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Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services VAPCP Spring Conference May 21, 2013

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Presentation on theme: "Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services VAPCP Spring Conference May 21, 2013"— Presentation transcript:

1 Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services VAPCP Spring Conference May 21, Department of Medical Assistance Services

2 Overview 2 Current structure of Medicare/Medicaid Opportunities for Coordinated Care in Virginia Virginia’s Program: Commonwealth Coordinated Care

3 Who are Medicare-Medicaid Enrollees? Receive both full benefit Medicare and Medicaid coverage 58.8% age 65 or older 41.2% under age 65 Often have multiple, complex health care needs. Over 9 million Americans are eligible for Medicare and Medicaid (known as Medicare- Medicaid enrollees) 3

4 Who are Medicare-Medicaid Enrollees? 4 Medicare-Medicaid enrollees include: Older adults, including those receiving long term care services and supports Individuals 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

5 Who Pays for Services in Virginia? MEDICARE  Hospital care  Physician & ancillary services  Skilled nursing facility (SNF) care (up to 100 days)  Home health care  Hospice  Prescription drugs  Durable medical equipment MEDICAID  Nursing facility (once Medicare benefits exhausted)  Home- and community-based services (HCBS)  Hospital once Medicare benefits exhausted  Optional services: personal care, select home health care, rehabilitative services, some behavioral health  Some prescription drugs not covered by Medicare  Durable medical equipment not covered by Medicare 5

6 The Problem for the U.S. & Virginia 6 Medicare 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 We can’t afford to continue to support rising costs without intervention.

7 Costs for Medicare- Medicaid vs. Medicare Only Enrollees 7 Source: Hilltop Institute -- MedPac, June 2008

8 8 WITHOUT COORDINATED CARE INDIVIDUALS MAY HAVE: x Three ID cards: Medicare, Medicaid, and prescription drugs x Three different sets of benefits-hard to understand all x Multiple providers who rarely communicate x Health care decisions uncoordinated and not made from the person-centered perspective x Serious consideration for nursing home placement; Medicare/Medicaid only pays for very limited home health aide services

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10 n Fragmented n Not Coordinated n Complicated n Difficult to Navigate n Not Focused on the Individual n Gaps in Care What Does the Medicare-Medicaid Benefit Look Like Now? Like navigating a traffic circle…. 10

11 The Solution: Commonwealth Coordinated Care Provides high-quality, person-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences Blends Medicare’s and Medicaid’s services and financing to streamline care and eliminate cost shifting 11

12 12 Creates one accountable entity to coordinate delivery of primary, preventive, acute, behavioral, and long-term services and supports Promotes the use of home- and community-based behavioral and long-term services and supports Supports improved transitions between acute and long-term facilities The Solution: Commonwealth Coordinated Care

13 Who is Eligible? 13 Full benefit Medicare-Medicaid Enrollees including but not limited to: Participants in the Elderly and Disabled with Consumer Direction Waiver, and Residents of nursing facilities Age 21 and Over Live in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)

14 Virginia’s Strategies to Address Needs Enhanced Care Management  DMAS 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 NFs  Behavioral “Health Homes” for individuals with SMI with MCOs partnering with the CSBs  Encouraging MCOs to link/sub-contract with different providers for care coordination (e.g., CSBs, adult day care centers, NFs) 14

15 Virginia’s Strategies to Address Needs  Develop 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 lines  Provide access to disease & chronic care management services that could improve overall health conditions and/or slow down decline  Develop strong quality improvement programs, measures and monitoring  Rate Development; will propose method for applying savings adjustments 15

16 16 Approximately 78,600 Medicare-Medicaid Enrollees Medicare-Medicaid Enrollees in Virginia eligible for Commonwealth Coordinated Care Region Nursing FacilityEDCD WavierCommunity Non-waiver Total Central VA4,4303,76216,13524,327 Northern VA1,9351,76612,95216,653 Tidewater3,0312,49212,57518,098 Charlottesville1, ,4276,747 Roanoke2,8331,3558,58312,771 Total13,70610,21754,67278,596

17 Proposed enrollment process 17 Eligible Populations Enrollment and Disenrollment Process and Timeframes: Opt-in only period; Passive enrollment; Two enrollment phases, based on regions Offering opt out provisions before and after enrollment Developing enrollment algorithms to connect individuals with MCOs based on past enrollment and provider networks, to extent feasible

18 Who is Not Eligible? 18 Individuals not eligible include those in: The ID, DD, Day Support, Alzheimer's Technology Assisted HCBS Waivers MH/ID facilities ICF/IDs PACE (although they can opt in) Long Stay Hospitals The Money Follows the Person (MFP) program

19 Benefits for Virginia 19 Eliminate cost shifting between Medicare and Medicaid and achieve cost savings for States and CMS Reduce avoidable, duplicative or unnecessary services Streamline administrative burden with a single set of appeals, auditing and marketing rules, and quality reporting measures Builds upon the success of managed care in Medicaid environment Promotes and measures improvements in quality of life and health outcomes Slows the rate of both Medicare and Medicaid cost growth

20 Benefits for Individuals and Families 20 One system of coordinated care Person-centered service coordination and case management One ID card for all care 24 hour/7 days a week, toll free number for assistance Disease and chronic care management (if applicable) Health plans may add supplemental/enhanced services, such as dental care, vision and hearing One appeals process Consumer protections

21 Benefits for Providers 21 One card for each member May participate with multiple Medicare/Medicaid Plans but will not have multiple authorization and payment processes between Medicaid and Medicare Initial authorization periods will be honored for up to 6 months Centralized appeal process

22 How Do Individuals Enroll? 22 Individuals may choose to enroll or may be passively enrolled Individuals always have the option to opt out of the program Once an individual is identified as being eligible for the Commonwealth Coordinated Care program, he/she will begin receiving notices of their eligibility for the program Individuals will first receive information during Medicare Advantage open enrollment period (October 15 – December 7)

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24 Consumer Protections 24  Choice of plans and providers  Continuity of care  Enrollment assistance  Ombudsman assistance  Person-centered approach  ADA, Civil Rights compliance  Beneficiary participation on MCO governing boards  Customer service - access to a 24/7 toll-free number  DMAS/CMS daily monitoring and oversight

25 Outreach and Education 25 Outreach and education will be conducted jointly by DMAS and Participating Plans. Outreach and Education by DMAS will include: Stakeholder engagement-Advisory Committee Dedicated website and Trainings to providers and local agencies Educational materials such as presentations, Toolkits, fact sheets, FAQs, public service announcements, Working with community partners to educate and inform- workgroups being formed Ombudsman and ADRC Grant

26 Virginia Demonstration Timeline 26 DateHigh Level Activity March 2013-Finalize MOU and RFP -Finalize State Plan Amendment and Waiver amendment April-Discuss MOU with CMS -Publish RFA -Develop Education and Outreach Plan -Submit State Plan Amendment May-Responses due from MCOs (mid-month) -Release data book - Begin Development of Readiness Review Documents June-Announce Selected MCOs - Publish draft rates July-Submit outreach and planning grant to CMS -Finalize rates -Begin Readiness Review -Draft 3-way contract

27 Virginia Demonstration Timeline 27 MonthHigh Level Activity August-Continue Readiness Review September-Sign 3-way Contract October-Begin Education and Outreach BLITZ (ongoing) November- December -Keep calm and carry on! January 2014-“Soft Start”-Begin Opt-in enrollment for 60 days March 2014-Begin MCO assignment April Tidewater and Richmond regions “go live” with passive enrollment

28 Contact Information 28 Emily Osl Carr Director, Office of Coordinated Care Virginia Department of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA (804)


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