http://dmasva.dmas.virginia.gov

1. Department of Medical Assistance Services Virginia Association of Area Agencies on Aging Emily Osl Carr Director, Office of Coordinated Care October 17, 2013 http://dmasva.dmas.virginia.gov

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. 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?

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

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

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 1-800 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. TimelineforNorthern 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: CCC@dmas.virginia.gov 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) 588-4888 Emily.carr@dmas.virginia.gov