1. Virginia’s Blueprint for the Integration of Acute and Long-Term Care Services The Second National Medicaid Congress Cindi B. Jones, Chief Deputy Director Department of Medical Assistance Services June 14, 2007

2. 2 The Elderly And Disabled Represent 30 Percent of Program Recipients Demographics Of Recipients In Virginia’s Medicaid Program Blind & Disabled 20% Adults 13% Aged 10% Children 57% Note: Unduplicated count of recipients in FY 2005 30%

3. 3 …Yet They Account For Three- Quarters Of Program Spending Children Adults Blind & Disabled Aged Expenditures 10% 20% 13% 57% 26% 45% 9% 21% Recipients 30% 71% Notes: FY 2005 recipient and expenditure data

4. 4 This Obviously Means The Cost Of Serving The Elderly and Disabled Is Substantially Greater Than The Cost Of Care For Children $1,725 $10,831 $3,109 $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 Aged Blind & Disabled All Recipients ChildrenAdults Notes: FY 2005 recipient and expenditure data $4,720 $ 11,595

5. 5 Virginia’s Waiver Programs For The Elderly And Disabled Are Expensive But Still Less Costly Than Comparable Institutional Care $29,705 $23,904 $112,558 $27,537 $112,558 $56,116 131,246 $98,485 Per Person Institution $ Waiver Programs AIDS DD MR Tech Assisted EDCD Per Person Waiver $ $27,947 $18,305

6. 6 DMAS’ Key LTC Performance Measure Focuses on Community Based Care

7. 7 Governor Kaine and General Assembly Directs DMAS to Develop A Blueprint for the Integration of Acute and Long Term Care 2006 Virginia Acts of the General Assembly (Item 302, ZZ) This plan shall explain how the various stakeholders will be involved in the development and implementation of the new program model(s); explain how the various stakeholders will be involved in the development and implementation of the new program model(s); describe the various steps for development and implementation of the program model(s), include a review of other States’ models, funding, populations served, services provided, education of clients and providers, and location of programs; and describe the various steps for development and implementation of the program model(s), include a review of other States’ models, funding, populations served, services provided, education of clients and providers, and location of programs; and describe the evaluation methods that will be used to ensure that the program provides access, quality, and consumer satisfaction. describe the evaluation methods that will be used to ensure that the program provides access, quality, and consumer satisfaction.

8. 8 DMAS Held a Series of Three Meetings on Acute and Long Term Care Integration Models and Issues (during Summer/Fall 2006) First Meeting: Provided an overview of Medicaid funded acute and long term care services in Virginia and across the United States. First Meeting: Provided an overview of Medicaid funded acute and long term care services in Virginia and across the United States. Second Meeting: Facilitated a meeting with stakeholders so they could provide input on the options for developing an integrated acute and long term care program in Virginia. Second Meeting: Facilitated a meeting with stakeholders so they could provide input on the options for developing an integrated acute and long term care program in Virginia. Third Meeting: Heard public comment on the integration of acute and long term care. Third Meeting: Heard public comment on the integration of acute and long term care.

9. 9 What is Integration? What is Integration? Current System—fee for service and fragmented Primary and Acute Care Services Primary and Acute Care Services –Physician –Hospital –Pharmacy –Labs –Disease Management Long Term Care Services Long Term Care Services –Nursing Homes –Home and Community Based Care Waiver programs (7) –Case Management New System—Managed care and coordinated Combines all acute and long term care services (except for certain waiver programs) under one capitated rate Combines all acute and long term care services (except for certain waiver programs) under one capitated rate Combines Medicare and Medicaid funding Combines Medicare and Medicaid funding ONE CALL—ALL CARE NEEDS ONE CALL—ALL CARE NEEDS Right Services at Right Time Right Services at Right Time

10. 10 Two Models for Integration Community Model: Program of All Inclusive Care for the Elderly or PACE. Combines Medicaid and Medicare funding to provide all medical, social, and long term care services through an adult day health care center. Community Model: Program of All Inclusive Care for the Elderly or PACE. Combines Medicaid and Medicare funding to provide all medical, social, and long term care services through an adult day health care center. Six communities actively pursuing PACE—6 were awarded start up grants ($250,000 each). Six communities actively pursuing PACE—6 were awarded start up grants ($250,000 each). –Hampton Roads (2) –Richmond (1) –Lynchburg (1) –Far Southwest (2)

