Post on 21-Dec-2015
http://www.dmas.virginia.gov
Karen Kimsey and Tammy WhitlockComplex Care and Services
Virginia Department of Medical Assistance Services DMAS Announcement to Interested Plans
June 2, 2015
Proposed Initiatives for Medicaid Managed Long-Term Services and Supports (MLTSS)
Department of Medical Assistance Services
Agenda
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Welcome
Medicaid Reform Initiatives
General Assembly Directives
Current Program Models
Medicaid Long Term Care Services
Future Managed Care Initiatives
o Medicaid Managed Care for Individuals Eligible for CCC but Not Enrolled
o Managed Long-Term Services and Supports
Next Steps
Questions
Phase 3Move Forward with Coordination of LTSS
Phase 2Implement Innovations in Service Delivery, Administration, &
Beneficiary Engagement
Phase 1Advance Reforms In-Progress
Moving Forward with Medicaid Reform Initiatives
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CURRENT STATUS OF PHASE 3 REFORMS (MIRC)Title Status
ID/DD Waiver Redesign
• October 2013 - First Phase of DBHDs Study completed• 5 Subgroups created and to provide recommendations for design• Based upon recommendations, plan is to amend current waivers• Amended waivers would be renamed - Community Living Waiver, Family
and Individual Supports Waiver, and Building Independence waiver. All waivers would serve both ID and DD populations
All non-dual EDCD waiver enrollees in Managed Care for medical needs
• In combination with the acute and long-term care (ALTC) Phase 1 program, this initiative became known as the health and acute care project (HAP)
• Individuals enrolled in Medallion 3 (M3) who subsequently enroll into one of 5 home and community based care waivers (excludes Tech Waiver) maintain their enrollment in M3 for acute and primary care services.
• In December 2014, DMAS transitioned individuals in the EDCD waiver, who were otherwise eligible for managed care, i.e., did not meet any managed care exclusions, into one of the Medallion 3.0 health plans for acute and primary care services. (Included approximately 2,700 EDCD individuals).
• As of May 1, 2015 8,010 HCBS individuals are enrolled in Medallion 3 for their acute and primary services; their long-term services and supports are paid through fee-for-service.
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Progressing
PHASE 3 REFORMS REMAINING. . .
Title Status
All inclusive Coordinated Care for LTC Beneficiaries (coordinated delivery for all LTSS)
Original Goal - By Summer 2016• Complete the transition of all non-dual waiver recipients in the six
home and community based care waivers and their community long term care services into coordinated care networks. (HAP for remaining waivers.)
Complete Statewide Commonwealth Coordinated Care by July 2018
Original Goal – By July 2018• Implemented the voluntary duals demonstration program in
March 2014; completed regional phases of automatic assignment phase in November 2014; currently operating in 103 of 134 localities; provides choice of at least 2 health plans per locality except for a few localities. Focus at this time is on quality evaluation, monitoring , oversight.
• Approximately 25K individuals are enrolled in CCC as of March 2015 and another 37K are eligible but not enrolled.
• July 2018- After the Commonwealth Coordinated Care (Duals) demonstration is completed, upon CMS approval expand statewide with all the remaining dual populations and all their medical, behavioral, and long term care services.
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VA General Assembly Directives
Beginning in 2011 and continuing in the 2015 session, the Virginia General Assembly has directed DMAS to continue with reform efforts to transition fee-for-service (FFS) populations into managed care so the Commonwealth can take advantage of the benefits of managed care as a delivery model, including:
(1) increased access due to larger and more comprehensive provider networks and network management;
(2) accountability;
(3) administrative benefits DMAS has not been able to replicate (care management, nurse and other call lines, maternity and education programs);
(4) budget predictability through capitated payments;
(5) focused quality improvement programs; and,
(6) tighter and more complex medical management. 6
VA General Assembly Directives
The 2015 Appropriations Act – Item 301.TTT, directs DMAS to seek reforms to include all remaining Medicaid populations and services, including long-term care and home- and community-based waiver services into cost-effective, managed and coordinated delivery systems.
