1. Department of Medical Assistance Services
Proposed Initiatives for Medicaid Managed Long-Term Services and Supports (MLTSS)
Karen Kimsey and Tammy Whitlock
Complex Care and Services
Virginia Department of Medical Assistance Services
DMAS Announcement to Interested Plans
June 2, 2015

2. Agenda Welcome Medicaid Reform Initiatives General Assembly Directives
Current Program Models
Medicaid Long Term Care Services
Future Managed Care Initiatives
Medicaid Managed Care for Individuals Eligible for CCC but Not Enrolled
Managed Long-Term Services and Supports
Next Steps
Questions
Welcome
This meeting shares information about the Department’s proposed initiative for transitioning Medicaid populations who are currently served through the DMAS fee-for-service delivery model into integrated managed care model(s). The anticipated implementation timeframe for the Managed Long-term Services and Supports (MLTSS) initiative is mid DMAS will only present information relevant to this MLTSS initiative during the meeting, therefore other DMAS projects and upcoming initiatives will not be discussed.
To maximize transparency, this is a public meeting; however, the information and presentations shared during the meeting will be targeted toward health plans that may be interested in submitting proposals once DMAS releases the related MLTSS Request for Proposal (RFP).

3. Moving Forward with Medicaid Reform Initiatives
Phase 3
Move Forward with Coordination of LTSS
Phase 2
Implement Innovations in Service Delivery, Administration, & Beneficiary Engagement
Phase 1
Advance Reforms In-Progress
Phase 1: Advance Reforms Currently in Progress
• CCC, BHSA, Managed Foster Care, New eligibility and enrollment system
Phase 2: Implement Innovations in Service Delivery, Administration, and Beneficiary Engagement
• Medallion 3.0 Enhancements
• Simplify the administration of Medicaid through any necessary waivers and/or State Plan authorization under Title XIX or XXI of the Social Security Act;
Phase 3: Move Forward with Coordination of Long-Term Services and Supports
ID/DD Waiver Redesign - Progressing
Move remaining populations into managed care (including facility-based and home and community-based services)

4. CURRENT STATUS OF PHASE 3 REFORMS (MIRC)
Title
Status
ID/DD Waiver Redesign
October First Phase of DBHDs Study completed
5 Subgroups created and to provide recommendations for design
Based upon recommendations, plan is to amend current waivers
Amended waivers would be renamed - Community Living Waiver, Family and Individual Supports Waiver, and Building Independence waiver. All waivers would serve both ID and DD populations
All non-dual EDCD waiver enrollees in Managed Care for medical needs
In combination with the acute and long-term care (ALTC) Phase 1 program, this initiative became known as the health and acute care project (HAP)
Individuals enrolled in Medallion 3 (M3) who subsequently enroll into one of 5 home and community based care waivers (excludes Tech Waiver) maintain their enrollment in M3 for acute and primary care services.
In December 2014, DMAS transitioned individuals in the EDCD waiver, who were otherwise eligible for managed care, i.e., did not meet any managed care exclusions, into one of the Medallion 3.0 health plans for acute and primary care services. (Included approximately 2,700 EDCD individuals).
As of May 1, ,010 HCBS individuals are enrolled in Medallion 3 for their acute and primary services; their long-term services and supports are paid through fee-for-service.
Progressing

5. PHASE 3 REFORMS REMAINING. . .
Title
Status
All inclusive Coordinated Care for LTC Beneficiaries (coordinated delivery for all LTSS)
Original Goal - By Summer 2016
Complete the transition of all non-dual waiver recipients in the six home and community based care waivers and their community long term care services into coordinated care networks. (HAP for remaining waivers.)
Complete Statewide Commonwealth Coordinated Care by July 2018
Original Goal – By July 2018
Implemented the voluntary duals demonstration program in March 2014; completed regional phases of automatic assignment phase in November 2014; currently operating in 103 of localities; provides choice of at least 2 health plans per locality except for a few localities. Focus at this time is on quality evaluation, monitoring , oversight.
Approximately 25K individuals are enrolled in CCC as of March and another 37K are eligible but not enrolled.
July After the Commonwealth Coordinated Care (Duals) demonstration is completed, upon CMS approval expand statewide with all the remaining dual populations and all their medical, behavioral, and long term care services.
These are the populations that we will be talking about later in the presentation

6. VA General Assembly Directives
Beginning in 2011 and continuing in the 2015 session, the Virginia General Assembly has directed DMAS to continue with reform efforts to transition fee-for-service (FFS) populations into managed care so the Commonwealth can take advantage of the benefits of managed care as a delivery model, including:
increased access due to larger and more comprehensive provider networks and network management;
accountability;
administrative benefits DMAS has not been able to replicate (care management, nurse and other call lines, maternity and education programs);
budget predictability through capitated payments;
focused quality improvement programs; and,
tighter and more complex medical management.
Acts of Assembly (2011, 2012, 2013, 2014, and 2015)

7. VA General Assembly Directives
The 2015 Appropriations Act – Item 301.TTT, directs DMAS to seek reforms to include all remaining Medicaid populations and services, including long-term care and home- and community-based waiver services into cost-effective, managed and coordinated delivery systems.

8. Current DMAS Service Models
Fee For Service
Serves certain coverage groups and is also the delivery system for most long-term services and supports (LTSS); often results in fragmented care coordination
Commonwealth Coordinated Care (CCC)
Serves certain full-benefit adult duals (age 21 and older) ; fully integrated model ; includes CCC eligible nursing facility and EDCD Waiver participants
Program of All-Inclusive Care for the Elderly (PACE)
Serves adults age 55 and older who meet nursing facility criteria; fully integrated system of care; community alternative to nursing facility care
Medallion 3.0
Serves pregnant women, children, adults (caretakers) and ABD without LTSS through a coordinated delivery model; excludes LTSS
With the exception of fee-for-service, DMAS Service models offer access to coordinated care
Under FFS, care coordination is difficult and fragmented
Fee for service is the vehicle that delivers most LTSS;
Our most vulnerable beneficiaries deserve access to integrated care across all delivery systems and level of care transitions

9. Composition of Virginia Medicaid Expenditures SFY 2014
Long-Term Care Services
Medical
Services

10. VA’s HCBS Waivers/Alternative Institutional Placements
Alternate Institutional Placement
Alzheimer’s Assisted Living
Nursing Facility
EDCD
Developmentally Disabled
Intermediate Care Facility for Individuals with Intellectual Disabilities
Intellectual Disability
Day Support
Technology Assisted
Specialized Care in Nursing Facility for Adult / Hospital for children
Waiver program service descriptions and eligibility criteria may be found on the DMAS website

11. Virginia Medicaid Expenditures Long Term Care Services
Strong commitment toward community based treatment
Notes:
Average annual growth total Long Term Care services – 7%
Average annual growth Institutional services– 3%
Average annual growth Community-Based services– 13%
Proportion of Long Term Care services paid through Community-Based care has increase from 32% in FY04 to 55% in FY14

12. Virginia Medicaid HCBS Waivers – Enrollment and Wait List Information
Slot/Wait List Summary
Enrollment *
Waiting List
EDCD
30,460
N/A
MR/ID
10,017
4,941** DD
909
807
Tech
293
Day Support
276
4,941 **
Alzheimer’s 56
Current wait list information is available on the web at
Notes:
*Enrollment for the HCBS Waivers as of March 2015 and is subject to frequent change
**This is the same waiting list for services
Source: Virginia MMIS, Databases

13. Proposed Future MLTSS Initiatives

14. Managed Long-Term Services and Supports Future
Coordinated system of care that focuses on improving access, quality, and efficiency
Provides greater flexibility to serve individuals before they have higher needs
Improves quality
Improves efficiency in the system
Includes value based purchasing models
Better manages and reduces expenditures
Regarding value based purchasing - we are exploring best practices and models used in other states, as well as Medicare, who has publically stated that by end of % of their payments will be value based and by the end of % of their payments will be value based.

15. The Plan
To move 107,000 individuals into mandatory managed care model(s) to improve their lives

16. Populations to Transition from FFS to Managed Care
Those Eligible for CCC but Who are Not Enrolled
(Approximately 37K)
Duals Excluded From the CCC Demo
(Approximately 50K)
Medicaid Only Individuals Receiving LTSS
(Approximately 20K)

17. Phased Implementation
Proposed
Phase 1 –
Managed Medicaid for
individuals eligible for CCC
but not enrolled
Mid 2016
Transition approximately 37,000 CCC eligible individuals who have chosen not to participate in CCC into a mandatory managed care program for Medicaid services.
Includes Medicaid primary and acute, LTSS, and behavioral services coordinated by a CCC health plan (Anthem, Humana and Virginia Premier).
Phase 1: FFS Medicaid will no longer be an option for individuals that opt out of CCC

18. Phase 1: Managed Medicaid Enrollment for CCC Opt-Outs
Proposed
Key strategy is to replace the current fee-for-service structure with managed care, for Medicaid services for individuals that opt-out of CCC
Improves continuity of care
Allows the health plans to provide care coordination on a continuous basis versus brief periods of opt-in/opt-out enrollment elections
Better care coordination could lead to better health outcomes
Allows the member to see the program benefits (coordinated care, value added services, enhanced benefits, 24 hour nurse line, etc.)
Increased enrollment stability could improve health plan viability
Allows DMAS and the CCC Plans to build on existing infrastructure, networks, and relationships
CMS rules require that CCC eligible individuals have the opportunity to opt-in or out at anytime.
We anticipate there will be movement between these two delivery models (CCC optional and managed care for individuals that opt-out of CCC).
Having the same plans will help with transition of and continuity of care for these CCC eligible individuals.
The mandatory program will run concurrently with the Demo.

19. Phase 1 Managed Medicaid for CCC Opt-Outs (Continued)
Proposed
Design Element
CCC with Full Integration
CCC with Medicaid Only (New)
Population
CCC Opt-Ins
CCC Opt-Outs
Services
Medicare/Medicaid covered services
Same Medicaid services as CCC; health plan will coordinate benefits with the individual’s Medicare plan
Service Area
CCC Demo Regions (
CCC Demo Regions
Health Plans
CCC Plans (Anthem, Humana, and Virginia Premier)
CCC Plans
Federal Authority
Dual Demonstration 1932(a) State Plan Amendment
CMS 1915 (b) (c) Waiver
Contract
CCC 3 Way Contract
New CCC 2 Way Contract
Member Materials
Member handbook and 1 CCC ID Card for Medicare and Medicaid
Member handbook and separate Medicaid Card
Appeals Process
Unified Medicare/Medicaid Process
Medicaid process consistent with Federal/State regulations
Need a name for the new CCC product

20. Phased Implementation
Proposed
Phase 2 –
Managed Long Term Services and Supports
Mid 2017
Transition approximately 70,000 eligible individuals, including duals not eligible for CCC and individuals receiving LTSS (institution or HCBS waiver) into coordinated care.
Includes primary and acute, LTSS, and behavioral services. The health plans will be selected through a competitive procurement process.
Phase 1: FFS Medicaid will no longer be an option for individuals that opt out of CCC

21. Phase 2: Managed Medicaid for CCC Excluded Duals and LTSS
Proposed
New managed care program for remaining FFS individuals receiving LTSS
Would be the fourth DMAS managed care program in addition to the current Medallion 3.0, PACE, and CCC programs
Serves two general populations:
Duals excluded from the current CCC demonstration program (children, excluded regions, and select individuals receiving home and community based waiver services)
Non-duals receiving LTC services in institutions and the 6 home and community based care waivers
Choice of at least 2 plans; participation is mandatory
The health plans will be selected through a competitive procurement process

22. Phase 2 - Managed LTSS Design Elements
Proposed
Design Element
MLTSS
Eligible Population
Duals not eligible for CCC and individuals receiving LTSS
Excluded Populations
ICF/ID, limited coverage groups, others are being considered
Included Services
Full spectrum of care (primary, acute, long-term, behavioral health, care coordination); integrated model
Excluded Services
Very few carve-outs; ID, DD, and DS waiver services, dental, and school services are being considered at this time
Service Area
Plan to phase in by region and to operate statewide
Health Plans
To be determined through competitive RFP process
Federal Authority
1915 (b) (c) waiver
Contract
Fully-capitated risk-based; actuarially sound cap rates
Offers value based payment opportunities
Health Plan Requirements
Bureau of Insurance Approval and MCHIP Certification through VDH ; approved or seeking approval by CMS to operate as a Dual SNP
Quality
NCQA Accreditation and 1915 (c) waiver quality assurances
Beneficiary Protections
Continuity of care, Ombudsman, appeals, others to be determined

23. MLTSS launch is anticipated mid-year 2017
Next Steps
MLTSS RFP
Development, Review,
Approval, Post
Evaluation, Award
Contract Execution
Regulatory Authority, Rate and Data Book Development
CMS 1915 (b)(c) Waiver
Regulations
Systems Changes
Requirements, Design, Testing, Implementation
Communication & Outreach
Town- halls, stakeholder calls, trainings, etc.
Assess MCO, DMAS, Other Contractor systems Readiness
Networks,
Systems
Transition
Etc.
Proposed
Managed Care Contract Signing and Assessment of MCO Contractor Readiness
MLTSS launch is anticipated mid-year 2017
Changes and Readiness of Contractors:
Enrollment broker, CD Fiscal Employer Agent, BHSA, Service Auth, Dental LogistiCare, etc.
Phased implementation
Mandatory Medicaid will begin for new passively assigned CCC individuals that opt-out in May/June 2016
Mandatory Medicaid for prior CCC opt-outs will begin Mid year 2016
MLTSS will be implemented in phases, the initial go-live is anticipated for mid-year of 2017
Vendor Presentations - June 29, 30 or July 1
DMAS invites companies with experience in integrated managed care models to participate in a 75 minute Vendor Demonstration (55 minute presentation with 20 minutes for questions) on either June 29, 30 or July 1. These presentations will be held in Conference Rooms 7A/B at the Virginia Department of Medical Assistance Services, 600 East Broad Street, Richmond, VA Specific time slots and registration information can be found at the end of this invitation.
Strategic Planning
On-Going:
Stakeholder Involvement
Consult with CMS
Consult with Mgmt
Public Comment

24. Stakeholders Are Key (Includes Health Plans)
Stakeholder involvement is crucial
Request for Comment
Meetings with Health Plans
Town Halls
Meetings with Stakeholder Groups (including Advisory Committee)
Public Comment Notice Posted on DMAS and VA Town Hall; comments due by June 16, 2015
Standardization across health plans – need their suggestions

25. Questions and Discussion
Topics to Avoid - Asking, Answering or Discussing
Costs or Budget
RFP – Structure, Scope or other questions related to possible future RFP
Other participants or their solutions
Period of Performance for possible future RFP
Vendor References

26. References
CCC Demo Regions – Available on the DMAS website at:
MLTSS updates will be posted as available on the DMAS website at:
Implementing Medicaid Reform in Virginia (Report to the General Assembly of Virginia, January 2014)