Kristin Burhop Director, Office of Coordinated Care Virginia Department of Medical Assistance Services Adult Services Committee September 18 th, Department of Medical Assistance Services

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

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

Medicare and Medicaid today 4 Medicare and Medicaid are not designed to work together resulting in an inefficient, more costly delivery system Costs of serving individuals on Medicare and Medicaid are rising exponentially Each program has its own set of rules, regulations, requirements and coverage At the national level we are spending 39% of Medicaid funds on 15% of the population *We can’t afford to continue to support rising costs without intervention*

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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 6

Who are Medicare-Medicaid Enrollees? 7 Receive full benefit Medicare and Medicaid coverage 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

Who are Medicare-Medicaid enrollees? 8 Source: Hilltop Institute -- MedPac, June 2008; based on data from the 2005 MCBS Cost and Use file *Data from 2003 MCBS

What does care look like for Medicare- Medicaid enrollees now? WITHOUT COORDINATED CARE INDIVIDUALS MAY HAVE: x Three ID cards: Medicare, Medicaid, and prescription drugs x Three different sets of benefits x Multiple providers with limited means of coordination x Health care decisions that are not coordinated and not made from the person-centered perspective 9

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

History of Integrated Care in Virginia 2006: DMAS released the Blueprint for the Integration of Acute and Long Term Care Services 2009: DMAS planned to launch VALTC; however, due to budget constraints, provider resistance, and other limitations, did not move forward with initiative 2010: DMAS applied for CMS “State Demonstrations to Integrate Care for Dual Eligible Individuals” and was not one of the 15 states accepted 2011 & 2012: Legislature directed DMAS to develop and implement a care coordination model for Medicare-Medicaid enrollees 2011: DMAS sent Letter of Intent to participate in CMS’ Financial Alignment Demonstration 2014: Virginia to launch Commonwealth Coordinated Care 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 12

13 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 The Solution: Commonwealth Coordinated Care

Who is Eligible? 14 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)

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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

Who is Not Eligible? 17 Individuals not eligible include those in: The ID, DD, Day Support, Alzheimer's, and 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 Hospice

Benefits for Virginia 18 Promotes and measures improvements in quality of life and health outcomes Eliminate cost shifting between Medicare and Medicaid and achieve cost savings for States and CMS Reduce duplicative or unnecessary services Streamline administrative burden with a single set of appeals, auditing and marketing rules, and quality reporting

Benefits for Individuals and Families 19 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 Unified appeals process For individuals with Serious Mental Illness (SMI), behavioral health homes will be created in partnership with CSBs

Benefits for Providers 20 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

How are Individuals enrolled? 21 Eligible individuals identified Individuals will first receive information in Fall 2013 Enrollment will be conducted in phases Enrollment will initially be voluntary, followed by automatic enrollment with ability to opt out anytime

Enrollment Enrollment will also be in two phases: The first phase is called “voluntary enrollment” where an individual proactively enrolls in the program The second phase is called “passive enrollment” (also known as automatic enrollment) where the individual is automatically enrolled into the CCC program 22

Intelligent Assignment For passive enrollment (automatic enrollment) where individuals don’t specify a specific health plan, DMAS has developed an “intelligent assignment” algorithm that assigns an individual to a specific health plan based on several factors. The process considers beneficiaries’ prior enrollment in health plans and providers so enrollees can be served as well as possible. 23

Intelligent Assignment The pre-assignment process will specifically consider the following: Individuals in a nursing facility will be pre-assigned to a health plan that includes that nursing facility in its network Individuals on the EDCD waiver will be pre-assigned to a health plan that includes the individual’s current adult day health care or personal care provider in its network 24

Intelligent Assignment If more than one health plan’s network includes the nursing facility or adult day provider or personal care provider used by an individual, they will be assigned to the health plan with which he/she was previously assigned in the past six (6)months. If the individual has no history with the health plans available under CCC, he/she will be assigned to a health plan in which their provider participates. 25

Intelligent Assignment Most importantly, if an individual is unhappy with the health plan chosen for them, he/she may request reassignment to another health plan. 26

Enrollment 27 Central Virginia/Richmond and Tidewater areas: Voluntary enrollment begins Early 2014 Coverage begins March 1, 2014 Automatic enrollment begins May 1, 2014 Coverage for those automatically enrolled begins July 1, 2014 Northern Virginia, Roanoke, Charlottesville areas: Voluntary enrollment begins May 1, 2014 Coverage begins June 1, 2014 Automatic enrollment begins August 1, 2014 Coverage for those automatically enrolled begins October 1, 2014

Health Plans 28 DMAS is in the process of negotiations with health plans to provide Commonwealth Coordinated Care Plans will be finalized this fall Currently negotiating with 3 plans Healthkeepers Humana Virginia Premier

Outreach and Education 29 Outreach and Education by DMAS will include: 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 VICAP counselors and Virginia’s Long- Term Care Ombudsmen

In the coming weeks…. 30 Continue Readiness Reviews with Health Plans in negotiation Continue design and implement various components of Commonwealth Coordinated Care with community and stakeholder feedback and input Continued Outreach and Education

Contact Information 31 Emily Osl Carr Director, Office of Coordinated Care Virginia Department of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA (804)