Commonwealth Coordinated CareVirginia’s Dual Eligible Financial
Alignment Demonstration
Kristin Burhop and Emily CarrVirginia Department of Medical Assistance Services
May 9, 2013
http://dmasva.dmas.virginia.gov 1
Department of Medical Assistance Services
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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
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?
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 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
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.
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What does care look like for Medicare-Medicaid enrollees now?
WITHOUT INTEGRATED CARE INDIVIDUALS MAY HAVE:
x Three ID cards: Medicare, Medicaid, and prescription drugs
x Three different sets of benefits
x Multiple providers who rarely communicate
x Health care decisions uncoordinated and not made from the patient-centered perspective
x Serious consideration for nursing home placement; Medicare/Medicaid only pays for very limited home health aide services
Medicaid Medicare
State Health Plan
Fragmented
Not Coordinated
Complicated
Difficult to Navigate
Not Focused on the Individual
Gaps in Care
What does care look like for Medicare-Medicaid enrollees now?
Like navigating a traffic circle….
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
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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
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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
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Approximately 78,600 Medicare-Medicaid Enrollees
Virginia’s Financial Alignment Demonstration
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
Total 13,706 10,217 54,672 78,596
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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
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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
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
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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
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1/1/2014 1/1/2015
2/1/2014 3/1/2014 4/1/2014 5/1/2014 6/1/2014 7/1/2014 8/1/2014 9/1/2014 10/1/2014 11/1/2014 12/1/2014
1/1/2014Demonstration Begins
5/1/2014 - 6/30/2014Phase I Initial Passive Enrollment Period
“Pre-assignment”
Duals Enrollment TimelinePhases I & II
1/1/14- 12/31/14
1/2/2014Enrollment Packet sent to Phase I Eligibles
1/1/2015Annual Enrollment Packet
Sent to all Individuals who Opted-OutPhases I & II
5/1/2014Enrollment Packet sent to Phase II Eligibles
7/1/2014Phase I Service Effective Date for Those Passively Enrolled
10/1/2014Phase II Service Effective Date for Those Passively Enrolled
2/1/2014Phase I Opt-In Rolling Effective Date
6/1/2014Phase II Opt-In Rolling Effective Date
7/31/2014 - 9/29/2014Phase II Initial Passive Enrollment Period
“Pre-assignment”
NotePassive Enrollment: After the initial pre-assignment period, any newly eligible individual will be placed in pre-assignment on a monthly basis. Those who are Included in pre-assignment will be eligible the 1st day of the 2nd month.Opt-In Enrollment: After the first Opt-In effective date, those who opt-in prior tothe 18th of the month will be eligible for services the 1st day of the following month.
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
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Virginia Demonstration Timeline
Date High Level ActivityMarch 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
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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
