Sarah Broughton, MSW: Outreach and Education Coordinator Patti Davidson, MSW: Program Analyst Elizabeth Smith, RN: Program Analyst Virginia Department of Medical Assistance Services Virginia Medicaid Waiver Network January 23, Department of Medical Assistance Services

Overview 2 Current structure Medicare/ Medicaid Introduction to Commonwealth Coordinated Care (CCC) Eligibility Enrollment Specific Benefits of CCC

Medicare-Medicaid Enrollees? 3 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)

Who Pays for Services in Virginia? 4 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

What does care look like for Medicare-Medicaid enrollees now? 5 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

Fragmented Not Coordinated Complicated Difficult to Navigate Not Focused on the Individual Gaps in Care What Does the Medicare-Medicaid Benefit Look Like Now? Like navigating a traffic circle…. 6

A Better Path to Health; Sally and Edna’s Story 7 The Voices for Better Health program at Community Catalyst has released a new video that highlights the challenges of our current health care system for dual eligibles and how integrated care has changed the lives of one older adult and her daughter.

Commonwealth Coordinated Care 8 Provides high-quality, person-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences CCC provides the same benefits currently available under Medicaid and Medicare Creates a single program to coordinate delivery of primary, preventive, acute, behavioral, and long-term services and supports

Commonwealth Coordinated Care 9 CCC also provides care coordination for beneficiaries Promotes the use of home- and community- based behavioral and long-term services and supports Promotes improved transitions between acute and long-term facilities

Who is eligible for CCC? 10 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)

11 Approximately 78,600 Medicare-Medicaid Enrollees Who is eligible for CCC? Region Nursing FacilityEDCD WaiverCommunity 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 for CCC? 12 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

Enrollment 13 Enrollment in CCC will be in five regions of the Commonwealth: Central Virginia/Richmond Tidewater Northern Virginia Roanoke area Charlottesville area

14 Virginia’s Service Regions

Enrollment 15 Enrollment will 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. Individuals will be automatically enrolled after considering the individual’s previous enrollment with the health plans, or the health plan network that includes their current adult day health provider or nursing facility (if applicable).

Enrollment 16 Most importantly, if an individual is unhappy with a chosen health plan, he/she may request reassignment to another health plan or opt out of the program and return to traditional Medicare and Medicaid

Commonwealth Coordinated Care Enrollment Timeline 17 Tidewater area March 2014: Voluntary enrollment begins April 2014: Coverage begins May 2014: Automatic enrollment begins July 2014: Coverage for those automatically enrolled begins

Commonwealth Coordinated Care Enrollment Timeline 18 Central Virginia/Richmond area March 2014: Voluntary enrollment begins April 2014: Coverage begins June 2014: Automatic enrollment begins August 2014: Coverage for those automatically enrolled begins

Commonwealth Coordinated Care Enrollment Timeline 19 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

CCC Benefits for Individuals and their Families 20 One system of coordinated care Person-centered care coordination One ID card for all care 24 hour/7 days a week, toll free number for assistance Unified appeals process

Additional CCC Benefits 21 Supplemental Services and Supports – in addition to current Medicare and Medicaid coverage (Varies according to health plan) Expanded Telehealth Services (Varies according to health plan) Behavioral Health Homes – NEW partnership between the health plans and the CSBs. Provides behavioral and physical health services in one system of care Health Risk Assessments – comprehensive assessment of the beneficiary’s medical psychosocial, cognitive and functional status

Health Risk Assessment (HRA) 22 A key component of CCC is a health risk assessment for each Enrollee, completed by the Health Plan’s care coordination team HRA- assists in determining medical, behavioral health, long-term supports and services (LTSS), and social needs Each HRA results in a person-centered plan of care, including: the Enrollee’s strengths and goals, any needed specialists and the plan for care coordination

Commonwealth Coordinated Care: Key Partnerships 23 CCC Enrollment Facilitator is Maximus VICAP Office of Long-Term Care Ombudsman Health Plans providing coverage under CCC:  Healthkeepers  Humana  Virginia Premier

Contact Information 24 Office of Coordinated Care Virginia Department of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA