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The Integration of Acute and Long Term Care Services: Virginia s Managed Care Program Presentation to Managed Care Or

2. Managed Care. DMAS' mandatory managed care program with contracted Managed Care Organizations (MCO)Program began in 1996 for seven localitiesCurrently operating in 110 localities serving 56% of Medicaid individuals Statewide Medicaid Enrollment as of August 1, 2007:Fee-for-Service255,926MEDALLION 51,079Medallion II383,103.

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The Integration of Acute and Long Term Care Services: Virginia s Managed Care Program Presentation to Managed Care Or

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    1. The Integration of Acute and Long Term Care Services: Virginia�s Managed Care Program Presentation to Managed Care Organizations

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    3. 3 Program Authority Medallion II operates as a result of: CMS 1915(b) Waiver � Effective 7/1/07 Code of Federal Regulations (CFR) (42 CFR Part 438, aka Balanced Budget Act implemented June 2002) Virginia State Plan for Title XIX Virginia Administrative Code for Managed Care (12 VAC30-120-360 through 420) MCO Contract

    4. 4 Virginia Medicaid Managed Care Program Coverage Map

    5. 5 Our Current MCO Partners Amerigroup Community Care Anthem HealthKeepers Plus Optima Family Care Southern Health - CareNet Virginia Premier Health Plan

    6. 6 MCO Eligibility Medicaid eligibility controlled by Department of Social Services MCO enrollment is mandatory for managed care eligible clients Majority of Medicaid clients are managed care eligible, however, some are not Always some FFS Medicaid clients

    7. 7 Currently Included in Managed Care Children Pregnant women Aged, Blind and Disabled Currently Excluded Populations Nursing Homes Other insurance (i.e., Medicare) Foster Care

    8. 8 Plan Highlights Virginia is one in a handful of states that requires MCOs to obtain National Committee for Quality Assurance (NCQA) accreditation. Three of the 5 have received national recognition. One health plan won a national award from the Disease Management Association of America for the prevention of sickle cell and reducing emergency department visits and hospitalizations. CMS has advised that Virginia is in the top 10 of all states contracting with managed care organizations. Immunization rate of 83% is substantially above the national average of 63% The HEDIS measure for �use of appropriate asthma medications� (87% - 95%) is above the national rate of 86%

    9. 9 Managed Care HelpLine The Enrollment Broker, Maximus, has been contracted since 2/1/03. Toll-free assistance to managed care enrollees. Provides telephone translation services. Completes health assessments with members. Refers recipients to other sources (i.e., Doral for dental) Keeps records of all calls and complaints.

    10. 10 DMAS Oversight of MCOs

    11. 11 Contract Modifications All health plans sign same standard contract. Annual contract revision process. Renews each year on July 1st. Collaborative process � MCO/DMAS open discussions. Amendments (i.e., program changes) as needed.

    12. 12 Questions ?? Questions and comments may be forwarded to us via ALTCMCO@dmas.virginia.gov

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