Navigating the curves in health care coverage
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Department of Medical Assistance Services. Navigating the Curves in Health Care Coverage. BPRO Fall Conference October 9, 2014. 1. We will talk about. Federal and State requirements- laws, regulations and budget amendments A Healthy Virginia

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Navigating the curves in health care coverage

Department of Medical Assistance Services

Navigating the Curves in Health Care Coverage

BPRO Fall Conference

October 9, 2014


We will talk about

We will talk about

  • Federal and State requirements- laws, regulations and budget amendments

  • A Healthy Virginia

  • Health Care Delivery

  • Handling the Workload

Federal and state requirements

Federal and State Requirements

  • Federal Laws - Affordable Care Act (ACA)

    • Modified Adjusted Gross Income (MAGI)

    • Former Foster Care

    • Hospital-based Presumptive Eligibility

    • Federal Health Insurance Marketplace (HIM) aka Federally Facilitated Marketplace (FFM)

    • Renewal Reconsideration Period

Federal and state requirements1

Federal and State Requirements

  • State Laws and Budget Amendments

    • Department of Corrections (DOC) inpatient hospitalization

    • Former Foster Care from any state

    • FAMIS Moms

    • Plan First

    • Medicaid Works

Federal and state requirements2

Federal and State Requirements

  • Modified Adjusted Gross Income (MAGI)

    • Mandatory implementation on January 1, 2014

    • Early implementation for applications filed on or after October 1, 2013

    • Changed methodology for:

      • Household composition

      • Countable income

      • Income limit conversion to MAGI equivalents

      • 5% FPL disregards

    • Mandatory for renewals on or after April 1, 2014

Federal and state requirements3

Federal and State Requirements

  • Former Foster Care (FFC)

    • Mandatory implementation on January 1, 2014 for former Virginia foster care children who had Medicaid and “aged” out of foster care

    • Coverage can extend up to age 26

    • No financial requirements

    • Must meet non-financial requirements, including Virginia residency

    • Full benefit package

    • General Assembly (GA) authorized Medicaid to include FFC from other states who meet “aged out” and Medicaid requirements, effective July 1, 2014

Federal and state requirements4

Federal and State Requirements

  • Hospital Presumptive Eligibility (HPE)

    • Temporary eligibility determined by hospitals

    • Certain MAGI covered groups

      • Child under age 19 – full benefit

      • LIFC Parent/caretaker relative – full benefit

      • Former foster care – full benefit

      • BCCPTA – only EWL sites – full benefit

      • Pregnant women – limited to outpatient prenatal care

      • Plan First – limited to family planning

    • Coverage begins date of hospital determination and ends at end of following month or when Medicaid application filed before end of following month is processed.

Federal and state requirements5

Federal and State Requirements


    • No wrong door; applications for health care coverage can be filed either through state and local or federal doors

    • If through state and local doors and ineligible due to income, referred to HIM

    • If through HIM and Medicaid/FAMIS likely, referred to state

    • If evaluated by both state and HIM and not eligible, individual will not be subject to a penalty for not having health insurance

Federal and state requirements6

Federal and State Requirements

  • Renewal Reconsideration Period

    • Renewals filed within 90 days of cancellation for failure to complete the renewal (cancel code 005) must be re-evaluated without requiring a new application

  • Example

    • Renewal due in October, not filed, coverage cancelled October 31

    • Renewal grace period is November - January

    • Renewal form returned December; eligibility must be re-evaluated for November and ongoing

    • Renewal completed in January and remains eligible

    • Enrollee must be notified of ongoing eligibility and next renewal scheduled for December

Federal and state requirements7

Federal and State Requirements

  • DOC inpatient hospitalizations

    • Implemented July 1, 2013

    • Must meet all Medicaid eligibility requirements

    • Coverage limited to inpatient hospital and medical care

    • New aid category 109

    • Applications processed by Southampton County, Greensville/Emporia, UVA and VCU Medical Centers

  • Cost savings initiative; shifts 100% of cost from state to 50% state and 50% federal (Medicaid) funds

