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Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services Arc Of Virginia Convention August 9, 2013.

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Presentation on theme: "Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services Arc Of Virginia Convention August 9, 2013."— Presentation transcript:

1 Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services Arc Of Virginia Convention August 9, 2013 An Introduction to Commonwealth Coordinated Care

2 Overview 2 Medicare/Medicaid today Opportunities for Coordinated Care in Virginia Virginia’s Program

3 Medicare and Medicaid today 3 Medicare and Medicaid: Not designed to work together Inefficient = more costly delivery system Each program has its own: Rules Regulations Requirements Coverage Some health plans that currently serve Medicare and Medicaid beneficiaries, administer different products that are not aligned

4 Medicare and Medicaid today 444 The costs of serving these individuals are rising exponentially: At the national level; spending 39% of Medicaid funds on 15% of the Medicaid population 1 In Virginia; spending 33% of Medicaid funds on 19% of the Medicaid population 2

5 Who are Medicare-Medicaid enrollees? 5 Older adults, including those receiving long term care services and supports Individuals with disabilities, including those receiving long term care and supports

6 Who are Medicare-Medicaid enrollees? 6 Individuals who have a unique set of circumstances, care and support needs, options and opportunities under a coordinated care system Individuals who receive full benefit Medicare and Medicaid coverage

7 Common characteristics and conditions 7 Source: Hilltop Institute -- MedPac, June 2008; based on data from the 2005 MCBS Cost and Use file *Data from 2003 MCBS

8 Costs for Medicare-Medicaid enrollees vs. costs for other Medicare enrollees 8 Source: Hilltop Institute -- MedPac, June 2008

9 Who are Medicare-Medicaid enrollees in Virginia? 9 65% are female 60% are age 65 and older 19% have 5 or more chronic conditions Average monthly spending on individuals on Medicare-Medicaid, is $2,479 compared to $567 for Medicare-only beneficiaries Source: Medicare-Medicaid Enrollee State Profile, Virginia, Centers for Medicare & Medicaid Services, 2007.

10 Who pays for what 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  Hospital once Medicare benefits exhausted  Home- and community-based services (HCBS)  Nursing facility (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 10

11 Challenges for Individuals Understanding two programs Confusion with billing Multiple insurance cards Not knowing who to call with questions Frustration over delays getting care and support Lack of holistic care 11

12 What does care look like for Medicare- Medicaid enrollees now? Three ID cards: Medicare, Medicaid, and prescription drugs Three different sets of benefits Multiple providers who may not coordinate Health care decisions uncoordinated and not made from a person-centered perspective 12

13 Fragmented Not Coordinated Complicated Difficult to Navigate Not Focused on the Individual Gaps in Care What does care look like for Medicare- Medicaid enrollees now? Like navigating a traffic circle…. 13

14 Virginia’s Solution: Provides high-quality, person-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences Blends Medicare and Medicaid services and financing to streamline care and eliminate cost shifting 14

15 15 Creates a single program 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 Virginia’s Solution:

16 16 Virginia is one of six states with a signed MOU

17 17 Virginia’s Service Regions

18 Who is eligible? 18 Full benefit Medicare-Medicaid Enrollees (entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits) Participants in the Elderly or Disabled with Consumer Direction Waiver Residents of nursing facilities Age 21 and Over Live in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)

19 19 Approximately 78,600 Medicare-Medicaid Enrollees Who is eligible? Region Nursing FacilityEDCD WavierCommunity Non-waiver Total Central VA4,4303,76216,13524,327 Northern VA1,9351,76612,95216,653 Tidewater3,0312,49212,57518,098 Charlottesville1,4778424,4276,747 Roanoke2,8331,3558,58312,771 Total13,70610,21754,67278,596

20 Who is not eligible? 20 Individuals not eligible include those in: ID, DD, Day Support, Alzheimer's Technology Assisted HCBS Waivers MH/ID facilities ICF/IDs PACE (although they can opt in) Long Stay Hospitals Money Follows the Person (MFP) program Hospice

21 Benefits for Virginia 21 Eliminates cost shifting Achieves cost savings Slows the rate of Medicaid cost growth for Virginia Reduces duplicative or unnecessary services Streamlines administrative burden Single set of quality reporting measures, appeals and auditing Promotes and measures improvements in quality of life and health outcomes

22 Benefits for Individuals and Families 22 One system of person-centered care One ID card for all care One 24/7 toll free phone number for assistance Behavioral health homes for individuals with Serious Mental Illness (SMI) A unified appeals process

23 Benefits for Individuals and Families Cont’d 23 Choice will remain (Participation, Health Plans, Services) Use of an external ombudsman Will use the same fiscal agent for consumer-directed services to ensure continuity of care Beneficiaries will not have to change providers until their authorization runs out and only if the provider is not in the network

24 How are Individuals Enrolled? 24 Eligible individuals will receive information during the national Medicare annual open enrollment period (October 15 – December 7, 2013) Enrollment will initially be voluntary, followed by automatic enrollment with ability to opt out anytime

25 Commonwealth Coordinated Care Enrollment Timeline 25 Central Virginia/Richmond and Tidewater areas: January 2014: Voluntary enrollment begins February 2014: Coverage begins May 2014: Automatic enrollment begins July 2014: Coverage for those automatically enrolled begins Northern Virginia, Roanoke, Charlottesville areas: May 2014: Voluntary enrollment begins June 2014: Coverage begins August 2014: Automatic enrollment begins October 2014: Coverage for those automatically enrolled begins

26 Outreach and Education 26 Stakeholder engagement Dedicated website 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 Partnering with Virginia Insurance Counseling Assistance program (VICAP) counselors and Virginia’s Long-Term Care Ombudsman Program

27 Outreach and Education 27 DMAS and Participating Plans will provide outreach and education to: Individuals and their families State agencies Local agencies Community partners Advocacy groups Associations Legislators Providers Nursing facilities

28 Role of VICAP Counselors 28 DARS and DMAS will train counselors Counselors will be provided with materials and tools Counselors will provide information to eligible enrollees and guide them through the process of connecting with an enrollment facilitator

29 Role of Virginia’s Long Term Care Ombudsmen 29 Receiving, investigating and resolving complaints about quality of long term care issues Assisting individuals in exercising their rights Mediating concerns between the individual and/or their families and the long term care provider

30 In the coming weeks…. 30 Announcement of the selection of participating health plans Formation of workgroups to design and implement various components Continued outreach and education

31 Contact Information 31 Office of Coordinated Care Virginia Department of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA 23219

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