1. Virginia Association of Area Agencies on Aging
Department of Medical Assistance Services
Virginia Association of Area Agencies on Aging
Emily Osl Carr
Director, Office of Coordinated Care
October 17, 2013

2. Overview Current structure of Medicare/Medicaid
History of Integrated Care in Virginia
Commonwealth Coordinated Care (CCC)

3. Medicare-Medicaid Enrollees?
Receive both full benefit Medicare and Medicaid coverage
58.8% age 65 or older
41.2% under age 65
Often have multiple, complex health care needs.
Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from February 2013.
Over 9 million Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees)

4. Who are Medicare-Medicaid enrollees?
Individuals who have a unique set of circumstances, care and support needs, options and opportunities under a coordinated care system
Individuals who receive full benefit Medicare and Medicaid coverage

5. Medicare and Medicaid today
Medicare and Medicaid are not designed to work together resulting in an inefficient, more costly delivery system
Costs of serving individuals on Medicare and Medicaid are rising exponentially
Each program has its own set of rules, regulations, requirements and coverage
*We can’t afford to continue to support
rising costs without intervention*

6. Medicare and Medicaid today
The costs of serving these individuals are rising exponentially:
1K. Young, et al. “Medicaid’s Role for Dual Eligible Beneficiaries.” Kaiser Commission on Medicaid and the Uninsured, April 2012.
At the national level; spending 40% of Medicaid funds on 15% of the Medicaid population1
In Virginia;
spending 33% of Medicaid funds on 19% of the Medicaid population2

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

9. What does care look like for Medicare-Medicaid enrollees now?
WITHOUT COORDINATED CARE INDIVIDUALS MAY HAVE:
Three ID cards: Medicare, Medicaid, and prescription drugs
Three different sets of benefits
Multiple providers with limited means of coordination
Health care decisions that are not coordinated and not made from the person-centered perspective

10. Challenges for Individuals
Understanding two programs
Confusion with billing
Multiple insurance cards
Not knowing who to call with questions
Frustration over delays, getting care and support
Lack of holistic care

11. What Does the Medicare-Medicaid Benefit Look Like Now?
Like navigating a traffic circle….
Fragmented
Not Coordinated
Complicated
Difficult to Navigate
Not Focused on the Individual
Gaps in Care

12. History of Integrated Care in Virginia
2006: DMAS released the Blueprint for the Integration of Acute and Long Term Care Services
2009: DMAS planned to launch VALTC; however, due to budget constraints, provider resistance, and other limitations, did not move forward with initiative
2010: DMAS applied for CMS “State Demonstrations to Integrate Care for Dual Eligible Individuals” and was not one of the 15 states accepted
2011 & 2012: Legislature directed DMAS to develop and implement a care coordination model for Medicare-Medicaid enrollees
2011: DMAS sent Letter of Intent to participate in CMS’ Financial Alignment Demonstration
2014: Virginia to launch Commonwealth Coordinated Care
Developed rates in 2008 that were not sufficient to interest plans (only Medicaid $)
No state plan personal care services
Stringent Long-Term Care Criteria: 4 ADLs plus medical nursing need
Lack of reimbursed care coordination included in the Elderly or
Disabled waiver

13. Virginia’s Solution: Commonwealth Coordinated Care
Beginning January 2014, Virginia is rolling out a new initiative called Commonwealth Coordinated Care or CCC.
Provides high-quality, person-centered care for Medicare-Medicaid enrollees that is focused on their needs and preferences
Blends Medicare and Medicaid services and financing to streamline care and eliminate cost shifting

14. Virginia’s Solution: Commonwealth Coordinated Care
Creates a single program 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
Supports improved transitions between acute and long term facilities

15. Benefits for Virginia Eliminates cost shifting Achieves savings
Slows the rate of Medicaid cost growth for Virginia
Reduces duplicative or unnecessary services
Streamlines administrative burden
Single set of quality reporting measures, appeals and auditing
Promotes and measures improvements in quality of life and health outcomes

16. Benefits for Individuals and Families
Person-centered service coordination/case management
One ID card for all care
One 24/7 toll free phone number for assistance
Behavioral health homes for individuals with Serious Mental Illness (SMI)
A unified appeals process

17. Health Plans
DMAS is in the process of negotiations with health plans to provide Commonwealth Coordinated Care
Plans will be finalized this fall
Currently negotiating with 3 plans
Healthkeepers
Humana
Virginia Premier

18. Behavioral Health Homes
DMAS estimates there are over 17,000 dual eligible individuals with SMI in Virginia
One of the unique features of the CCC is the opportunity for health plans to develop behavioral health homes.
Behavioral health homes are a team-based services delivery model that provides comprehensive and continuous care to patients, including care management, with the goal of maximizing health outcomes.

