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An Introduction to Commonwealth Coordinated Care. Karen E. Kimsey Deputy Director of Complex Care and Services Virginia Department of Medical Assistance Services Arc Of Virginia Convention August 9, 2013. http://dmasva.dmas.virginia.gov. Overview. Medicare/Medicaid today

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slide1

An Introduction to Commonwealth Coordinated Care

Karen E. Kimsey

Deputy Director of Complex Care and Services

Virginia Department of Medical Assistance Services

Arc Of Virginia Convention

August 9, 2013

http://dmasva.dmas.virginia.gov

overview
Overview
  • Medicare/Medicaid today
  • Opportunities for Coordinated Care in Virginia
  • Virginia’s Program
medicare and medicaid today
Medicare and Medicaid today
  • Medicare and Medicaid:
    • Not designed to work together
    • Inefficient = more costly delivery system
  • Each program has its own:
    • Rules
    • Regulations
    • Requirements
    • Coverage
  • Some health plans that currently serve Medicare and Medicaid beneficiaries, administer different products that are not aligned
medicare and medicaid today1
Medicare and Medicaid today
  • The costs of serving these individuals are rising exponentially:

At the national level; spending 39% of Medicaid funds on 15% of the Medicaid population1

In Virginia;

spending 33% of Medicaid funds on 19% of the Medicaid population2

who are medicare medicaid enrollees
Who are Medicare-Medicaid enrollees?
  • Older adults, including those receiving long term care services and supports
  • Individuals with disabilities, including those receiving long term care and supports
who are medicare medicaid enrollees1
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
common characteristics and conditions
Common characteristics and conditions

Source: Hilltop Institute -- MedPac, June 2008; based on data from the 2005 MCBS Cost and Use file

*Data from 2003 MCBS http://www.cms.hhs.gov/MCBS/Downloads/CNP_2003_dhsec8.pdf

costs for medicare medicaid enrollees vs costs for other medicare enrollees
Costs for Medicare-Medicaid enrollees vs. costs for other Medicare enrollees

Source: Hilltop Institute -- MedPac, June 2008

who are medicare medicaid enrollees in virginia
Who are Medicare-Medicaid enrollees in Virginia?
  • 65% are female
  • 60% are age 65 and older
  • 19% have 5 or more chronic conditions
  • Average monthly spending on individuals on Medicare-Medicaid, is $2,479 compared to $567 for Medicare-only beneficiaries

Source: Medicare-Medicaid Enrollee State Profile, Virginia, Centers for Medicare & Medicaid Services, 2007.

who pays for what services in virginia
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
challenges for individuals
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
slide13

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
virginia s solution
Virginia’s Solution:
  • 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
virginia s solution1
Virginia’s Solution:
  • 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
who is eligible
Who is eligible?
  • 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)
slide19

Who is eligible?

Approximately 78,600 Medicare-Medicaid Enrollees

who is not eligible
Who is not eligible?
  • 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
benefits for virginia
Benefits for Virginia
  • Eliminates cost shifting
  • Achieves cost 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
benefits for individuals and families
Benefits for Individuals and Families
  • One system of person-centered care
  • 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
benefits for individuals and families cont d
Benefits for Individuals and Families Cont’d
  • Choice will remain (Participation, Health Plans, Services)
  • Use of an external ombudsman
  • Will use the same fiscal agent for consumer-directed services to ensure continuity of care
  • Beneficiaries will not have to change providers until their authorization runs out and only if the provider is not in the network
how are individuals enrolled
How are Individuals Enrolled?
  • Eligible individuals will receive information during the national Medicare annual open enrollment period (October 15 – December 7, 2013)
  • Enrollment will initially be voluntary, followed by automatic enrollment with ability to opt out anytime
commonwealth coordinated care enrollment timeline
Commonwealth Coordinated Care Enrollment Timeline
  • Central Virginia/Richmond and Tidewater areas:
    • January 2014: Voluntary enrollment begins
    • February 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
outreach and education
Outreach and Education
  • Stakeholder engagement
  • Dedicated website
  • Trainings to providers and local agencies
  • Educational materials such as presentations, toolkits, fact sheets, FAQs, public service announcements
  • Working with community partners to educate and inform
  • Partnering with Virginia Insurance Counseling Assistance program (VICAP) counselors and Virginia’s Long-Term Care Ombudsman Program
outreach and education1
Outreach and Education
  • DMAS and Participating Plans will provide outreach and education to:
    • Individuals and their families
    • State agencies
    • Local agencies
    • Community partners
    • Advocacy groups
    • Associations
    • Legislators
    • Providers
    • Nursing facilities
role of vicap counselors
Role of VICAP Counselors
  • DARS and DMAS will train counselors
  • Counselors will be provided with materials and tools
  • Counselors will provide information to eligible enrollees and guide them through the process of connecting with an enrollment facilitator
role of virginia s long term care ombudsmen
Role of Virginia’s Long Term Care Ombudsmen
  • Receiving, investigating and resolving complaints about quality of long term care issues
  • Assisting individuals in exercising their rights
  • Mediating concerns between the individual and/or their families and the long term care provider
in the coming weeks
In the coming weeks….
  • Announcement of the selection of participating health plans
  • Formation of workgroups to design and implement various components
  • Continued outreach and education
contact information
Contact Information

Office of Coordinated Care

Virginia Department of Medical Assistance Services

600 E. Broad Street, Suite 1300

Richmond, VA 23219

CCC@dmas.virginia.gov