An Introduction to Commonwealth Coordinated Care Plus Department of Medical Assistance Services An Introduction to Commonwealth Coordinated Care Plus (A Managed Long Term Services and Supports Program) Presented by: Sandra Brown Department of Medical Assistance Services October 2016 http://dmas.virginia.gov 1

Agenda Virginia Public Procurement Key Facts about Virginia Medicaid Legislative Mandates National Trends Commonwealth Coordinated Care Plus A comparison of CCC Plus and CCC Next Steps Ongoing Opportunity for Stakeholder Input CCC Plus References http://www.dmas.virginia.gov 2

Virginia Public Procurement Act Presently, we are operating under a competitive procurement and we may not be able to respond to all of your questions. DMAS must operate under strict Code of Ethics Rules until successful completion of the competitive procurement process (also known as the RFP process), in accordance with the Virginia Public Procurement Act, §2.2‐4300 of the Code of Virginia. DMAS published the RFP on April 29, 2016, and it is available at: http://www.dmas.virginia.gov/Content_pgs/rfp.aspx http://www.dmas.virginia.gov 3

Virginia’s Medicaid Program Facts 1 Million + Virginians covered by Medicaid/CHIP 2in3 Residents in nursing facilities supported by Medicaid - Primary payer for LTSS 1in8 Virginians rely on Medicaid 50% Medicaid beneficiaries are children 58% Long-Term Services & Supports spending is in the community 1in3 Births in Virginia covered by Medicaid Behavioral Health Medicaid is primary payer for services http://www.dmas.virginia.gov 4

Virginia Medicaid Population and Expenditures Medicaid expenditures are disproportionate to covered populations. Older adults and individuals with disabilities make up over 25% of the total population, yet almost 70% of expenditures are attributed to this group. http://www.dmas.virginia.gov 5

Legislative Mandates: Managed Care Consistent with Virginia General Assembly and Medicaid reform initiatives, DMAS is moving forward transitioning individuals from fee-for-service delivery models into managed care. General Assembly Directives beginning 2011 through 2015 Continue to transition fee-for-service populations into managed care Phase 3 of Medicaid Reform Initiatives Move forward with managed long term services and supports (MLTSS) initiatives Value of Managed Care Timely access to appropriate, high-quality care; comprehensive care coordination; and budget predictability http://www.dmas.virginia.gov 6

Benefits of Managed Care Managed Care Basics DMAS contracts with managed care organizations (MCO) DMAS pays a per-member per-month (PMPM) payment MCOs contract with providers and pay claims 75% of Virginia Medicaid enrollees are currently enrolled in Medallion 3, a managed care program. Benefits of Managed Care Improves quality of care Broader provider network More flexible – can include services that cannot be provided in fee-for-service Actuarial soundness to ensure rates are not too low Care coordination assists member with navigation through system Private sector shares risk with government http://www.dmas.virginia.gov 7

Introducing Commonwealth Coordinated Care Plus (CCC Plus) New statewide Medicaid managed care program beginning July 2017 Will serve approximately 213,000 individuals with complex care needs Integrated delivery model that includes medical services, behavioral health services and long-term services and supports http://www.dmas.virginia.gov 8

CCC Plus Person Centered Delivery Model Fully Integrated & Person Centered Model Integrates Physical, Behavioral, SUD, & LTSS Intensive Care Coordination/ Integration with Medicare Timely Access & Enhanced Community Capacity Improved Quality Management Rewards High Quality Care with Value Based Payments Improved Efficiency and Fiscal Stability http://www.dmas.virginia.gov 9

Medicare and Medicaid MEDICAID COVERS Hospital care MEDICARE COVERS Hospital care Physician & ancillary services Skilled nursing facility (SNF) care Home health care Hospice care Prescription drugs Durable medical equipment MEDICAID COVERS Medicare Cost Sharing Hospital and SNF (when Medicare benefits are exhausted) Nursing home (custodial) HCBS waiver services Community behavioral health and substance use disorder services, Medicare non-covered services, like OTC drugs, some DME and supplies, etc. http://www.dmas.virginia.gov 10

How will Medicare and Medicaid coordinate? CCC Plus requires each participating health plan to become a D-SNP as part of their plan offerings. D-SNP’s are Dual Eligible Special Needs Plans. D-SNP’s are Medicare Advantage Plans that include Part A, Part B, Part D and supplemental benefits. D-SNP’s operate under contracts with Medicare and Medicaid. Once D-SNP’s are operational, CCC Plus individuals will have the option to choose the same plan for Medicare and Medicaid coverage. 6 health plans start 1/1/17 http://www.dmas.virginia.gov 11

CCC Plus Populations 213,653 Individuals Duals (Full Medicaid) with and without LTSS Not CCC Enrolled 87,414 CCC Enrolled 27,281 will transition 1/2018 Non Duals with LTSS FFS 9,818 Medallion 3.0 HAP* 9,713 Non Dual /Non LTSS aged, blind or disabled Individuals 79,427 Aged, Blind, Disabled (ABD) 3,039 Medallion 3.0 76,388 114,695 19,531 Approximations based upon July 31, 2016 MMIS Data *HAP - http://www.dmas.virginia.gov/Content_pgs/mc-home.aspx http://www.dmas.virginia.gov 12

Commonwealth Coordinated Care Plus Regions CCC Plus will operate statewide, across 6 regions, and will offer individuals choice between at least 2 health plans per region CCC Plus Health Plans will be competitively procured (RFP) RFP Released April 29, 2016 Southwest Roanoke / Alleghany Western / Charlottesville Northern / Winchester Central Tidewater A list of CCC Plus regions by locality is available at: http://www.dmas.virginia.gov/Content_pgs/mltss-proinfo.aspx http://www.dmas.virginia.gov 13

CCC Plus Populations by Region CCC Plus Enrollment By Region and Launch Date Date Regions Regional launch All Populations July 1, 2017 Tidewater 19,863 45,952 September 1, 2017 Central 23,342 52,067 October 1, 2017 Charlottesville/Western 16,851 29,736 November 1, 2017 Roanoke/Alleghany 11,639 25,712 Southwest 12,669 21,717 December 1, 2017 Northern/Winchester 25,620 38,469 January 2018 CCC Demonstration (Transition plan determined with CMS) 27,281 Aged, Blind and Disabled (ABD) (Transitioning from Medallion 3.0) 76,388 Total All Regions 213,653 Source – VAMMIS Data; totals are based on CCC Plus target population data as of July 31, 2016 All populations is CCC + ABD + MLTSS by region – make new chart http://www.dmas.virginia.gov 14

CCC Plus Excluded Populations and Services Carved-Out Services Limited Coverage Groups (Family Planning, GAP, QMB only, HIPP, etc.) ICF-ID Facilities Veterans Nursing Facilities Psychiatric Residential Treatment Level C Money Follows the Person Hospice and ESRD (CCC Plus enrolled individuals who elect hospice or have ESRD will remain CCC Plus enrolled) Medallion 3.0 and FAMIS MCO PACE Dental School Health Services Intellectual Disability Case Management ID, DD, and DS Waiver Services, including waiver related transportation services (acute care will be under CCC Plus) Individuals and Families Developmental Disability Services Support Coordination Preadmission Screening Excluded Populations are not CCC Plus eligible; coverage will continue through fee-for-service (or through the Medallion 3.0/FAMIS MCO or PACE provider for MCO/PACE enrolled individuals) CCC Plus carved-out services are paid through fee-for-service for CCC Plus enrolled individuals http://www.dmas.virginia.gov 15

Health Plans Selected for Negotiations in all 6 Regions Aetna Better Health of Virginia Anthem HealthKeepers Plus Humana Magellan Complete Care of Virginia Optima Health United Healthcare Virginia Premier Health Plan http://www.dmas.virginia.gov/Content_atchs/mltss/Stakeholder%20Notice%20regarding%20negotiations.pdf http://www.dmas.virginia.gov

CCC Plus Builds on CCC Lessons Learned CCC allows Virginia the unique opportunity to integrate care for individuals who receive both Medicare and Medicaid, with the primary goal to improve health outcomes through coordinated care. Virginia is fully committed to maintaining a robust CCC program through the end of the Demonstration. CCC lessons learned will continue to inform the CCC Plus implementation going forward: Value of provider and member outreach and education Value of transparent/collaborative engagement with plans and CMS Value of engaging stakeholders throughout the design, development, and implementation process http://www.dmas.virginia.gov 17

CCC Plus Incorporates CCC Best Practices High quality care in the least restrictive and most integrated treatment setting Integrated person-centered model focused on individual needs and preferences Care coordination and health risk assessments for all members Member assistance through DARS (VICAP, long-term care ombudsman) Behavioral health homes that integrate behavioral and physical health services http://www.dmas.virginia.gov 18

Key Differences Between CCC Plus & CCC Continuity of Care Period is 90 Days Operates statewide in six regions Mandatory Enrollment Plans may differ by region CCC Plus Continuity of care period is 90 days No exception for nursing home provider Continuity of Care Period is 180 Days CCC Operates in five of the six regions Optional Enrollment 3 Health plans across 5 regions Continuity of care period is 180 days Allows for any willing nursing home provider Populations include duals/non-duals, children/adults, NF and five HCBS Waivers Populations include full dual adults; including NF and EDCD HCBS Waiver Health plans may vary by region Coordination of Medicare benefits through companion D-SNP or MA Plan Coordination of Medicare benefits through same Medicare/Medicaid Plan Plans may have narrower networks Any willing provider for LTSS http://www.dmas.virginia.gov 19

CCC Plus Enrollee Benefits Person centered, individualized support plan Same standard Medicaid services provided Choice between at least 2 health plans Care coordinator for each individual Assistance with needs related to housing, food and community Possible additional benefits offered by health plans http://www.dmas.virginia.gov 20

CCC Plus Enrollment Enrollment Broker: Maximus Neutral third party Broker will assist in determining which providers are contracted with specific health plans. Broker will answer questions about additional benefits offered by participating health plans. Enrollment notification begins approximately 45 days prior to effective date. http://www.dmas.virginia.gov 21

Health Plan Assignment Enrollees will receive an Initial Notice letter with an initial assignment into a health plan (Managed Care Organization or MCO) and a comparison chart of all the MCOs in their region. Enrollees can change their MCO by calling the enrollment broker Maximus by the “call by date” in their Initial Notice letter or via website. “Call by dates” will be on or before the 18th of the month prior to the MCO effective date. A “Confirmation Notice” will be mailed to the member confirming MCO final assignment Enrollees have 90 days from the Confirmation Notice to change final MCO assignment through Maximus. Beginning in 2017, an annual open enrollment period will occur in October – December. http://www.dmas.virginia.gov 22

Intelligent Assignment Initial assignment is based upon the members region Factors taken into consideration to being assigned to a particular MCO include: Two month reenrollment process or previously enrolled Medicare Managed care plan (MAC Id). 2-month previous Medicaid managed care enrollment (i.e., CCC+, Medallion 3.0 or CCC) Nursing Facility, EDCD Waiver or Tech Waiver (if provider participates with more than one MCO within that region, members will be randomly assigned) If the member has no considerations listed above, members will be randomly assigned to the MCO’s within their region Exceptions: January 2018 transition: the ABD transition from Medallion 3 to CCC Plus will not consider prior MCO enrollment history in the assignment algorithm. The transition from CCC to CCC Plus does consider the prior MCO enrollment, where the individual will remain with their CCC health plan if their health plan is operating as a CCC+ plan in the member’s locality on 1/1/2018. http://www.dmas.virginia.gov 23

Enrollee Protections During the continuity of care period of 90 days, MCOs have to pay existing providers MCO must go out of network to provide a service that they don’t have in network Members in Nursing Facility (NF) at the time of enrollment will not be moved even if the NF doesn’t choose to participate. NF will be paid as an out of network provider http://www.dmas.virginia.gov 24

CCC Plus Provider Benefits Medicaid rates are the floor for NF, waivers, early intervention and community behavioral health services Value based payment opportunities Enrollee periodic health risk assessments enhance care planning Care coordinator fosters communication among an interdisciplinary care team Care coordinator assists with problem solving and connects enrollees to local resources http://www.dmas.virginia.gov 25

Provider Enrollment Providers need to contract with MCOs to serve the CCC+ population Contact provider relations department of MCOs to discuss joining an MCOs network Credentialing of providers by MCOs can take 90 – 120 days to complete. http://www.dmas.virginia.gov 26

Service Authorizations and Coverage MCOs must cover services that are covered in the Virginia Medicaid State Plan Do not have to adhere to service limits Can choose to require authorization for services even if DMAS doesn’t require it now Most MCOs use a portal for service authorizations http://www.dmas.virginia.gov 27

CCC Plus Health Plan Selection Evaluate, negotiate, readiness, & award Work with CMS 1915 b/c Waivers Regulations Readiness review MCO Contracts Systems Enhancements Connectivity Transition of Care Monitoring Ongoing Stakeholder & Member Engagement/ Outreach & Education Regional Implementation & Ongoing Monitoring & Program Evaluation Next Steps . . . http://www.dmas.virginia.gov 28

Ongoing Stakeholder Input Providers and stakeholders can directly improve the CCC Plus design by communicating what is working well and what needs improvement 1 What are your concerns, worries, questions, and suggestions ? 2 What is working well under CCC and what are the areas of opportunity? 3 What is needed for a successful CCC Plus program launch and a smooth transition from CCC to CCC Plus? Once CCC Plus health plans have been selected, DMAS will facilitate collaborative meetings between DMAS, the health plans and stakeholders/providers. 4 http://www.dmas.virginia.gov 29

Thank You! For More Information . . . Send CCC Plus questions, concerns, and suggestions to: vamltss@dmas.virginia.gov Additional CCC Plus information is available at: http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx http://www.dmas.virginia.gov 30