19. Behavioral Health Home
Examples of the types of providers in the health plan network include but are not limited to the following:
Psychiatrists
Clinical psychologists
Licensed clinical social workers
Outpatient substance abuse treatment providers
Residential substance abuse treatment providers for pregnant women

20. Behavioral Health Homes
Expected outcomes for the health homes are:
Reduced use of the ER for routine care
Regular use of preventive strategies
Reduced hospitalizations and re-admissions
Coordinated prescribing and medication management
Crisis prevention and avoidance

21. Who is eligible for CCC?
Full benefit Medicare-Medicaid Enrollees (entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits)
Participants in the Elderly or Disabled with Consumer Direction Waiver
Residents of nursing facilities
Age 21 and Over
Live in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)

22. Virginia’s Service Regions

23. Who is eligible for CCC?
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
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

24. Who is not eligible for CCC?
Individuals not eligible include those in:
ID, DD, Day Support, Alzheimer's, Technology Assisted HCBS Waivers
MH/ID facilities
ICF/IDs
PACE (although they can opt in)
Long Stay Hospitals
Money Follows the Person (MFP) program
Hospice

25. Enrollment Enrollment will be in two phases:
The first phase is called “voluntary enrollment” where an individual proactively enrolls in the program
The second phase is called “passive enrollment” (also known as automatic enrollment) where the individual is automatically enrolled into the CCC program

26. Intelligent Assignment
For passive enrollment (automatic enrollment) where individuals don’t specify a specific health plan, DMAS has developed an “intelligent assignment” algorithm that assigns an individual to a specific health plan based on several factors
The process considers beneficiaries’ prior enrollment in health plans and providers

27. Intelligent Assignment
The pre-assignment process will specifically consider the following:
Individuals in a nursing facility will be pre-assigned to a health plan that includes that nursing facility in its network
Individuals on the EDCD waiver will be pre-assigned to a health plan that includes the individual’s current adult day health care

28. Intelligent Assignment
If more than one health plan’s network includes the nursing facility or adult day provider used by an individual, they will be assigned to the health plan with which he/she was previously assigned in the past six (6)months.
If the individual has no history with the health plans available under CCC, he/she will be assigned to a health plan in which their provider participates.

29. Intelligent Assignment
Most importantly, if an individual is unhappy with the health plan chosen for them, he/she may request reassignment to another health plan.

30. Commonwealth Coordinated Care Enrollment Timeline
Central Virginia/Richmond and Tidewater areas:
Early 2014: Voluntary enrollment begins
March 2014: Coverage begins
May 2014: Automatic enrollment begins
July 2014: Coverage for those automatically enrolled begins
Northern Virginia, Roanoke, Charlottesville areas:
May 2014: Voluntary enrollment begins
June 2014: Coverage begins
August 2014: Automatic enrollment begins
October 2014: Coverage for those automatically enrolled begins

31. Enrollment
The enrollment letters being mailed to individuals will introduce them to the CCC program and encourage them to sign up
Individuals who don’t proactively sign up, will receive additional letters letting them know they will be automatically enrolled
Letters will include a brochure comparing each health plan and an enrollment form
Individuals may choose the plan they want or allow a plan to be chosen for them
Individuals will be directed to call a number to sign up for CCC

32. CCC Educator and OC Coordinator
Coordinated Care Educator and Options Counseling Coordinator working with VICAP Counselors to inform, educate and provide guidance to CCC-eligible individuals
Educator and Coordinator will be housed at DARS.
Educator and Coordinator will work collaboratively with DMAS to enhance educational opportunities at venues serving Virginia’s five service regions

33. CCC Educator and OC Coordinator
Coordinated Care Educator will:
Guide prospective enrollees to the enrollment facilitator
Work with the appropriate local VICAP office for additional counseling
The Options Counseling Coordinator will:
Focus on partnerships and venues for CCC information events
Create a strong network of partners for a comprehensive outreach system to serve enrollees

34. CCC Educator and OC Coordinator
These new positions are being created to serve as a liaison between the AAAs and VICAP Counselors and DMAS, assist VICAP Counselors in educating beneficiaries about the program, and to help beneficiaries and their families in their Medicare and Medicaid supports.

35. Timeline for Central Virginia/Richmond and Tidewater areas
Fall 2013: VICAP Counselors provide basic information on CCC to eligible individuals.
Late Fall 2013: Coordinated Care Educator and Options Counseling Coordinator are hired to assist in outreach efforts.
Early 2014: first letters are mailed to eligible individuals.
March 2014: For those signed up with CCC, coverage begins.
May 2014: Automatic enrollment begins.
July 2014: For those automatically enrolled in CCC, coverage begins.

36. Timeline for Northern Virginia, Roanoke, Charlottesville areas
Fall 2013: VICAP Counselors provide basic information on CCC to eligible individuals.
Late Fall 2013: Coordinated Care Educator and Options Counseling Coordinator are hired to assist in outreach efforts.
May 2014: First letters are mailed out to eligible individuals
June 2014: for those signed up for CCC, coverage begins.
August 2014: Automatic enrollment begins.
October 2014: Coverage for those automatically enrolled begins.

37. In the coming weeks….
Continue Readiness Reviews with Health Plans in negotiation
Continue design and implement various components of Commonwealth Coordinated Care with community and stakeholder feedback and input
Continued Outreach and Education

38. Contact Information
Technical assistance will be available on an ongoing basis from DMAS.
Questions may be directed to: or to:
Emily Osl Carr
Director, Office of Coordinated Care
Virginia Department of Medical Assistance Services
600 E. Broad Street, Suite 1300
Richmond, VA 23219
(804)