1. Department of Medical Assistance Services
Commonwealth Coordinated Care Virginia’s Dual Eligible Financial Alignment Demonstration
Kristin Burhop and Emily Carr
Virginia Department of Medical Assistance Services
May 9, 2013 1

2. Overview Current structure of Medicare/Medicaid
Opportunities for Integrated Care in Virginia
Virginia’s Medicare-Medicaid Financial Alignment Demonstration

3. Who are Medicare-Medicaid enrollees?
Receive both Medicare and Medicaid coverage
Focus on “Full Duals” in CMS’ demonstration
58.8% age 65 or older
41.2% under age 65
Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
10.2M Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees or “dual eligibles”) & 7.4M are “full duals”

4. Who pays for what services?
MEDICAID
Medicare cost sharing
Nursing home (once Medicare benefits exhausted)
Home- and community-based services (HCBS)
Hospital once Medicare benefits exhausted
Optional services (vary by state): dental, vision, HCBS, personal care, and select home health care
Some prescription drugs not covered by Medicare
Durable medical equipment not covered by Medicare
MEDICARE
Hospital care
Physician & ancillary services
Skilled nursing facility (SNF) care (up to 100 days)
Home health care
Hospice
Prescription drugs
Durable medical equipment

5. The Problem Dual eligible individuals:
Often have multiple, complex health care needs
May have physical, intellectual and behavioral disabilities
See multiple providers - need to navigate fragmented, complex medical, behavioral, social and long-term services and supports systems

6. For Providers
Confusion - two sets of rules, multiple insurance cards, overlapping benefits with different requirements, (e.g., pre-authorization, benefit limits, appeals timelines, reporting requirements, audits, etc.)
Poor communication between providers
Incomplete knowledge of individual’s condition, test results, prescriptions, etc
Limited time, staff resources or financial incentives to coordinate services.

8. What does care look like for Medicare-Medicaid enrollees now?
WITHOUT INTEGRATED CARE INDIVIDUALS MAY HAVE:
Three ID cards: Medicare, Medicaid, and prescription drugs
Three different sets of benefits
Multiple providers who rarely communicate
Health care decisions uncoordinated and not made from the patient-centered perspective
Serious consideration for nursing home placement; Medicare/Medicaid only pays for very limited home health aide services

9. What does care look like for Medicare-Medicaid enrollees now?
Like navigating a traffic circle….
Fragmented
Not Coordinated
Complicated
Difficult to Navigate
Not Focused on the Individual
Gaps in Care
Medicaid
Medicare
State
Health Plan

10. The solution- Integrated Care!
Virginia has the goal of providing person-centered, conflict free care coordination to dual eligible's.
Creates one accountable entity 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
Blends Medicare’s and Medicaid’s services and financing to streamline care and eliminate cost shifting
Provides high-quality, patient-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences

11. Virginia’s Financial Alignment Demonstration
Full benefit Medicare-Medicaid Enrollees including:
Elderly and Disabled with Consumer Direction Waiver participants; and
Nursing Facility residents
Age 21 and Over
Live in demonstration regions (Northern VA, Tidewater, Richmond/Central, Charlottesville; Roanoke)
Voluntary, Passive Enrollment

12. Virginia’s Financial Alignment Demonstration
Individuals not eligible include:
Those in the ID, DD, Day Support, Alzheimer's Technology Assisted HCBS Waivers
Those in MH/ID facilities
Those in ICF/IDs
Those in PACE (although they can opt in); and
Those in Long Stay Hospitals

13. Virginia’s Financial Alignment Demonstration
Approximately 78,600 Medicare-Medicaid Enrollees
          Region               
Nursing Facility
EDCD Wavier
Community Non-waiver
Total
Central VA
4,430
3,762
16,135
24,327
Northern VA
1,935
1,766
12,952
16,653
Tidewater
3,031
2,492
12,575
18,098
Western/
Charlottesville
1,477
842
4,427
6,747
Roanoke
2,833
1,355
8,583
12,771
13,706
10,217
54,672
78,596

14. Beneficiary Protections:
Choice of plans and providers
Continuity of care
Enrollment assistance
Ombudsman
Person-Centered approach
ADA, Civil Rights compliance
Beneficiary participation on MCO governing boards
Customer service - access to a 24/7 toll-free number
DMAS/CMS day-to-day monitoring and oversight

15. Outreach Identifying internal and external stakeholders
Beneficiaries and family/representatives
Providers
Advocacy groups
Community social organizations
Sister agencies
Contractors
Local programs
Modes and venues to reach stakeholders

16. Outreach and Education
Stakeholder engagement
Meetings with various stakeholder groups
Fact sheet available for program overview
Ombudsman and other community partners will play a critical role in beneficiary education
Dual Eligible Advisory Committee workgroup
design and operational issues
solicit feedback
suggestions
Develop a comprehensive education and outreach plan; will be engaging stakeholders and enlisting the assistance from national experts to effectively communicate Initiative
Grant funding opportunities to help cover education and outreach costs
Established dedicated website and box

17. States and CMS are working together to
Engage stakeholders at every level in both design and implementation
Public stakeholder meetings and work groups
Opportunities for feedback on proposals, contracts or policies
Several demonstration-specific websites
Multifaceted communications and outreach plans
Coordination with ADRC/SHIPs, AAA and other systems entry points

18. Proposed enrollment process
Eligible Populations
Enrollment and Disenrollment Process and Timeframes:
Opt-in only period;
Passive enrollment;
Two enrollment phases, based on regions
Offering opt out provisions before and after enrollment
Developing enrollment algorithms to connect individuals with MCOs based on past enrollment and provider networks, to extent feasible

20. Virginia’s Strategies to Address Needs
Enhanced Care Management
Stakeholder workgroup will help design care management, including expectations, levels of care management, how to best manage care for subpopulations (e.g., chronic conditions, dementia, behavioral health needs, etc.), how to structure transition programs in hospitals and NFs
Behavioral “Health Homes” for individuals with SMI with MCOs partnering with the CSBs
Encouraging MCOs to link/sub-contract with different providers for care coordination (e.g., CSBs, adult day care centers, NFs)

21. Virginia’s Strategies to meet Needs
Other opportunities:
Develop strong consumer protections (e.g., external ombudsman, grievances and appeals)
Ensure individuals only have to make one call to receive all their Medicaid and Medicare funded services – 24/7 help lines
Provide access to disease & chronic care management services that could improve overall health conditions and/or slow down decline
Develop strong quality improvement programs, measures and monitoring
Rate Development; will propose method for applying savings adjustments

22. Virginia Demonstration Timeline
Date
High Level Activity
March 2013
-Finalize MOU and RFP
Finalize State Plan Amendment and Waiver amendment
April
-Discuss MOU with CMS
-Publish RFA
-Develop Education and Outreach Plan
-Submit State Plan Amendment
May
-Responses due from MCOs (mid-month)
-Release data book
- Begin Development of Readiness Review Documents
June
-Announce Selected MCOs
- Publish draft rates
July
-Submit outreach and planning grant to CMS
Finalize rates
Begin Readiness Review
Draft 3-way contract

23. Virginia Demonstration Timeline
Month
High Level Activity
August
-Continue Readiness Review
September
-Sign 3-way Contract
October
-Begin Education and Outreach BLITZ (ongoing)
November-December
Keep calm and carry on!
January 2014
“Soft Start”-Begin Opt-in enrollment for 60 days
March 2014
-Begin MCO assignment
April 2014
- Tidewater and Richmond regions “go live” with passive enrollment