Acute and Long-Term Care ALTC Integration

1. Acute and Long-Term Care (ALTC) Integration MCO Meeting #3: Hot Topics October 10, 2007 ALTCMCO@dmas.virginia.gov

2. Meeting Overview Hot Topics Meeting Enrollment Overview �Patient Pay� for Waiver services Role of the Consumer Direction Fiscal Agent Medicaid Responsibility for Dual Eligibles 10 Minute Q&As and Discussion Between Each Presentation

3. Enrollment Suzanne Gore, Integrated Care Program Manager

5. Dual Eligibles Included in ALTC

6. Full Benefit Dual (a.k.a. � QMB-Plus) Participants who are fully eligible for both Medicare and Medicaid. Included in the Virginia Administrative Code as �Qualified Medicare Beneficiaries (QMB) Plus.� This program will not include individuals who are required to �spend down� income in order to Medicaid eligibility requirements.

7. Full Benefit Dual (a.k.a. � QMB-Plus) This program will also not include �non� full benefit dual eligibles such as: Qualified Medicare Beneficiaries (QMBs), Special Low Income Medicare Beneficiaries (SLMBs), Qualified Disabled Working Individuals (QDWIs), or Qualified Individuals (QI). These are individuals for whom DMAS only pays a limited amount each month toward their cost of care (e.g., deductibles).

8. What does Virginia Medicaid pay for Full Benefit Dual Eligibles? Dual eligibles may receive Medicaid coverage for the following: Medicare monthly premiums for Part A, Part B, or both. Coinsurance, copayment, and deductible for Medicare-allowed services. Medicaid-covered services, even those that are not allowed by Medicare. DMAS is currently completing a rigorous analysis of claims paid for dual eligibles.

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

10. Elderly or Disabled with Consumer Direction (EDCD) Wavier Participants Must be determined eligible for the EDCD waiver by the participant�s local department of social services. Must meet nursing facility criteria and income and resource requirements. Participants receive Medicaid primary and acute care services along with home and community-based long-term care services.

11. EDCD Waiver Services Included in ALTC Adult Day Health Care Personal Emergency Response System Personal Care (Provided by an agency or consumer directed) Respite Care (Provided by an agency or consumer directed) Service Facilitation (to assist individuals who wish to consumer direct services) Assistive Technology Environmental Modifications Provider Manual available on the web: http://websrvr.dmas.virginia.gov/manuals/edcd/edcd.htm

12. Combo Participants: Dual Eligible/EDCD Waiver Enrollee Some individuals are eligible for both Medicare and the EDCD waiver. These individuals will receive a combined service package.

14. How will a participant become enrolled in ALTC?

17. Population Summary (10/04/07)

18. Enrollment Mandatory enrollment in to Medicaid MCO with option to change plans within 90 days. Medicare Advantage/Special Needs Plan enrollment is voluntary � DMAS cannot mandate enrollment. Limited good-cause opt-out (to fee-for-service) provisions for existing EDCD participants who transition to ALTC MCO. Still in draft form, but may be allowed only if: Approved by Disenrollment Review Panel; If no long-term care or specialty provider available within geographic contractual standards; or If severing an existing long-term care provider relationship would cause undue hardship on the participant.

19. Enrollment, continued Developing protocol to pre-assign participants to MA/SNP if they are already enrolled in one. MA/SNP plans will be encouraged to market to Medicaid enrollees (based on Medicare guidelines). DMAS has no existing plans to match existing Part D enrollees with ALTC MCO pre-assignment. Possible issue to consider.

20. Questions on Enrollment? Cheryl Roberts

21. Post Eligibility Treatment of Income Patient Pay Elderly or Disabled with Consumer Direction (EDCD) Waiver Karen Packer, Senior Policy Analyst

22. Patient Pay Federal Regulation State Option Process Example Communication

23. Federal Regulation 42 CFR 435.726 Post-eligibility treatment of income of individuals receiving home and community-based services furnished under a waiver: Application of patient income to the cost of care.

24. Federal Regulation 42 CFR 435.726 The agency (Medicaid) must reduce its payment for home and community-based services provided to an individual by all that remains after deducting the following amounts, in the following order, from the individual�s total income:

25. Federal Regulation 42 CFR 435.726 Maintenance needs that the state may set � personal maintenance allowance Allowance for spouse Allowance for dependent family members Incurred non-covered medical expenses Medicare and health insurance premiums, deductibles, or copays Necessary medical care not covered by Medicaid

26. State Option The state may set amount for personal maintenance In 2006, Virginia increased basic personal maintenance allowance from 100% SSI payment (currently $623) to 165% SSI payment (currently $1028). Special earning allowance; amount depends on number of hours employed. Guardian fees, if any, up to 5% of monthly income. Personal maintenance allowance cannot exceed 300% SSI ($1,869).

27. Process Screener sends DMAS-96 verifying level of care for EDCD waiver is met to local department of social services and service provider. Service provider sends DMAS-122 verifying begin date of services to local department of social services. Local department of social services sends DMAS-122 to service provider verifying eligibility and the amount of patient pay.

28. Example- Process October 1, 2007 : Individual applies for Medicaid and is screened for EDCD waiver services October 20, 2007: Screener sends copy of DMAS-96 to local department of social services and to service provider October 24, 2007: Local department of social services determines eligibility using LTC rules If eligible, patient pay is calculated by subtracting personal maintenance allowance, spousal allowance, dependent family allowance, and non-covered medical expenses from individual's gross income. Remainder is patient pay. October 31, 2007: Worker enrolls individual in MMIS, and sends notice of approval and patient pay obligation to individual and completed DMAS-122 to provider

29. Example- Calculation $1500 Gross Income - $1028 Personal Maintenance Allowance - $ 300 Health Insurance Premium $ 170 Patient Pay Amount Participant pays patient pay amount to provider with the most billable hours.

30. Communication Communication is critical Applicant Screener Local department of social services Service provider

31. Patient Pay - ALTC Options and MCO Questions Cheryl Roberts

32. Patient Pay: Personal Maintenance Allowance (PMA) for waiver services Option #1: Maintain status quo: Provider providing majority of services collects the PMA from participant. MCO reduces amount paid to provider by the PMA. Option #2: Allow MCO to collect patient pay however they choose: Directly from the participant or through the provider. Option #3: Increase rate to 300% SSI DMAS is looking into raising the PMA to 300% of SSI and this may remove this issue entirely.

33. Consumer Direction & Role of the Fiscal Intermediary Paula Van Meter, Contract Monitor

34. Consumer-Directed Services Medicaid recipient, enrolled in a Medicaid waiver may employ their own attendant to meet their personal care, respite care or attendant care needs. DMAS pays wages to attendant through contract with Public Partnerships, LLC (PPL). In September 2007, 3078 Medicaid recipients received consumer-directed services. Wages for attendants are $11.14 for Northern Virginia and $8.60 for the rest of the state.

35. Public Partnerships, LLC (PPL) What do they do?

36. Definitions = Glossary Consumer = Medicaid Recipient = Medicaid Enrollee = Employer* Provider = Attendant = Employee *If a consumer is unable to direct their own care and be their own employer, someone else may be the Employer = Employer of Record

37. What does PPL do as a fiscal intermediary for the Medicaid Recipient? Act on their behalf to: process all payroll documentation make any necessary payments represent the employer/employee when necessary (i.e. answer questions about payroll taxes, attend unemployment hearings) retire accounts when no longer in consumer-directed services With the following entities: Internal Revenue Service Virginia Department of Taxation Virginia Employment Commission

38. �what else? Obtain and retire the Federal Employer Identification Number. Collect and process all enrollment paperwork, such as I-9, Verification of Employment. Process criminal history checks and central registry checks to assure attendant meets Virginia regulations, notify recipient of failure to pass check. Process all timesheets for attendants within authorized service amounts.

39. � there is more Edit timesheets for overlapping days, times and services Pay attendants via check or direct deposit Process any payroll deductions (liens, garnishment summons, patient pay, etc) Complete employment verifications Answer customer service calls Keep up with all state and federal forms and laws Etc, etc�

40. What does PPL do as a fiscal intermediary for DMAS? Ensure the Medicaid Recipients needs are met as described above Process authorization files received from DMAS Ensure attendants enrolled meet Virginia Administrative Code (VAC) requirements, such as over 18 years old Process all criminal history checks with Virginia State Police to assure compliance with VAC requirements (Central Registry checks are completed with Dept. of Social Services.) And more�

41. Consumer Direction Cheryl Roberts Role of PPL in the ALTC Program Questions?

42. Consumer Direction (CD): DMAS would like to maintain PPL as fiscal intermediary for all CD services�. But also give the MCOs the ability to coordinate, authorize, and review consumer directed services. There is opportunity for expanded efficiency, quality, and oversight in CD services.

43. Proposed Breakdown of CD Services Administrative Service (DMAS) DMAS pays PPL administrative PMPM PPL Provides: Payroll Set-up Payroll Processing Filing of Tax and Social Security Contributions Assists participants with Forms Sends claim information to MCO Medical Services (MCO) MCO responsible for authorization and oversight of CD services Reviews approved services and role as an �employer� with participant (currently provided by �service facilitators�) Reimburses for CD attendant services (for personal care and respite) via invoice from PPL. CD attendant and �service facilitation� services included under capitation rate

44. Coverage for Medicare Beneficiaries Dan Sullivan, Systems Analyst

45. Types of Medicare Coverage Fee-for-service Medicare Advantage (MA) Plan Special Needs Plan

46. What�s Covered? Medicare premiums (will most likely be paid by DMAS) Coinsurance and deductible Copayment for enrollees in a Medicare HMO Medicaid covered services not covered by Medicare Medicaid is the payer of last resort

47. Medicaid�s Reimbursement of Medicare Claims Total payment not to exceed Medicaid allowed amount. Will pay for coinsurance and deductible up to Medicaid allowed less other payments. Medicaid liability can be $0 � claim is denied.

48. Crossover Claim: Example

49. Pharmacy Benefits No Crossover claims for pharmacy claims. Part D coverage established for FFS claims: If Part D covered, claim is denied If not covered by Part D, paid

50. Dual Eligibles�.Questions? Cheryl Roberts

51. Wrap-up Please submit questions, comments, or suggestions by Friday, October 12 to ALTCMCO@dmas.virginia.gov. Next meeting: October 31 from 1-3 p.m. Thank you!