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Virginia Acute and Long-Term Care Integration VALTC

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Virginia Acute and Long-Term Care Integration VALTC

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    1. 1 Virginia Acute and Long-Term Care Integration (VALTC) Department of Medical Assistance Services Suzanne Gore, Integrated Care Program Manager Suzanne.gore@dmas.virginia.gov Adrienne Fegans, Program Operations Administrator Adrienne.fegans@dmas.virginia.gov April 9, 2008

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    3. 3 What is Acute and Long-Term Care Integration? An Opportunity

    4. 4 VALTC Mission To improve the quality of life of Virginias Medicaid-enrolled seniors and adults with disabilities by empowering them to remain independent and reside in the setting of their choice for as long as possible through the provision of a streamlined primary, acute, and long-term care service delivery system that offers ongoing access to quality health and long-term care services, care coordination, and referrals to appropriate community resources.

    5. 5 Integration of Acute and Long-Term Care Main concept: Offer primary, acute, and long-term care services through a managed care program To accomplish this, DMAS is integrating populations and services previously excluded from managed care into managed care.

    6. 6 Localities Included in Tidewater Pilot

    7. 7 Localities Included in Tidewater Pilot Prospective MCOs must contract for all targeted populations in the core localities within the designated region. MCOs may include the provision of services for any or all targeted populations in the non-core localities; DMAS, however, must have a minimum of two MCOs in each of the core and non-core localities in order to implement the program in those areas.

    8. 8 Populations Full benefit dual eligibles (Medicare and Medicaid) Elderly or Disabled with Consumer Direction (EDCD) waiver participants

    9. 9 Population Summary

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    11. 11 Elderly or Disabled with Consumer Direction (EDCD) Home and Community-Based Long-Term Care Services

    12. 12 Special Populations: EDCD Waiver Elderly or Disabled with Consumer Direction (EDCD) waiver program One of seven home and community-based wavier programs. 13,965 EDCD waiver participants in SFY2007 statewide. Participants currently enrolled in FFS. Enrollment not capped; often serves as waiting area for other waivers. Waiver enrollment is growing.

    13. 13 New Services: EDCD Waiver EDCD waiver services: Adult Day Services, Personal Care, Respite Care, Electronic Monitoring, Service Facilitation for Consumer Directed Personal and Respite Care Assistive Technology, Environmental Modifications; and Transition Services & Coordination (offered as a carved out).

    14. 14 New Services: EDCD Waiver Services vary depending on the individuals service plan. All EDCD participants must meet the nursing facility level of care criteria. Participants may meet a higher financial eligibility threshold (300% of the SSI payment level for one person). Depending on income level, participants are often responsible to cover a portion of their care (patient pay). All participants must have an annual assessment and service plan update in their preferred setting. Special Feature: Consumer Direction - Individual directs his own care.

    15. 15 New Services: EDCD Waiver Consumer Direction: Available option for personal care and respite care. Participants hire their own attendant care provider. Must be an extenuating circumstance for attendant to be a family member. Training of attendants by the MCO may be encouraged, but not required. DMAS will include current PMPM for CD fiscal agent in capitation rate.

    16. 16 Enrollment: EDCD Waiver Enrollment in VALTC is mandatory. Participants may request to opt-out of VALTC if enrollment would detrimentally impact the health, safety, or welfare of the participant. Opt-out requests will be evaluated by a DMAS committee on a case-by-case basis to ensure appropriate, accessible, and quality care for the individual. EDCD participants have an expedited enrollment process. EDCD participants must receive services within 30 days of enrollment in the EDCD program.

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    19. 19 Dual Eligibles Integrating Medicare and Medicaid

    20. 20 Special Populations: Dual Eligibles Receive both Medicare and Medicaid. Currently participate in FFS. Receive majority of care through Medicare. Enrollment: Dual eligibles will be pre-assigned to a VALTC MCO based on an algorithm through a 60 day pre-assignment cycle. Participants are encouraged to select the plan that is the best fit for them. Participants will have the option to disenroll into another plan within the first 90 days of participation.

    21. 21 New Services: Dual Eligibles Dual eligibles may receive Medicaid coverage for the following: Not included in VALTC capitation rate: Medicare monthly premiums for Part A, Part B, or both (DMAS will pay Medicare Part A and/or Part B premiums. Premiums will not be included in the capitation rate). Included in VALTC capitation rate: Coinsurance, copayment, and deductible for Medicare-allowed services (i.e., crossover claims). Medicaid-covered services (including certain medications), even those that are not allowed by Medicare.

    22. 22 Claims Process: Dual Eligible VALTC MCOs will receive crossover claims through three scenarios: Participant enrolled in the VALTC Medicaid MCO and Medicare fee-for-service; Participant enrolled in the VALTC Medicaid MCO and in a different MCOs Medicare Advantage plan or SNP; or Participant enrolled in the VALTC Medicaid MCOs Medicare Advantage plan or SNP.

