1. http://dmas.virginia.gov 1 Department of Medical Assistance Services An Introduction to Managed Long Term Services and Supports (MLTSS) Department of Medical Assistance Services May 2016

2. 2 http://www.dmas.virginia.gov Agenda  Background and Key Facts  Legislative Mandates  National Trends  Vision and Goals  Populations, Services and Regions  Proposed Launch  MLTSS and CCC Comparison  Delivery System Reform Incentive Payment (DSRIP)  Next Steps  Ongoing Opportunity for Stakeholder Input  MLTSS and DSRIP References

3. 3 http://www.dmas.virginia.gov Virginia Public Procurement Act DMAS must operate under strict Code of Ethics Rules until successful completion of the MLTSS 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 MLTSS RFP on April 29, 2016 and it is available at: http://www.dmas.virginia.gov/Content_pgs/rfp.aspx http://www.dmas.virginia.gov/Content_pgs/rfp.aspx Presently we are operating under a competitive procurement and we may not be able to respond to all of your questions

4. 4 http://www.dmas.virginia.gov Virginia’s Medicaid Program Key Facts 1 in 8 Virginians rely on Medicaid 1 in 3 Births covered in Virginia 58% Long-Term Services & Supports spending is in the community 1 Million + Virginians covered by Medicaid/CHIP 50% Medicaid beneficiaries are children 2 in 3 Residents in nursing facilities supported by Medicaid - Primary payer for LTSS Behavioral Health Medicaid is primary payer for services

5. 5 http://www.dmas.virginia.gov 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. Medicaid Population and Expenditures

6. 6 http://www.dmas.virginia.gov Medicaid Expenditure Breakdown Virginia’s Medicaid Expenditures Breakdown

7. 7 http://www.dmas.virginia.gov MLTSS: Legislative Mandates 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 Consistent with Virginia General Assembly and Medicaid reform initiatives, DMAS is moving forward transitioning individuals from fee-for-service delivery models into managed care

8. 8 http://www.dmas.virginia.gov MLTSS and National Trends Virginia’s MLTSS efforts are consistent with National trends Many states are moving LTSS into managed care programs and towards payment/outcome driven delivery models – LTSS spending trends are unsustainable – Managed care offers flexibility not otherwise available through fee-for-service – Affordable Care Act emphasis on care coordination/integration of care

9. 9 http://www.dmas.virginia.gov Benefits of Managed Care 9 Managed Care Basics DMAS contracts with managed care organizations (MCO) DMAS pays a per-member per- month (PMPM) MCOs contract with providers and pay claims 75% of Virginia Medicaid Enrollees currently enrolled State-wide for Medallion 3 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 Medicaid no longer a “welfare program” – it is health coverage Private sector shares risk with government

10. 10 http://www.dmas.virginia.gov MLTSS: Vision and Goals Provide individuals with high-quality, person centered care and enhanced opportunities to improve their lives 1 Improve community-based infrastructure and community capacity to enable/ support care in the least restrictive and most integrated setting 2 Promote innovation and value- based payment strategies 3 Provide care coordination and better accommodate progressive needs of members 4 5 Better manage and reduce expenditures; reduce service gaps and the need for avoidable services, such as hospitalizations and emergency room use VISION: To implement a coordinated system of care that builds on lessons learned and focuses on improved quality, access and efficiency

11. 11 http://www.dmas.virginia.gov MLTSS 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

12. 12 http://www.dmas.virginia.gov MLTSS Populations Approximately 212,000 Individuals Duals (Full Medicaid) with and without LTSS Not CCC Enrolled 45,000 excluded; 39,000 eligible/ not enrolled CCC Enrolled 29,000 will transition 1/2018 Non Duals with LTSS FFS 11,000 Medallion 3.0 HAP* 9,000 Non Dual /Non LTSS aged, blind or disabled Individuals 79,000 FFS Aged, Blind, Disabled (ABD) 3,000 Medallion 3.0 Aged, Blind, Disabled (ABD) 76,000 will transition 1/2018 Approximations based upon March 2016 MMIS Data 20,000113,000 *HAP - http://www.dmas.virginia.gov/Content_pgs/mc-home.aspxhttp://www.dmas.virginia.gov/Content_pgs/mc-home.aspx

13. 13 http://www.dmas.virginia.gov MLTSS Excluded Populations and 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 (MLTSS enrolled individuals who elect hospice or have ESRD will remain MLTSS enrolled)  Medallion 3.0 and FAMIS MCO  PACE  Dental  School Health Services  Community Intellectual Disability Case Management  ID, DD, and DS Waiver Services, including waiver related transportation services, until after the completion of the ID/DD redesign  Individuals and Families Developmental Disability Services Support Coordination  Preadmission Screening Excluded PopulationsCarved-Out Services Excluded Populations are not MLTSS eligible; coverage will continue through fee-for-service (or through the Medallion 3.0/FAMIS MCO or PACE provider for MCO/PACE enrolled individuals) MLTSS carved-out services are paid through fee-for-service for MLTSS enrolled individuals

