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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

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Department of Medical Assistance Services

Navigating the Curves in Health Care Coverage

BPRO Fall Conference

October 9, 2014


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 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 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 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 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 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 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 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 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 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 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 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

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 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 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 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 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 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 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 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 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

  • 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 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 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 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 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 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

  • 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 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 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 Workload

  • Need to enter TPL

    • Tricare for Life

    • Etna

    • Any other coverage polices

  • Do not enter Medicare Advantage Plans as TPL

Navigating the Curves


Thank you!

DMAS Eligibility Unit

  • Cindy Olson (804) 225-4282

  • Karen Packer (804) 225-4104

  • Kelly Pauley (804) 786-7958

  • Susan Hart (804) 625-3667

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