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Fee For ServiceServes certain coverage groups and is also the delivery system for most long-
term services and supports (LTSS); often results in fragmented care
coordination
Commonwealth Coordinated Care (CCC)
Serves certain full-benefit adult duals (age 21 and older) ; fully integrated
model ; includes CCC eligible nursing facility and EDCD Waiver participants
Program of All-Inclusive Care for the Elderly (PACE)
Serves adults age 55 and older who meet nursing facility criteria; fully
integrated system of care; community alternative to nursing facility care
Medallion 3.0Serves pregnant women, children, adults
(caretakers) and ABD without LTSS through a coordinated delivery model;
excludes LTSS
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Current DMAS Service Models
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Composition of Virginia Medicaid Expenditures SFY 2014
46%
Dental2%Medicare Premiums
6%Indigent Care
5%
Behavioral Health Services
9%
33%
Nurs-ing
Facil-ity,
ICF/ID44%
Waivers
56%
Long-Term Care Expenditures
Managed Care Fee-For-Service
$2.4b
$1.2b
Medical Services by Delivery Type
Long-Term Care
ServicesMedicalServices
VA’s HCBS Waivers/Alternative Institutional Placements
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WaiverAlternate Institutional Placement
Alzheimer’s Assisted Living Nursing Facility
EDCD Nursing Facility
Developmentally Disabled Intermediate Care Facility for Individuals with Intellectual Disabilities
Intellectual DisabilityIntermediate Care Facility for Individuals with Intellectual Disabilities
Day SupportIntermediate Care Facility for Individuals with Intellectual Disabilities
Technology Assisted Specialized Care in Nursing Facility for Adult / Hospital for children
Waiver program service descriptions and eligibility criteria may be found on the DMAS website
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Virginia Medicaid Expenditures Long Term Care Services
FY
04
FY
05
FY
06
FY
07
FY
08
FY
09
FY
10
FY
11
FY
12
FY
13
FY
14
$.0
$.5
$1.0
$1.5
$2.0
$2.5
$3.0
Community-Based
Institutional
Long-Term Care
$b
illio
ns
Notes: Average annual growth total Long Term Care services – 7%Average annual growth Institutional services– 3%Average annual growth Community-Based services– 13%Proportion of Long Term Care services paid through Community-Based care has increase from 32% in FY04 to 55% in FY14
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Virginia Medicaid HCBS Waivers – Enrollment and Wait List Information
Notes: *Enrollment for the HCBS Waivers as of March 2015 and is subject to frequent change**This is the same waiting list for servicesSource: Virginia MMIS, Databases
Slot/Wait List Summary Enrollment * Waiting List
EDCD 30,460 N/A
MR/ID 10,017 4,941**
DD 909 807
Tech 293 N/A
Day Support 276 4,941 **
Alzheimer’s 56 N/A
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Proposed Future MLTSS Initiatives
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Managed Long-Term Services and Supports Future
Coordinated system of care that focuses on improving access, quality, and efficiencyo Provides greater flexibility to serve individuals
before they have higher needso Improves qualityo Improves efficiency in the systemo Includes value based purchasing models o Better manages and reduces expenditures
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To move 107,000 individuals into
mandatory managed care
model(s) to improve their lives
The Plan
Those Eligible for CCC but
Who are Not Enrolled
(Approximately 37K)
Duals Excluded From the CCC
Demo(Approximately 50K)
Medicaid Only Individuals
Receiving LTSS(Approximately 20K)
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Populations to Transition from FFS to Managed Care
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Phased Implementation
Phase 1 – Managed
Medicaid for individuals
eligible for CCC but not enrolled
Mid 2016
• Transition approximately 37,000 CCC eligible individuals who have chosen not to participate in CCC into a mandatory managed care program for Medicaid services.
• Includes Medicaid primary and acute, LTSS, and behavioral services coordinated by a CCC health plan (Anthem, Humana and Virginia Premier).
Proposed
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Phase 1: Managed Medicaid Enrollment for CCC Opt-Outs
Key strategy is to replace the current fee-for-service structure with managed care, for Medicaid services for individuals that opt-out of CCC
Improves continuity of careo Allows the health plans to provide care coordination on a continuous basis versus
brief periods of opt-in/opt-out enrollment elections
o Better care coordination could lead to better health outcomes
o Allows the member to see the program benefits (coordinated care, value added services, enhanced benefits, 24 hour nurse line, etc.)