Federal and state requirements8

Federal and State Requirements


    • GA Budget amendment to reinstate FAMIS Moms

    • Implementation scheduled for Nov 1

    • Income limit will be 200% FPL

    • Uses MAGI methodology

    • New deemed newborn aid category

      • AC 010 for newborns in families with income greater than 143%, but less than or equal to 150% FPL

      • AC 014 for newborns in families with income greater than 150%, but less than or equal to 200% FPL

Federal and state requirements9

Federal and State Requirements

  • Plan First

    • Income limit will be increased to 200% FPL effective November 1; casts a wider net

    • Do not enroll individuals under age 19 or over age 64 unless they specifically request the coverage

    • Remember to refer Plan First enrollees to the federal HIM, unless they have Medicare

Federal and state requirements10

Federal and State Requirements

  • Medicaid Works Changes effective November 1

    • Earnings limit increased to $75,000 year

    • Increases in SSDI payment from increase in earnings while in Medicaid Works and COLA are not counted as income as long as deposited into WIN account

    • Up to 6 months of Unemployment benefits due to loss of employment through no fault of his own will not be counted as income, but must be deposited into WIN account.

    • Spousal and parental income are not counted or deemed in determining income eligibility for Medicaid Works.

A healthy virginia

A Healthy Virginia

Governor McAuliffe’s 10 point plan

  • GAP – Governor’s Access Plan to cover people with serious mental illness (SMI) diagnosis

    • Implementation scheduled for January 2015

    • Screenings will be done for those without SMI diagnosis

    • Applications will be filed and processed through Cover Virginia Call Center/Central Processing Center; no LDSS involvement

    • Ages 19 – 64 with no creditable health coverage

    • No resource test; 100% FPL income limit

    • Limited benefit package; no inpatient services

    • Expected to provide services to 20,000

A healthy virginia1

A Healthy Virginia

  • Improve coordination of care for adults and children already enrolled in Medicaid who have SMI

    • DMAS will be working with DBHDS to establish heath home to coordinate care

    • Model of care that will integrate individual’s

      • primary

      • acute

      • behavioral, and

      • long-term care services

    • Could help up to 13,000 people

    • Implementation beginning July 1, 2015 in Southwest Virginia

A healthy virginia2

A Healthy Virginia

3 & 4. Sign up more people for Medicaid, FAMIS and the federal HIM

  • 35,000 children in FAMIS

  • 160,000 in federal HIM

  • Virginia allocated $4.3 million in federal funds for outreach

  • DMAS has applied for an additional $10 million

  • DMAS recently hired experienced child health outreach/advocates to help coordinate effort

A healthy virginia3

A Healthy Virginia

5. Open FAMIS to eligible state employees

  • makes FAMIS available to uninsured children of state employees who meet all other FAMIS requirements

  • provides comprehensive health insurance to children of lower income state employees

  • expected to cover 5,000 children

A healthy virginia4

A Healthy Virginia

  • Provide dental benefits to pregnant women

    • both Medicaid and FAMIS

    • expected to provide services to 45,000

    • expected to reduce/decrease:

      • Pre-term birth

      • Need for emergency dental expenditures

      • Cost of dental care for their children

A healthy virginia5

A Healthy Virginia

  • New Website to inform Virginians of coverage options and help them enroll

    − Cover Virginia enhancements

    • User friendly

    • Additional information

    • Easier access for filing application

    • Eligibility calculator to help users find the right health program for themselves and their family members

    • Link to resources for one-on-one assistance for individuals needing help with applications

A healthy virginia6

A Healthy Virginia

  • Accelerating access to quality health care for veterans

    • coordination with Veterans Health Administration, Secretary of Health and Human Resources, and Secretary of Veterans and Defense Affairs to take full advantage recent legislation signed by President Obama that made $10 billion in federal money available to veterans to seek health care outside of the VA system if they have barriers to access

A healthy virginia7

A Healthy Virginia

  • Take bold steps to reduce deaths from prescription drug abuse and heroin abuse

    • Last year more Virginians died of an overdose than were killed in car accidents

    • Prescription drug abuse has reached crisis level – some county death rates are highest in the country

    • Create Task Force to Combat Prescription Drug and Heroin abuse with goal of reducing number of drug-related deaths; had 1st meeting on October 2, 2014

