Managed Medicaid in Virginia

Revenue Cycle Trends and Updates LTC/Post Acute Care Case Management of Reimbursement

Government sponsored program days numberedPayment TransformationDelivery Model Redesign

Accountability for QualityAbility to document improved outcomesDrive reduced LOS without elevated risks of returns to hospitalStrong customer satisfaction

High Deductible EnvironmentProvider burden for estimatesImplementation/Cost of Verification tools and online technologyAcceptance of Payments electronically

ICD -10 10/1/2015

Transition to Price Based Payment

Three key pieces of legislation

Affordable Care Act (Medicaid Expansion)Health Benefit Exchange Financial Alignment Demonstration

Cost Based vs Price Based OperationCOST BASED

Government Sponsored, Per Diem

PRICE BASED

RUGs III based Reimbursement 11/1

Possibility of higher reimbursement

Increased importance of detailed and accurate documentation

Commonwealth Coordinated Care is a program the coordinates care for dual eligible residents in the State of Virginia. The care provided is not limited to Long Term Care and includes acute, behavioral and primary services.

CCC is a State and Federal program. CMS and DMAS have chosen three MMPs (Medicare –Medicaid plans) to provide services in the five designated service regions. Anthem Healthkeepers, Humana and Virginia premier.

CCC EligibleDual Eligible

Age 21 or older

Non Hospice

Non comprehensive/Group plan/Tricare

Non QMB Only

Non PACE

Patient’s who have opted for a Medicare replacement are eligible

CCC Billing (MDS/DMAS/DSS)Custodial Assessments continue (92 days) and are transmitted to the

State (more often can help with CMI)

PPS Assessments continue on Medicare schedule and are held (ie Medicare Replacement)

Medicaid Eligibility Process remains unchanged

Redetermination process remains unchanged

Level of Care process remains unchanged

UAI process remains unchanged

Retro Medicaid, prior period will be billable to traditional Medicaid

CCC Payment, Medicaid 07/01/2014-10/31/2014

Reimbursement methods unchanged from current practice

11/01/2014

Centers will be reimbursed utilizing the Medicaid RUG III-34 grouper individual cmi risk adjustment payment

07/01/2014

Price BasedDirect rate =

Avg center case mix

Direct Cost to Ceiling not as important

No rate letters issued

11/01/2014

Price BasedDirect rate =

Resident Medicaid score

RUG III -34 grouper RUGS scores entered on

Medicaid claim

Medicaid Reimbursement Changes

12/31/2017

CCC Program ends

DMAS will enroll fee for service

populations into a MLTSS program

Potential Future Changes

CCC to MLTSS transition

Consistent with General Assembly directives in years 2011 and 2015 the Department of Medical Assistance Services will transition the majority of remaining Fee for Service (FFS) Medicaid enrollees into a coordinated and integrated managed care program

Intellectual Disability Programs will more than likely remain Fee for Service

CCC to MLTSS transition

DMAS will procure health plans to Administer the MLTSS program via a competitive procurement process (RFP)

Selected plans must have or be working towards obtaining the NCQA accreditation and approval by CMS to operate as a Dual Special Needs Plan

MLTSS will operate State-wide, plans may vary by region, there must be at least two health plans per region

Questions ?