1 Department of Medical Assistance Services An Introduction to Commonwealth Coordinated Care Plus (A Managed Long Term Services and Supports Program) Presented by: Tammy Whitlock Department of Medical Assistance Services September 14, 2016

2 Agenda  Virginia Public Procurement  Key Facts about Virginia Medicaid  Legislative Mandates  National Trends  Commonwealth Coordinated Care Plus  A comparison of CCC Plus and CCC  Next Steps  Ongoing Opportunity for Stakeholder Input  CCC Plus References

3 Virginia Public Procurement Act DMAS must operate under strict Code of Ethics Rules until successful completion of the competitive procurement process (also known as the RFP process), in accordance with the Virginia Public Procurement Act, §2.2‐4300 of the Code of Virginia. DMAS published the RFP on April 29, 2016, and it is available at: Presently, we are operating under a competitive procurement and we may not be able to respond to all of your questions.

4 Virginia’s Medicaid Program Facts 1 in 8 Virginians rely on Medicaid 1 in 3 Births in Virginia covered by Medicaid 58% Long-Term Services & Supports spending is in the community 1 Million + Virginians covered by Medicaid/CHIP 50% Medicaid beneficiaries are children 2 in 3 Residents in nursing facilities supported by Medicaid - Primary payer for LTSS Behavioral Health Medicaid is primary payer for services

5 Medicaid expenditures are disproportionate to covered populations. Older adults and individuals with disabilities make up over 25% of the total population, yet almost 70% of expenditures are attributed to this group. Virginia Medicaid Population and Expenditures

6 Legislative Mandates: Managed Care General Assembly Directives beginning 2011 through 2015 Continue to transition fee- for-service populations into managed care Phase 3 of Medicaid Reform Initiatives Move forward with managed long term services and supports (MLTSS) initiatives Value of Managed Care Timely access to appropriate, high- quality care; comprehensive care coordination; and budget predictability Consistent with Virginia General Assembly and Medicaid reform initiatives, DMAS is moving forward transitioning individuals from fee-for-service delivery models into managed care.

7 Benefits of Managed Care 7 Managed Care Basics DMAS contracts with managed care organizations (MCO) DMAS pays a per-member per- month (PMPM) payment MCOs contract with providers and pay claims 75% of Virginia Medicaid enrollees are currently enrolled in Medallion 3, a managed care program. Benefits of Managed Care Improves quality of care Broader provider network More flexible – can include services that cannot be provided in fee-for- service Actuarial soundness to ensure rates are not too low Care coordination assists member with navigation through system Medicaid no longer a “welfare program” – it is health coverage Private sector shares risk with government

8 Introducing Commonwealth Coordinated Care Plus (CCC Plus) 8 New statewide Medicaid managed care program beginning July Will serve 212,750 individuals with complex care needs. Integrated delivery model that includes medical services, behavioral health services and long-term services and supports.

9 Commonwealth Coordinated Care Plus: Vision and Goals Provide individuals with high-quality, person centered care and enhanced opportunities to improve their lives 1 Improve community-based infrastructure and community capacity to enable/ support care in the least restrictive and most integrated setting 2 Promote innovation and value- based payment strategies 3 Provide care coordination and better accommodate progressive needs of members 4 5 Better manage and reduce expenditures; reduce service gaps and the need for avoidable services, such as hospitalizations and emergency room use VISION: To implement a coordinated system of care that builds on lessons learned and focuses on improved quality, access and efficiency

10 CCC Plus Person Centered Delivery Model Fully Integrated & Person Centered Model Integrates Physical, Behavioral, SUD, & LTSS Intensive Care Coordination/ Integration with Medicare Timely Access & Enhanced Community Capacity Improved Quality Management Rewards High Quality Care with Value Based Payments Improved Efficiency and Fiscal Stability

11 Medicare and Medicaid MEDICARE COVERS  Hospital care  Physician & ancillary services  Skilled nursing facility (SNF) care  Home health care  Hospice care  Prescription drugs  Durable medical equipment MEDICAID COVERS  Medicare Cost Sharing  Hospital and SNF (when Medicare benefits are exhausted)  Nursing home (custodial)  HCBS waiver services  Community behavioral health and substance use disorder services,  Medicare non-covered services, like OTC drugs, some DME and supplies, etc.