    23. 23 Scenario A: Participant enrolled in the VALTC Medicaid MCO and Medicare fee-for-service Providers submit claims through their standard Medicare claims process. GHI processes the Medicare liability and pays the provider for the Medicare portion of the claim. GHI then sends the crossover remittance to First Health Services (the DMAS fiscal agent). First Health Services pays the provider for any VALTC Medicaid carved out service. First Health Services then sends the remittance to the applicable VALTC MCO for payment of any remaining Medicaid liability (e.g. crossover payment). The VALTC MCO processes the remittance and pays the provider any further amount owed.

    24. 24 Scenario B: Participant enrolled in the VALTC Medicaid MCO and in a different MCOs Medicare Advantage plan or SNP Providers submit claims to the proper Medicare Advantage Plan or SNP and that plan pays the provider for the Medicare portion of the claim. Next, the provider submits the remittance to the VALTC MCO. The VALTC MCO pays the remaining Medicaid liability of the claim. If liability remains for a carved out service, the provider resubmits the claim to First Health Services for payment of the carved out service.

    25. 25 Scenario C: Participant enrolled in the VALTC Medicaid MCOs Medicare Advantage plan or SNP Providers submit claims to the proper Medicare Advantage Plan or SNP and the VALTC plan pays the provider for both the Medicare and Medicaid liability. If liability remains for a carved out service, the provider resubmits the claim to First Health Services for payment of the carved out service.

    26. 26 Care Coordination

    27. 27 Care Coordination VALTC will include the following levels of care coordination: Standard care coordination: For all participants (both dual eligibles and EDCD participants) Expanded care coordination for individuals enrolled in the EDCD waiver: Required EDCD care coordination Optional EDCD care coordination

    28. 28 Standard: Care Coordination Care coordination for all participants (dual and EDCD) Access to a 24 hour/7 days a week nurse help-line; Customer service line: Offer referrals to Medicare services and appeals when appropriate; and Provide information on program options. Referral of participants to appropriate community resources.

    29. 29 Expanded: Mandatory Care Coordination for EDCD All EDCD participants must take part in these activities. Performance of annual level of care re-evaluations and service plan updates to ensure necessity of EDCD services and to identify unmet medical or social needs; Coordination with social service agencies (e.g. local departments of health and social services); Participating in discharge planning (to include nursing facility discharge), when appropriate, to ensure awareness of and access to community based services; Providing a point person for recipients and caregivers; Monitoring of services provided; and Maintaining and monitoring individual service records.

    30. 30 Expanded: Optional Care Coordination for EDCD MCOs must offer these services, however participation by the member is optional. Setting up appointments; Setting up transportation; Shepherding medical/LTC information between providers; and Coordination with Medicare services if individual is enrolled in MCOs Medicare plan.

    31. 31 Nursing Facility Coverage

    32. 32 Nursing Facility Coverage Sixty days of a nursing facility stay is covered under VALTC. Participants must be referred by their MCO. Participants must meet nursing facility criteria. Sixty day coverage does not include step-down care. DMAS will pay the nursing facilities directly and adjust capitation payments accordingly.

    33. 33 Nursing Facility Coverage: 60 Day Clock If a Medicaid beneficiary enters a nursing facility under a Medicare Part A stay, the 60-day clock for continued VALTC MCO enrollment will begin upon entry to the nursing facility. The 60 day clock stops after the individual is discharged from the nursing facility and placed in a community setting. Upon completion of the 60-day period, if the beneficiary remains in the nursing facility, he/she will be excluded from VALTC.

    34. 34 Differences between VALTC and the existing DMAS Managed Care Program

    35. 35 How is VALTC Different Than Medallion II? VALTC will cover populations previously excluded from managed care. VALTC will offer care coordination for EDCD participants. VALTC will include new long-term care services. VALTC will include consumer directed services.

    36. 36 How is VALTC Different Than Medallion II? VALTC MCOs will process Medicare crossover claims. VALTC participants have greater health care needs. VALTC participants have the opportunity to enroll in Medicare Advantage plans.

    37. 37 Implementation Advisory Group Beginning summer 2008. Membership will include representatives from participating MCOs and DMAS staff members. Collaborative to provide training, clarify requirements, identify challenges, and resolve implementation issues. Planned topics include: Long-term care services- including consumer direction Long-term care quality measures Dual eligible claims processing Screening, eligibility criteria, and enrollment Care coordination

    38. 38 Next Steps Adrienne Fegans

    39. 39 Contracting Timeline

    40. 40 Requirements to Contract for VALTC Financial, management, and administrative capabilities Quality improvement and utilization management processes Network of providers with appropriate demographic placement and specialties

    41. 41 Requirements to Contract for VALTC Informational programs for enrollees and consumer protections Ability to process information and data, and render appropriate reports quickly, efficiently, and completely HIPAA confidentiality requirements

    42. 42 Thank you! We look forward to working with you on this initiative. Questions?

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