A healthy virginia8

A Healthy Virginia

  • Aggressively pursue federal grants that can bring new $$$ into Virginia for health care

    − Governor McAuliffe has directed his staff to pursue everyfederal grant currently available for health care and innovation

Health care delivery

Health Care Delivery

  • Most Medicaid services will be provided through a managed care model:

    • Medallion 3.0

    • Commonwealth Coordinated Care (CCC)

    • Program of All-Inclusive Care for the Elderly (PACE)

  • Enrollees who have other insurance, closed period of coverage, hospice, Tech waiver, PACE or are out of state are excluded from Medallion 3.0

Health care delivery1

Health Care Delivery

  • Medallion 3.0 Current version of managed care

    • Current Managed Care Organizations (MCOs)

      • Anthem

      • CoventryCares

      • InTotal {INOVA}

      • Kaiser

      • Optima {Sentara}

      • Virginia Premier {VCU}

  • 70% of Medicaid and FAMIS enrollees are in managed care; 30% in fee-for-service

Health care delivery2

Health Care Delivery

  • Benefits to MCO Members:

    • Coordination of acute and primary medical care services

    • Case management of health services

    • 24-hour nurse advice line

    • Improved access to providers

    • Targeted services for chronic conditions

    • Wider array of assessment and wellness services

Health care delivery3

Health Care Delivery

  • HAP – Health and Acute Care Program

    • ABD who receive CBC waiver (other than Tech) services

    • Acute and medical care services will be covered by the MCO

    • Waiver services and transportation to waiver services will be paid through fee-for-service

    • 2,700currently enrolled in EDCD waiver who are currently fee-for-service will be transitioned into managed care in December

Health care delivery4

Health Care Delivery

  • CCC – Commonwealth Coordinated Care

    • Full Medicaid and Medicare

    • Over age 21

    • Live in demonstration areas

    • Get care coordinator to help find services

    • Supplemental services

    • Voluntary and passive enrollment; may opt out

    • Cannot have other comprehensive insurance

Health care delivery5

Health Care Delivery

  • Migration of foster care and adoption assistance children to managed care has been very successful

  • New expedited process for managed care assignment

    • If enrolled by 18th, managed care assignment effective 1st of following month

    • If reinstatement, system will assign to former MCO or MCO of other family member

    • 90 days to change initial assignment

    • Changes made for first of following month

    • Maximus Managed Care Helpline: 1-800-643-2273

Handling the workload

Handling the Workload

  • Numbers

    • $7,000,000,000 + in expenditures

    • 1,022,591 existing enrollees

    • 400,000 + uninsured Virginians

    • 35,000 average cancellations last 7 months

    • 4,131 average 012 (returned mail) cancellations

    • 120 local departments of social services

    • 1 Central Processing Unit/Call Center

Handling the workload1

Handling the Workload

  • No Wrong Door

    • Single, simplified, streamline application

    • Simplified transition between coverages

    • Multiple ways to apply

  • CPU and Cover Virginia Call Center

    • FFM backlog and telephone applications

    • In Dec

      • All FFM

      • MAGI only

        • CommonHelp

        • telephone

Handling the workload2

Handling the Workload

  • VaCMS will save the day

    • All Medicaid in VaCMS August 2015

    • Electronic referral to DDS

    • Electronic Asset verification

    • Patient pay calculation will be in VaCMS

  • MMIS

    • DMAS working to remove edit for annual cancellation of Qualified Individuals on December 31; not ready for 2014

    • Please list authorized representative on Comments screen in MMIS

    • Always ask enrollee for current address and update MMIS if changed

Handling the workload3

Handling the Workload

  • Need to enter TPL

    • Tricare for Life

    • Etna

    • Any other coverage polices

  • Do not enter Medicare Advantage Plans as TPL

Navigating the curves

Navigating the Curves


Thank you!

Dmas eligibility unit

DMAS Eligibility Unit

  • Cindy Olson (804) 225-4282 [email protected]

  • Karen Packer (804) 225-4104 [email protected]

  • Kelly Pauley (804) 786-7958 [email protected]

  • Susan Hart (804) 625-3667

    [email protected]

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