12 How will Medicare and Medicaid coordinate? CCC Plus requires each participating health plan to become a D-SNP as part of their plan offerings. D- SNP’s are Dual Eligible Special Needs Plans. D-SNP’s are Medicare Advantage Plans that include Part A, Part B, Part D and supplemental benefits. D-SNP’s operate under contracts with Medicare and Medicaid. Once D-SNP’s are operational, CCC Plus individuals will have the option to choose the same plan for Medicare and Medicaid coverage.

13 CCC Plus Populations Approximately 212,750 Individuals Duals (Full Medicaid) with and without LTSS Not CCC Enrolled 87,255 CCC Enrolled 26,866 will transition 1/2018 Non Duals with LTSS FFS 9,710 Medallion 3.0 HAP* 9,411 Non Dual /Non LTSS aged, blind or disabled Individuals 79,504 FFS Aged, Blind, Disabled (ABD) 2,939 Medallion 3.0 Aged, Blind, Disabled (ABD) 76,565 will transition 1/2018 Approximations based upon March 2016 MMIS Data 19,121114,121 *HAP -

14 CCC Plus Populations Duals Approximations based upon March 2016 MMIS Data 19,121 There are 114,121 duals eligible for CCC Plus. Of those, 26,866 are currently enrolled in CCC. All individuals in CCC on January 1, 2018, will then transfer into CCC Plus on that date. An additional 87,255 duals are not enrolled in CCC and will be enrolled into CCC Plus by region per the timeline.

15 Commonwealth Coordinated Care Plus Regions CCC Plus will operate statewide, across 6 regions, and will offer individuals choice between at least 2 health plans per region CCC Plus Health Plans will be competitively procured (RFP) RFP Released April 29, 2016 A list of CCC Plus regions by locality is available at: Western / Charlottesville Southwest Roanoke / AlleghanyNorthern / WinchesterCentral Tidewater

16 CCC Plus Populations by Region CCC Plus Enrollment By Region and Launch Date DateRegionsRegional launch All Populations July 1, 2017Tidewater 18,19243,155 September 1, 2017Central 24,62754,468 October, 2017Charlottesville/Western 16,79329,643 November 1, 2017Roanoke/Alleghany 11,52025,566 November 1, 2017Southwest 12,65821,789 December 1, 2017Northern/Winchester 25,52538,125 January 2018CCC Demonstration (Transition plan determined with CMS) 26,866 January 2018Aged, Blind and Disabled (ABD) (Transitioning from Medallion 3.0) 76,565 TotalAll Regions212,746 Source – VAMMIS Data; totals are based on CCC Plus target population data as of April 30, 2016 A list of CCC Plus regions by locality is available at:

17 CCC Plus Excluded Populations and Services  Limited Coverage Groups (Family Planning, GAP, QMB only, HIPP, etc.)  ICF-ID Facilities  Veterans Nursing Facilities  Psychiatric Residential Treatment Level C  Money Follows the Person  Hospice and ESRD (CCC Plus enrolled individuals who elect hospice or have ESRD will remain CCC Plus enrolled)  Medallion 3.0 and FAMIS MCO  PACE  Dental  School Health Services  Community Intellectual Disability Case Management  ID, DD, and DS Waiver Services, including waiver related transportation services (acute care will be under CCC Plus)  Individuals and Families Developmental Disability Services Support Coordination  Preadmission Screening Excluded PopulationsCarved-Out Services Excluded Populations are not CCC Plus eligible; coverage will continue through fee-for-service (or through the Medallion 3.0/FAMIS MCO or PACE provider for MCO/PACE enrolled individuals) CCC Plus carved-out services are paid through fee-for-service for CCC Plus enrolled individuals

18 CCC Plus Builds on CCC Lessons Learned  CCC allows Virginia the unique opportunity to integrate care for individuals who receive both Medicare and Medicaid, with the primary goal to improve health outcomes through coordinated care.  Virginia is fully committed to maintaining a robust CCC program through the end of the Demonstration.  CCC lessons learned will continue to inform the CCC Plus implementation going forward: o Value of provider and member outreach and education o Value of transparent/collaborative engagement with plans and CMS o Value of engaging stakeholders throughout the design, development, and implementation process

19 CCC Plus Incorporates CCC Best Practices High quality care in the least restrictive and most integrated treatment setting Integrated person-centered model focused on individual needs and preferences Care coordination and health risk assessments for all members Member assistance through DARS (VICAP, long-term care ombudsman) Behavioral health homes that integrate behavioral and physical health services

20 CCC Plus Enrollee Benefits Person centered, individualized support plan Same standard Medicaid services provided Choice between at least 2 health plans Care coordinator for each individual Team of health care professionals working together Assistance with needs related to housing, food and community Possible additional benefits offered by health plans

21 CCC Plus Enrollment Enrollment Broker: Maximus Neutral third party Broker will assist in determining which providers are contracted with specific health plans. Broker will answer questions about additional benefits offered by participating health plans. Enrollment begins approximately 45 days prior to effective date.

