Commonwealth Coordinated Care Virginia’s Dual Eligible Financial Alignment Demonstration

1. Department of Medical Assistance Services Commonwealth Coordinated CareVirginia’s Dual Eligible Financial Alignment Demonstration Kristin Burhop and Emily Carr Virginia Department of Medical Assistance Services May 9, 2013 http://dmasva.dmas.virginia.gov 1

2. Overview • Current structure of Medicare/Medicaid • Opportunities for Integrated Care in Virginia • Virginia’s Medicare-Medicaid Financial Alignment Demonstration

3. 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”

4. 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

5. 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

6. 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.

8. What does care look like for Medicare-Medicaid enrollees now?

9. What does care look like for Medicare-Medicaid enrollees now? Like navigating a traffic circle…. • Fragmented • Not Coordinated • Complicated • Difficult to Navigate • Not Focused on the Individual • Gaps in Care Medicaid Medicare State Health Plan

10. 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

11. 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

12. 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

13. Virginia’s Financial Alignment Demonstration • Approximately 78,600 Medicare-Medicaid Enrollees

14. 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

15. 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

16. 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 dualintegration@dmas.virginia.gov

17. 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

18. 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

20. 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)

21. 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

22. Virginia Demonstration Timeline

23. Virginia Demonstration Timeline