11. 11 Two Models for Integration (continued) Regional Model: Could range from a capitated payment system for Medicaid (potentially integrating Medicare funding) for acute care costs with care coordination for long term care services, to a fully capitated system for all acute and long term care services Regional Model: Could range from a capitated payment system for Medicaid (potentially integrating Medicare funding) for acute care costs with care coordination for long term care services, to a fully capitated system for all acute and long term care services

12. 12 Development of a Plan: Populations Covered All 234,945 Low-Income Seniors and Persons with Disabilities (ABD) Development of a Plan: Populations Covered All 234,945 Low-Income Seniors and Persons with Disabilities (ABD) Medicaid Only (non- duals) 86,732 clients Medicaid Only (non- duals) 86,732 clients –Don’t use long term care services (79,045 clients) –Use long term care services (7,687 clients) Medicaid and Medicare (dual eligibles) 148,213 clients Medicaid and Medicare (dual eligibles) 148,213 clients –Don’t use long term care services (115,152 clients) –Use long term care services (33,061 clients)

13. 13 Development of a Plan: Services Included All Medicaid and Medicare primary, acute and long term care services (including nursing facility care and home and community based waiver services) All Medicaid and Medicare primary, acute and long term care services (including nursing facility care and home and community based waiver services) –Home health and personal care services will continue to be the cornerstone to keeping clients in their homes Services carved out: Services carved out: –Behavioral Health Services (state plan option only) –Certain waiver programs (MR, DS, DD, Technology Assisted)

14. 14 Development of a Plan: Enrollment Options Community Model/PACE: Enrollment will be voluntary Community Model/PACE: Enrollment will be voluntary Regional Model: Enrollment will be mandatory for managed care programs for acute care needs only; enrollment will be voluntary for managed care program for both acute and long term care needs (clients will be enrolled and have the opportunity to opt out). Regional Model: Enrollment will be mandatory for managed care programs for acute care needs only; enrollment will be voluntary for managed care program for both acute and long term care needs (clients will be enrolled and have the opportunity to opt out).

15. 15 Development of a Plan: Providers Community Model: Federal and state approved PACE sites Community Model: Federal and state approved PACE sites Regional Models: Current managed care organizations and/or Medicare Advantage Plans, Special Needs Plans Regional Models: Current managed care organizations and/or Medicare Advantage Plans, Special Needs Plans

16. 16 Integration Models Will Be Phased In Community Model/PACE Community Model/PACE –Current System: One Pre-PACE site more than 10 years (Sentara Senior Community Center) –Phase I (2007-2008): Six full PACE sites Two in Hampton Roads, One in Richmond, Two in the far Southwest, One in Lynchburg Two in Hampton Roads, One in Richmond, Two in the far Southwest, One in Lynchburg –Phase II (2007-2009): DMAS determines underserved areas of the state and issues a Request for Application for additional PACE sites. Next site location is Northern Virginia DMAS determines underserved areas of the state and issues a Request for Application for additional PACE sites. Next site location is Northern Virginia

17. 17 Integration Models Will Be Phased In (continued) Regional Models Regional Models –Current System: Managed care for acute care needs only—49,000 ABDs with no Medicare and with no long term care services. –Phase I (2007-2008): Expands managed care for primary and acute care needs only to the ABDs with no Medicare but who have long term care needs. LTC services remain fee for service. Will not include nursing facility residents Will not include nursing facility residents Will not include Technology Assisted Waiver clients Will not include Technology Assisted Waiver clients Will not move current LTC waiver clients into managed care. Will not move current LTC waiver clients into managed care.

18. 18 Integration Models Will Be Phased In (continued) Regional Models Regional Models –Phase II (2008-2010): Fully integrates acute and long term care services and combines Medicaid and Medicare funding. Excludes certain home and community- based care waiver program services (MR, DS, DD, Tech) but does include the clients for coordination of acute and primary care services. Next Steps Next Steps –Will include stakeholder input throughout the development and implementation of this phase –Will develop a Request for Proposals in 2007 –Will start as a pilot/regional program in 2008 –Movement of populations, services, and funding sources likely to be phased in over time