Increased enrollment stability could improve health plan viability
Allows DMAS and the CCC Plans to build on existing infrastructure, networks, and relationships
Proposed
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Phase 1 Managed Medicaid for CCC Opt-Outs (Continued)
Design Element CCC with Full Integration CCC with Medicaid Only (New)
Population CCC Opt-Ins CCC Opt-Outs
Services Medicare/Medicaid covered services
Same Medicaid services as CCC; health plan will coordinate benefits with the individual’s Medicare plan
Service Area CCC Demo Regions (http://www.dmas.virginia.gov/Content_pgs/mmfa-imme.aspx
CCC Demo Regions
Health Plans CCC Plans (Anthem, Humana, and Virginia Premier)
CCC Plans
Federal Authority
Dual Demonstration 1932(a) State Plan Amendment
CMS 1915 (b) (c) Waiver
Contract CCC 3 Way Contract New CCC 2 Way Contract
Member Materials
Member handbook and 1 CCC ID Card for Medicare and Medicaid
Member handbook and separate Medicaid Card
Appeals Process Unified Medicare/Medicaid Process
Medicaid process consistent with Federal/State regulations
Proposed
Phased Implementation
Phase 2 – Managed Long Term
Services and SupportsMid 2017
• Transition approximately 70,000 eligible individuals, including duals not eligible for CCC and individuals receiving LTSS (institution or HCBS waiver) into coordinated care.
• Includes primary and acute, LTSS, and behavioral services. The health plans will be selected through a competitive procurement process.
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Proposed
New managed care program for remaining FFS individuals receiving LTSS
Would be the fourth DMAS managed care program in addition to the current Medallion 3.0, PACE, and CCC programs
Serves two general populations: o Duals excluded from the current CCC demonstration program
(children, excluded regions, and select individuals receiving home and community based waiver services)
o Non-duals receiving LTC services in institutions and the 6 home and community based care waivers
Choice of at least 2 plans; participation is mandatoryo The health plans will be selected through a competitive
procurement process
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Phase 2: Managed Medicaid for CCC Excluded Duals and LTSSProposed
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Phase 2 - Managed LTSS Design ElementsDesign Element MLTSS
Eligible Population Duals not eligible for CCC and individuals receiving LTSS
Excluded Populations ICF/ID, limited coverage groups, others are being considered
Included Services Full spectrum of care (primary, acute, long-term, behavioral health, care coordination); integrated model
Excluded Services Very few carve-outs; ID, DD, and DS waiver services, dental, and school services are being considered at this time
Service Area Plan to phase in by region and to operate statewide
Health Plans To be determined through competitive RFP process
Federal Authority 1915 (b) (c) waiver
Contract Fully-capitated risk-based; actuarially sound cap rates Offers value based payment opportunities
Health Plan Requirements
Bureau of Insurance Approval and MCHIP Certification through VDH ; approved or seeking approval by CMS to operate as a Dual SNP
Quality NCQA Accreditation and 1915 (c) waiver quality assurances
Beneficiary Protections Continuity of care, Ombudsman, appeals, others to be determined
Proposed
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Next Steps
MLTSS RFP• Development, Review, • Approval, Post• Evaluation, Award• Contract Execution
Regulatory Authority, Rate and Data Book Development• CMS 1915 (b)(c) Waiver• Regulations Systems Changes
• Requirements, Design, Testing, Implementation
Communication & Outreach• Town- halls,
stakeholder calls, trainings, etc.
AssessMCO, DMAS, Other Contractor systems Readiness• Networks,• Systems• Transition• Etc.
Public Comment
On-Going:• Stakeholder Involvement• Consult with CMS• Consult with Mgmt
Changes and Readiness of Contractors: Enrollment broker, CD Fiscal Employer Agent, BHSA, Service Auth, Dental LogistiCare, etc.
Strategic Planning
Managed Care Contract Signing and Assessment of MCO Contractor Readiness
MLTSS launch is anticipated
mid-year 2017
Proposed
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Stakeholders Are Key(Includes Health Plans)
Stakeholder involvement is crucialo Request for Commento Meetings with Health
Planso Town Hallso Meetings with
Stakeholder Groups (including Advisory Committee)
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Questions and Discussion
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References
CCC Demo Regions – Available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/mmfa-imme.aspx
MLTSS updates will be posted as available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx
Implementing Medicaid Reform in Virginia (Report to the General Assembly of Virginia, January 2014) http://leg2.state.va.us/dls/h&sdocs.nsf/By+Year/HD62014/$file/HD6.pdf