Managed Medicaid in Virginia

Revenue Cycle Trends and Updates LTC/Post Acute Care  Case Management of Reimbursement Government sponsored program days numbered Payment Transformation Delivery Model Redesign  Accountability for Quality Ability to document improved outcomes Drive reduced LOS without elevated risks of returns to hospital Strong customer satisfaction  High Deductible Environment Provider burden for estimates Implementation/Cost of Verification tools and online technology Acceptance of Payments electronically  ICD /1/2015

Transition to Price Based Payment Three key pieces of legislation  Affordable Care Act (Medicaid Expansion)  Health Benefit Exchange  Financial Alignment Demonstration

Cost Based vs Price Based Operation COST BASED Government Sponsored, Per Diem PRICE BASED RUGs III based Reimbursement 11/1 Possibility of higher reimbursement Increased importance of detailed and accurate documentation

 Commonwealth Coordinated Care is a program the coordinates care for dual eligible residents in the State of Virginia. The care provided is not limited to Long Term Care and includes acute, behavioral and primary services.  CCC is a State and Federal program. CMS and DMAS have chosen three MMPs (Medicare –Medicaid plans) to provide services in the five designated service regions. Anthem Healthkeepers, Humana and Virginia premier.

CCC Eligible  Dual Eligible  Age 21 or older  Non Hospice  Non comprehensive/Group plan/Tricare  Non QMB Only  Non PACE  Patient’s who have opted for a Medicare replacement are eligible

CCC Billing (MDS/DMAS/DSS)  Custodial Assessments continue (92 days) and are transmitted to the State (more often can help with CMI)  PPS Assessments continue on Medicare schedule and are held (ie Medicare Replacement)  Medicaid Eligibility Process remains unchanged  Redetermination process remains unchanged  Level of Care process remains unchanged  UAI process remains unchanged  Retro Medicaid, prior period will be billable to traditional Medicaid

CCC Payment, Medicaid  07/01/ /31/2014 Reimbursement methods unchanged from current practice  11/01/2014 Centers will be reimbursed utilizing the Medicaid RUG III-34 grouper individual cmi risk adjustment payment

07/01/2014 Price Based Direct rate = Avg center case mix Direct Cost to Ceiling not as important No rate letters issued 11/01/2014 Price Based Direct rate = Resident Medicaid score RUG III -34 grouper RUGS scores entered on Medicaid claim Medicaid Reimbursement Changes

12/31/2017 CCC Program ends DMAS will enroll fee for service populations into a MLTSS program Potential Future Changes

CCC to MLTSS transition  Consistent with General Assembly directives in years 2011 and 2015 the Department of Medical Assistance Services will transition the majority of remaining Fee for Service (FFS) Medicaid enrollees into a coordinated and integrated managed care program  Intellectual Disability Programs will more than likely remain Fee for Service

CCC to MLTSS transition  DMAS will procure health plans to Administer the MLTSS program via a competitive procurement process (RFP)  Selected plans must have or be working towards obtaining the NCQA accreditation and approval by CMS to operate as a Dual Special Needs Plan  MLTSS will operate State-wide, plans may vary by region, there must be at least two health plans per region

Questions ?