness Reviews with Health Plans in negotiation

Continue design and implement various components of Commonwealth Coordinated Care with community and stakeholder feedback and input

Continued Outreach and Education

Contact Information31Emily Osl CarrDirector, Office of Coordinated CareVirginia Department of Medical Assistance Services600 E. Broad Street, Suite 1300Richmond, VA 23219(804) 588-4888Emily.carr@dmas.virginia.govChart10.930.370.10.040.210.140.280.190.150.110.20.070.190.020.280.090.390.110.130.12

Medicare-Medicaid EnrolleesOther Medicare Beneficiaries

Current slides (12_2008)Duals vs. non-dualsSource: Medicare Chartbook, 2005, KFF (data from MCBS 2002 Access to Care file)

Other data sourcesSourceDataMedPac Report to Congress, June 2004MCBS 2001 Cost & Use fileMedPac Databook, June 2005MCBS 2002 Cost & Use fileKFF website2002 seems to be most current

2003 dataSource: 2003 MCBS data tables: http://www.cms.hhs.gov/MCBS/Downloads/CNP_2003_dhsec8.pdfDualsNon-dualsSexMale3745Female6355AgeUnder 4514245-6423865-74274675-84223385+1311Race/ethnicityWhite5683Black227Hispanic156Other84Disease/conditions2+ chronic conditions7672Alzheimer's104Pulmonary disease2114Diabetes2819Stroke1511Health statusExcellent616Very good1228Good2831Fair3418Poor218Functional limitationNone2656IADL only18141-2 ADLs25193-6 ADLs3111Residential statusCommunity8298Long-term care facility192Education0-8 years33109-12 years, no diploma2314High school graduate2532Voc/tech48Some College916College degree621

2005 dataSource: MedPAC: A data book: Healthcare spending and the Medicare program, June 2008; Section 3Data: 2005 MCBS Cost & Use fileDualsNon-dualsOther Medicare BeneficiariesDual Eligibles (Medicare Beneficiaries with Medicaid)Income < 200% FPL37%93%SexAlzheimer's*4%10%Male3845Pulmonary disease*14%21%Female6255Diabetes*19%28%Stroke*11%15%AgePoor health status7%20%Under 653911Reside in LTC facility2%19%65-7426453-6 ADLs9%28%75-842332Under 6511%39%85+131285+12%13%Race/ethnicityWhite, non-Hispanic5783Black, non-Hispanic198Hispanic156Other94Disease/conditions2+ chronic conditionsAlzheimer'sPulmonary diseaseDiabetesStrokeHealth statusExcellent/very good1645Good/Fair6348Poor207Functional limitationNo ADLs47711-2 ADLs25193-6 ADLs289Residential statusCommunity8198Long-term care facility192EducationNo high school diploma5423High school graduate2431Some college or more18459699Income statusBelow poverty539100-125% poverty217125-200% poverty1921200-400% poverty536Over 400% poverty128ResidenceUrban7177Rural2823Average Medicare paymentInpatient hospital$4,586$2,618Physician$2,880$2,058Outpatient hospital$1,641$749Home health$500$311Skilled nursing facility$1,078$317Hospice$273$136Total$10,994$6,212Percentage using Medicare serviceInpatient hospital27.818.3Physician89.683.7Outpatient hospital72.661.3Home health10.67.8Skilled nursing facility8.67.3Hospice3.11.8Any service91.885.2Medicare enrollees1684Medicare spending2575Medicaid enrollment5.8 million(source-data compendium)

2005 data

Dual Eligibles (Medicare Beneficiaries with Medicaid)Other Medicare BeneficiariesCharacteristics of Dual Eligibles Compared to Other Medicare Beneficiaries, 2005

Medicaid data from CPSwhite, nh25722black, nh9054Asian, nh1208Other1754Total37738

2008 dataSource: Medicare: A primer 2009 (KFF): http://www.kff.org/medicare/upload/7615-02.pdfDuals, full6.2 millionDuals, partial1.7 million