Suzanne S. Gore Director, Policy and Research Virginia Department of Medical Assistance Services SNP Alliance Meeting October 10, 2013 Commonwealth Coordinated Care Department of Medical Assistance Services

Composition of Virginia Medicaid Expenditures SFY 2012 Notes: Long-Term Care Services Medical Services 2

Virginia Medicaid Expenditures – Long Term Care Services Notes: Average annual growth total Long Term Care services – 8% Average annual growth Institutional services– 4% Average annual growth Community-Based services– 14% Proportion of Long Term Care services paid through Community-Based care has increase from 30% in FY02 to 51% in FY12 3

Coordinated Service Delivery Service delivery should be efficient, cost effective, and provide quality services. Efficient Administration DMAS should be accountable, streamlined, and transparent. Significant Beneficiary Engagement Individuals should be engaged in, responsible for, and active participants in their health care. Goals of Medicaid Reform 4

Virginia’s Dual Eligible Demonstration: C ommonwealth Coordinated Care Demonstration beginning January 1, 2014 and running through December 31, 2017 Will provide high-quality, person-centered care for Medicare-Medicaid beneficiaries that is focused on their needs and preferences Blends Medicare’s and Medicaid’s services and financing to streamline care and eliminate cost shifting 5

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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) 7

Who is Not Eligible? Individuals not eligible include those in: The ID, DD, Day Support, Alzheimer's 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 8

Approximately 78,600 Medicare-Medicaid Enrollees Medicare-Medicaid Enrollees in Virginia eligible for Commonwealth Coordinated Care Region Nursing FacilityEDCD WavierCommunity Non-waiver Total Central VA4,4303,76216,13524,327 Northern VA1,9351,76612,95216,653 Tidewater3,0312,49212,57518,098 Charlottesville1, ,4276,747 Roanoke2,8331,3558,58312,771 Total13,70610,21754,67278,596 9

Proposed enrollment process 10 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

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Signed MOU In May Virginia became the 6 th state with a signed MOU Massachusetts (capitated model) Ohio (capitated model) Illinois (capitated model) California (capitated model) Washington State (managed fee-for-service model) Purpose of MOU: Principles for CMS and DMAS to implement and operate the CCC program Activities CMS and DMAS will conduct in preparation for implementation Signifies that a state is accepted into the Demonstration 13

Virginia MOU Sections Demonstration Authority Contracting Process Enrollment and Disenrollment Process Delivery Systems Beneficiary Protections Appeals and Grievances Reporting Quality Management Financing and Payment Evaluation Additional terms and appendices 14

15 Stakeholder Input and Support  Requests put in the MOU  Use of behavioral health homes for SMI population  Emphasis on transitions between settings of care  Waived Skilled Medicare hospital stay  Followed Medicaid rules for Telehealth  Required standard fiscal agent for consumer directed services  Required Plans to describe how they will reimburse nursing facilities; minimize administrative burdens

Virginia MOU Highlights Focus on consumer engagement; Public meetings Monitoring both individual and provider experiences Surveys Focus groups Website updates Data analysis Savings percentage applied Savings in year 3 will be reduced to 3% if 1/3 of plans experience losses exceeding 3% of revenue in all regions in which those plans participate in year 1 16

Plans shall have Beneficiary input process Systems for monitoring quality of services and care Beneficiary input on governing boards that represent diversity of population 3/4 year demonstration January December 2017 Financing and Payment Sophisticated risk adjustment model (4 categories) Based on age, under/ over 65 Residence based in nursing facility or community 17 Virginia MOU Highlights

Achievements and Progress n Received approval for 1932(a) State Plan Amendment to CMS (allows for voluntary managed care program) n Savings adjustments MMIS systems changes in progress 57% complete n Update on procurement process n Rate setting Guidance documents Marketing Enrollment Reporting 18

Activities Underway Meeting weekly with Outreach and Education workgroup Hire staff for Office of Coordinated Care within DMAS to provide full attention to the CCC program n Finalize Three Way contract in October/November Continue to develop evaluation program with beneficiary and stakeholder input and partnership with GMU Participate in CHCS initiative, INSIDE (Implementing New Systems of Integration for Dual Eligibles) 19

Activities Underway Continue discussion of topics that need to be operationally defined prior to launch (e.g. Patient pay) State Ombudsman office submitted grant application for options counseling; submitting application for ombudsman funding Continue comprehensive education and outreach plan, engaging stakeholders and enlisting assistance from national experts Weekly calls with CMS 20

Next Steps: Virginia Demonstration Timeline MonthHigh Level Activity October-Finalize negotiations and post intent to award for selected health plans -Finalize Medicare and Medicaid rates -Sign 3-way Contract -Complete readiness reviews November- December -Continue to prepare for implementation January 2014-Opt-in enrollment begins in Central and Tidewater regions July 2014-Passive enrollment begins in Central and Tidewater regions -Opt-in enrollment begins in Western/Charlottesville, Northern Virginia, and Roanoke regions October 2014-Passive enrollment begins in Western/Charlottesville, Northern Virginia, and Roanoke regions 21