Medicaid Waiver Proposal

1. STATE OF WEST VIRGINIA Medicaid Waiver Proposal Joe Manchin III, Governor April 14, 2005 West Virginia Department of Health and Human Resources

2. West Virginia Beneficiaries by Enrollment Group 191,316 91,190 60,233 31,144

3. 8.33% 21.00% 24.39% 16.11% 44.16% 7.48% 51.17% 27.36% Beneficiaries Expenditures West Virginia Beneficiaries by Expenditures WEST VIRGINIA MEDICAID BENEFICIARIES AND EXPENDITURES BY ENROLLMENT GROUP, FFY 2003 100% Elderly (31,144) 90% Blind & Disabled (91,190) 80% Adults (60,233) 70% Children (191,316) 60% Source: CMS 2082 50% Data from MMIS System 40% 30% Note: Beneficiaries are 20% enrollees who received a Medicaid service. 10% Blind & Disabled 0% includes adults, children, and elderly who qualify based on a disability.

4. Barriers to Managing the Medicaid Program • Categorical eligibility groups • All or nothing benefits packages • Cost-sharing rules which limit beneficiary participation • Mandatory services i.e. NEMT • No means to incentivize participants to maintain and/or improve their health • State responsibility for cost of care for Dual Eligibles • Lack of a comprehensive electronic medical record for beneficiaries limits the ability to manage patient care

5. The West Virginia ModelNot a Rolls Royce for a few but a West Virginia made Toyota for many • Personal Responsibility Agreement • Base eligibility on income rather than on category • Eliminate Waivers • Tailor Benefits • Cost Sharing • Manage All Aspects of Care • Pay for Performance

6. Personal Responsibility • Participants sign an agreement acknowledging that they are partners with the taxpayers of WV. • The taxpayers pay for their medical care and in return participants agree to: a) to comply with medical protocols (i.e., keep doctors appointments, take their medications as prescribed) b) help to control program costs by reviewing EOBs c) share in program costs through co-pays, premiums d) engage in healthy lifestyles e) if they choose not to adhere to the agreement then they will pay higher copays or premiums

7. Tailored Benefits • Ensure that participants receive the right care, at the right place, at the right time by the right provider • Eliminate waivers • Use evidence-based medicine to manage services by duration, scope and severity

8. Cost Sharing for Eligibility • Eligibility based upon Federal Poverty Level rather than upon category (following the Arizona model) • Sliding fee scale for co-pays and premiums established so that more people can be covered

9. Managing Care • Like the private sector, participants are members of an HMO for a full year • Expand disease state management to include long-term care, the disabled, and the medically fragile • Use comprehensive electronic medical care to manage care – including Medicare drug benefit information for dual eligibles

10. Pay for Performance • Base reimbursement rates for health maintenance organizations based on health outcomes • Pay PCCM providers based on health outcomes – may include bonuses • Reward participants based on improved health (i.e., weight loss, stop smoking, et cetera)

11. Financing and Timeline • Reinstate match rate from 2004 (75.36%) until waiver is implemented • Upon implementation, use 2005 as the base year convert to per capita rate (Medicaid expenditures/# of enrollees) with health expenditure index inflation going forward (similar to clawback calculation) • Implement waiver July 1, 2006