14. 14 http://www.dmas.virginia.gov Coordination with Medicare 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. MLTSS plans must operate (or obtain approval to operate ) as Medicare Dual Special Needs Plans (DSNP) DSNPs operate under contract with Medicare and Medicaid Once DSNPs are operational, MLTSS individuals will have the option to choose the same plan for Medicare and Medicaid coverage DMAS Contracts (DSNP and MLTSS) will facilitate care coordination across the full continuum of care

15. 15 http://www.dmas.virginia.gov Proposed MLTSS Regions MLTSS will operate statewide, across 6 regions, and will offer individuals choice between at least 2 health plans per region MLTSS Health Plans will be competitively procured (RFP) A list of MLTSS regions by locality is available at: http://www.dmas.virginia.gov/Content_pgs/mltss-proinfo.aspxhttp://www.dmas.virginia.gov/Content_pgs/mltss-proinfo.aspx

16. 16 http://www.dmas.virginia.gov Proposed MLTSS Launch Timeline DateRegionsRegional Launch All Populations July 1, 2017Tidewater 17,39542,910 September 1, 2017Central 23,57354,275 October, 2017Charlottesville/Western 16,48129,614 November 1, 2017Roanoke/Alleghany and Southwest 23,66547,291 December 1, 2017Northern/Winchester 25,09937,964 January 2018CCC Demonstration (Transition plan is to be determined with CMS) 29,510 January 2018Aged, Blind and Disabled (ABD) (Transitioning from Medallion 3.0) 76,331 TotalAll Regions212,054 MLTSS Implementation Phases Source – VAMMIS Data; *Approximate totals based upon MLTSS targeted population as of March 2016 A list of MLTSS regions by locality is available at: http://www.dmas.virginia.gov/Content_pgs/mltss-proinfo.aspxhttp://www.dmas.virginia.gov/Content_pgs/mltss-proinfo.aspx

17. 17 http://www.dmas.virginia.gov MLTSS 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 MLTSS implementation going forward o Value of provider and member outreach and education o Value of transparent/collaborative engagement with plans and CMS o Value of engaging stakeholders throughout the design, development, and implementation process

18. 18 http://www.dmas.virginia.gov MLTSS 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 protections through DARS (VICAP, long-term care ombudsman) Behavioral health homes that integrate behavioral and physical health services

19. 19 http://www.dmas.virginia.gov Key Differences Between MLTSS & CCC Any willing provider for LTSS Plans may have narrower networks Continuity of Care Period is 90 Days Operates statewide in six regions Mandatory Enrollment Plans may differ by region MLTSS 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 Coordination of Medicare benefits through companion DSNP or MA Plan Coordination of Medicare benefits through same Medicare Medicaid Plan Populations include full dual adults; including NF and EDCD HCBS Waiver Populations include duals/non-duals, children/adults, NF and five HCBS Waivers Health plans may vary by region

20. 20 http://www.dmas.virginia.gov Delivery System Reform Incentive Payment (DSRIP) 20 MLTSSDSRIP DSRIP is a Medicaid innovation waiver focused on transforming how care is delivered and paid for in Virginia’s Medicaid delivery system Alignment of MLTSS and DSRIP creates a powerful opportunity to strengthen and integrate care delivery 1.Virginia Medicaid’s community delivery structure (One Community) 2.Payment reforms toward value-based purchasing Opportunity to Improve Care to Members

21. Leverage Benefits DSRIP will strengthen community capacity across the continuum Engage Now is the time to learn more about delivery system reform You may be approached by a coordinating entity to participate in a Virginia Integration Partnership (VIP) Continue Learning DSRIP is in early development and design stage Information posted to DMAS webpage: http://www.dmas.virginia.gov/Content_pgs/ dsrip.aspx http://www.dmas.virginia.gov/Content_pgs/ dsrip.aspx DSRIP Key Takeaways 21 Increasing awareness of DSRIP program will help communities: DMAS will invest in provider infrastructure and supports in order for providers, payers, health plans, and the Department to succeed in the shift toward a new model of care and Medicaid payment models. http://www.dmas.virginia.gov

22. 22 http://www.dmas.virginia.gov MLTSS Health Plan Selection Evaluate, negotiate, readiness, & award Work with CMS 1115 Waiver 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...

23. 23 http://www.dmas.virginia.gov Ongoing Stakeholder Input What are your concerns, worries, questions, and suggestions ? 1 What is needed for a successful MLTSS program launch and a smooth transition from CCC to MLTSS? 2 Once MLTSS health plans have been selected, DMAS will facilitate collaborative meetings between DMAS, the health plans and stakeholders/providers 4 3 What is working well under CCC and what are the areas of opportunity? Providers and stakeholders can directly improve the MLTSS design by communicating what is working well and what needs improvement

24. 24 http://www.dmas.virginia.gov Thank You! For More Information... Send MLTSS questions, concerns, and suggestions to: vamltss@dmas.virginia.gov Additional MLTSS information is available at: http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx Additional DSRIP information is available at: http://www.dmas.virginia.gov/Content_pgs/dsrip.aspx