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 http://www.dmas.virginia.gov

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-2017. 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).

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)

CURRENT STATUS OF PHASE 3 REFORMS (MIRC) Title Status ID/DD Waiver Redesign October 2013 - 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, 2015 8,010 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

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 134 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 2015 and another 37K are eligible but not enrolled. July 2018- 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

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)

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.

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

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

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

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

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 http://www.dmas.virginia.gov 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

Proposed Future MLTSS Initiatives

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 2015 30% of their payments will be value based and by the end of 2016 50% of their payments will be value based.

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

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)

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

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.

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 (http://www.dmas.virginia.gov/Content_pgs/mmfa-imme.aspx 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

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

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

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

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 23219. 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

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

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

References CCC Demo Regions – Available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/mmfa-imme.aspx MLTSS updates will be posted as available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx Implementing Medicaid Reform in Virginia (Report to the General Assembly of Virginia, January 2014) http://leg2.state.va.us/dls/h&sdocs.nsf/By+Year/HD62014/$file/HD6.pdf