22 Health Plan Assignment Enrollees will receive an Initial Notice letter with an initial assignment into a health plan (Managed Care Organization or MCO) and a comparison chart of all the MCOs in their region. Enrollees can change their MCO by calling the enrollment broker Maximus by the “call by date” in their Initial Notice letter. “Call by dates” will be on or before the 18 th of the month prior to the MCO effective date. A “Confirmation Notice” will be mailed to the member confirming MCO final assignment Enrollees have 90 days from the Confirmation Notice to change final MCO assignment through Maximus. Beginning in 2018, a 60 day open enrollment period will occur in October – December.

23 Intelligent Assignment Initial assignment is based upon the members region Factors taken into consideration to being assigned to a particular MCO include: 2-month re-enrollment process or previously enrolled Medicare Managed care plan (MAC Id). 2-month previous Medicaid managed care enrollment (i.e., CCC+, Medallion 3.0 or CCC) Nursing Facility Waiver or EDCD Waiver or Tech Waiver (if there are more than one MCO’s participating with member’s providers within that region, members will be randomly assigned) If the member has no considerations listed above, members will be randomly assigned to the MCO’s within their region

24 Enrollee Protections During the continuity of care period of 90 days, MCOs have to pay existing providers MCO must go out of network to provide a service that they don’t have in network Members in Nursing Facility (NF) at the time of enrollment will not be moved even if the NF doesn’t choose to participate. NF will be paid as an out of network provider

25 CCC+ Provider Benefits Medicaid rates are the floor for NF, waivers, early intervention and behavioral health services Value based payment opportunities Enrollee periodic health risk assessments enhance care planning Care coordinator fosters communication among an interdisciplinary care team Care coordinator assists with problem solving and connects enrollees to local resources

26 Provider Enrollment Providers need to contract with MCOs to serve the CCC+ population Contact provider relations department of MCOs to discuss joining an MCOs network DMAS requires MCOs to have NCQA accreditation Providers must meet NCQA standards and follow state and federal requirements Credentialing of providers by MCOs can take 90 – 120 days to complete.

27 Service Authorizations and Coverage MCOs must cover services that are covered in the Virginia Medicaid State Plan Do not have to adhere to service limits Can choose to require authorization for services even if DMAS doesn’t require it now Most MCOs use a portal for service authorizations

28 Key Differences Between CCC Plus & CCC Any willing provider for LTSS Plans may have narrower networks Continuity of Care Period is 90 Days Operates statewide in six regions Mandatory Enrollment Plans may differ by region CCC Plus Continuity of care period is 90 days No exception for nursing home provider Continuity of Care Period is 180 Days CCC Operates in five of the six regions Optional Enrollment 3 Health plans across 5 regions Continuity of care period is 180 days Allows for any willing nursing home provider Coordination of Medicare benefits through companion D-SNP or MA Plan Coordination of Medicare benefits through same Medicare/Medicaid Plan Populations include full dual adults; including NF and EDCD HCBS Waiver Populations include duals/non-duals, children/adults, NF and five HCBS Waivers Health plans may vary by region

29 CCC Plus Health Plan Selection Evaluate, negotiate, readiness, & award Work with CMS 1915 b/c Waivers Regulations Readiness review MCO Contracts Systems Enhancements Connectivity Transition of Care Monitoring Ongoing Stakeholder & Member Engagement/ Outreach & Education Regional Implementation & Ongoing Monitoring & Program Evaluation Next Steps...

30 Ongoing Stakeholder Input What are your concerns, worries, questions, and suggestions ? 1 What is needed for a successful CCC Plus program launch and a smooth transition from CCC to CCC Plus? 2 Once CCC Plus health plans have been selected, DMAS will facilitate collaborative meetings between DMAS, the health plans and stakeholders/providers. 4 3 What is working well under CCC and what are the areas of opportunity? Providers and stakeholders can directly improve the CCC Plus design by communicating what is working well and what needs improvement

31 Thank You! For More Information... Send CCC Plus questions, concerns, and suggestions to: Additional CCC Plus information is available at: