Department of Medical Assistance Services Commonwealth Coordinated Care Virginia’s Dual Eligible Financial Alignment Demonstration Kristin Burhop and Emily Carr Virginia Department of Medical Assistance Services May 9, 2013 http://dmasva.dmas.virginia.gov 1

Overview Current structure of Medicare/Medicaid Opportunities for Integrated Care in Virginia Virginia’s Medicare-Medicaid Financial Alignment Demonstration

Who are Medicare-Medicaid enrollees? Receive both Medicare and Medicaid coverage Focus on “Full Duals” in CMS’ demonstration 58.8% age 65 or older 41.2% under age 65 Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from 2006-2011. February 2013. 10.2M Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees or “dual eligibles”) & 7.4M are “full duals”

Who pays for what services? MEDICAID Medicare cost sharing Nursing home (once Medicare benefits exhausted) Home- and community-based services (HCBS) Hospital once Medicare benefits exhausted Optional services (vary by state): dental, vision, HCBS, personal care, and select home health care Some prescription drugs not covered by Medicare Durable medical equipment not covered by Medicare MEDICARE Hospital care Physician & ancillary services Skilled nursing facility (SNF) care (up to 100 days) Home health care Hospice Prescription drugs Durable medical equipment

The Problem Dual eligible individuals: Often have multiple, complex health care needs May have physical, intellectual and behavioral disabilities See multiple providers - need to navigate fragmented, complex medical, behavioral, social and long-term services and supports systems

For Providers Confusion - two sets of rules, multiple insurance cards, overlapping benefits with different requirements, (e.g., pre-authorization, benefit limits, appeals timelines, reporting requirements, audits, etc.) Poor communication between providers Incomplete knowledge of individual’s condition, test results, prescriptions, etc Limited time, staff resources or financial incentives to coordinate services.

What does care look like for Medicare-Medicaid enrollees now? WITHOUT INTEGRATED CARE INDIVIDUALS MAY HAVE: Three ID cards: Medicare, Medicaid, and prescription drugs Three different sets of benefits Multiple providers who rarely communicate Health care decisions uncoordinated and not made from the patient-centered perspective Serious consideration for nursing home placement; Medicare/Medicaid only pays for very limited home health aide services

What does care look like for Medicare-Medicaid enrollees now? Like navigating a traffic circle…. Fragmented Not Coordinated Complicated Difficult to Navigate Not Focused on the Individual Gaps in Care Medicaid Medicare State Health Plan

The solution- Integrated Care! Virginia has the goal of providing person-centered, conflict free care coordination to dual eligible's. Creates one accountable entity 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 Blends Medicare’s and Medicaid’s services and financing to streamline care and eliminate cost shifting Provides high-quality, patient-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences

Virginia’s Financial Alignment Demonstration Full benefit Medicare-Medicaid Enrollees including: Elderly and Disabled with Consumer Direction Waiver participants; and Nursing Facility residents Age 21 and Over Live in demonstration regions (Northern VA, Tidewater, Richmond/Central, Charlottesville; Roanoke) Voluntary, Passive Enrollment

Virginia’s Financial Alignment Demonstration Individuals not eligible include: Those in the ID, DD, Day Support, Alzheimer's Technology Assisted HCBS Waivers Those in MH/ID facilities Those in ICF/IDs Those in PACE (although they can opt in); and Those in Long Stay Hospitals

Virginia’s Financial Alignment Demonstration Approximately 78,600 Medicare-Medicaid Enrollees           Region                Nursing Facility EDCD Wavier Community Non-waiver Total Central VA 4,430 3,762 16,135 24,327 Northern VA 1,935 1,766 12,952 16,653 Tidewater 3,031 2,492 12,575 18,098 Western/ Charlottesville 1,477 842 4,427 6,747 Roanoke 2,833 1,355 8,583 12,771 13,706 10,217 54,672 78,596

Beneficiary Protections: Choice of plans and providers Continuity of care Enrollment assistance Ombudsman Person-Centered approach ADA, Civil Rights compliance Beneficiary participation on MCO governing boards Customer service - access to a 24/7 toll-free number DMAS/CMS day-to-day monitoring and oversight

Outreach Identifying internal and external stakeholders Beneficiaries and family/representatives Providers Advocacy groups Community social organizations Sister agencies Contractors Local programs Modes and venues to reach stakeholders

Outreach and Education Stakeholder engagement Meetings with various stakeholder groups Fact sheet available for program overview Ombudsman and other community partners will play a critical role in beneficiary education Dual Eligible Advisory Committee workgroup design and operational issues solicit feedback suggestions Develop a comprehensive education and outreach plan; will be engaging stakeholders and enlisting the assistance from national experts to effectively communicate Initiative Grant funding opportunities to help cover education and outreach costs Established dedicated website and e-mail box dualintegration@dmas.virginia.gov

States and CMS are working together to Engage stakeholders at every level in both design and implementation Public stakeholder meetings and work groups Opportunities for feedback on proposals, contracts or policies Several demonstration-specific websites Multifaceted communications and outreach plans Coordination with ADRC/SHIPs, AAA and other systems entry points

Proposed enrollment process 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

Virginia’s Strategies to Address Needs Enhanced Care Management Stakeholder workgroup will help design care management, including expectations, levels of care management, how to best manage care for subpopulations (e.g., chronic conditions, dementia, behavioral health needs, etc.), how to structure transition programs in hospitals and NFs Behavioral “Health Homes” for individuals with SMI with MCOs partnering with the CSBs Encouraging MCOs to link/sub-contract with different providers for care coordination (e.g., CSBs, adult day care centers, NFs)

Virginia’s Strategies to meet Needs Other opportunities: Develop strong consumer protections (e.g., external ombudsman, grievances and appeals) Ensure individuals only have to make one call to receive all their Medicaid and Medicare funded services – 24/7 help lines Provide access to disease & chronic care management services that could improve overall health conditions and/or slow down decline Develop strong quality improvement programs, measures and monitoring Rate Development; will propose method for applying savings adjustments

Virginia Demonstration Timeline Date High Level Activity March 2013 -Finalize MOU and RFP Finalize State Plan Amendment and Waiver amendment April -Discuss MOU with CMS -Publish RFA -Develop Education and Outreach Plan -Submit State Plan Amendment May -Responses due from MCOs (mid-month) -Release data book - Begin Development of Readiness Review Documents June -Announce Selected MCOs - Publish draft rates July -Submit outreach and planning grant to CMS Finalize rates Begin Readiness Review Draft 3-way contract

Virginia Demonstration Timeline Month High Level Activity August -Continue Readiness Review September -Sign 3-way Contract October -Begin Education and Outreach BLITZ (ongoing) November-December Keep calm and carry on! January 2014 “Soft Start”-Begin Opt-in enrollment for 60 days March 2014 -Begin MCO assignment April 2014 - Tidewater and Richmond regions “go live” with passive enrollment