Kristin Burhop Director, Office of Coordinated Care

1. Department of Medical Assistance Services Kristin Burhop Director, Office of Coordinated Care Virginia Department of Medical Assistance Services Adult Services Committee September 18th, 2013 http://dmasva.dmas.virginia.gov

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

3. 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)

4. Medicare and Medicaid today • 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*

6. 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

7. Who are Medicare-Medicaid Enrollees? • 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

8. Who are Medicare-Medicaid enrollees? Source: Hilltop Institute -- MedPac, June 2008; based on data from the 2005 MCBS Cost and Use file *Data from 2003 MCBS http://www.cms.hhs.gov/MCBS/Downloads/CNP_2003_dhsec8.pdf

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

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

11. 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

12. 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

13. The Solution: Commonwealth Coordinated Care • 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

14. Who is Eligible? • 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)

16. Medicare-Medicaid Enrollees in Virginia eligible for Commonwealth Coordinated Care • Approximately 78,600 Medicare-Medicaid Enrollees

17. Who is Not Eligible? • 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

18. Benefits for Virginia • 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

19. Benefits for Individuals and Families • 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

20. Benefits for Providers • 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

21. How are Individuals enrolled? • 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

22. 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

23. 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.

24. 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

25. 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.

26. 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.

27. Enrollment • 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

28. Health Plans • 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

29. Outreach and Education • 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

30. In the coming weeks…. • 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

31. Contact Information Emily Osl Carr Director, Office of Coordinated Care Virginia Department of Medical Assistance Services 600 E. Broad Street, Suite 1300 Richmond, VA 23219 (804) 588-4888 Emily.carr@dmas.virginia.gov