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
 Opportunities for Coordinated Care in Virginia
 Virginia’s Program
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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
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and Medicaid beneficiaries, administer different
products that are not aligned
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
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In Virginia;
spending 33% of
Medicaid funds on
19% of the Medicaid
population2
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
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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
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Common characteristics and conditions
93%
Income < 200% FPL
Alzheimer's*
37%
10%
4%
21%
Pulmonary disease*
14%
28%
Diabetes*
19%
15%
Stroke*
20%
Poor health status
Reside in LTC facility
3-6 ADLs
Under 65
85+
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Medicare-Medicaid
Enrollees
11%
7%
Other Medicare
Beneficiaries
19%
2%
28%
9%
39%
11%
13%
12%
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
Average Medicare Payment,
by Service Type and Eligibility Status, 2005
$4,586
Inpatient hospital
$2,618
$2,880
Physician
$2,058
Outpatient
hospital
Medicare-Medicaid
Enrollees
Other Medicare
Benef iciaries
$1,641
$749
$500
$311
Home health
Skilled nursing
facility
$1,078
$317
$273
$136
Hospice
$0
$1,000
$2,000
$3,000
$4,000
$5,000
Average Medicare Payment
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Source: Hilltop Institute -- MedPac, June 2008
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.
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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
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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
 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
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What does care look like for MedicareMedicaid enrollees now?
Three ID cards: Medicare, Medicaid, and prescription
drugs
Three different sets of benefits
Multiple providers who may not coordinate
Health care decisions uncoordinated and not made from
a person-centered perspective
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What does care look like for MedicareMedicaid enrollees now?
Like navigating a traffic circle….
• Fragmented
• Not Coordinated
• Complicated
• Difficult to Navigate
• Not Focused on the Individual
• Gaps in Care
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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
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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
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Virginia is one of six states with a
signed MOU
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Virginia’s Service Regions
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Who is eligible?
• Full benefit Medicare-Medicaid Enrollees (entitled to
•
•
•
•
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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)
Who is eligible?
Approximately 78,600 Medicare-Medicaid Enrollees
Region
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Nursing Facility
EDCD Wavier
Community
Non-waiver
Total
Central VA
4,430
3,762
16,135
24,327
Northern VA
1,935
1,766
12,952
16,653
Tidewater
3,031
2,492
12,575
18,098
Charlottesville
1,477
842
4,427
6,747
Roanoke
2,833
1,355
8,583
12,771
Total
13,706
10,217
54,672
78,596
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
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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
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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
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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
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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
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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:




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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
 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
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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
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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
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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
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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
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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
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