The Integration of Acute and Long Term Care Services: Virginias Managed Care Program Presentation to

1
The Integration of Acute and Long Term Care
Services Virginias Managed Care
ProgramPresentation to Managed Care
Organizations
Department of Medical Assistance
Services September 10, 2007
2
Managed Care

• DMAS mandatory managed care program with
  contracted Managed Care Organizations (MCO)
• Program began in 1996 for seven localities
• Currently operating in 110 localities serving 56
  of Medicaid individuals
• Statewide Medicaid Enrollment as of August 1,
  2007
• Fee-for-Service 255,926 MEDALLION
  51,079
• Medallion II 383,103

3
Program Authority

• Medallion II operates as a result of
• CMS 1915(b) Waiver Effective 7/1/07
• Code of Federal Regulations (CFR)
• (42 CFR Part 438, aka Balanced Budget Act
  implemented June 2002)
• Virginia State Plan for Title XIX
• Virginia Administrative Code for Managed Care (12
  VAC30-120-360 through 420)
• MCO Contract

4
Virginia Medicaid Managed Care Program Coverage
Map
5
Our Current MCO Partners

• Amerigroup Community Care
• Anthem HealthKeepers Plus
• Optima Family Care
• Southern Health - CareNet
• Virginia Premier Health Plan

6
MCO Eligibility

• Medicaid eligibility controlled by Department of
  Social Services
• MCO enrollment is mandatory for managed care
  eligible clients
• Majority of Medicaid clients are managed care
  eligible, however, some are not
• Always some FFS Medicaid clients

7
Currently Included in Managed Care

• Children
• Pregnant women
• Aged, Blind and Disabled
• Currently Excluded Populations
• Nursing Homes
• Other insurance (i.e., Medicare)
• Foster Care

8
Plan Highlights

• Virginia is one in a handful of states that
  requires MCOs to obtain National Committee for
  Quality Assurance (NCQA) accreditation. Three of
  the 5 have received national recognition.
• One health plan won a national award from the
  Disease Management Association of America for the
  prevention of sickle cell and reducing emergency
  department visits and hospitalizations.
• CMS has advised that Virginia is in the top 10 of
  all states contracting with managed care
  organizations.
• Immunization rate of 83 is substantially above
  the national average of 63
• The HEDIS measure for use of appropriate asthma
  medications (87 - 95) is above the national
  rate of 86

9
Managed Care HelpLine

• The Enrollment Broker, Maximus, has been
  contracted since 2/1/03.
• Toll-free assistance to managed care enrollees.
• Provides telephone translation services.
• Completes health assessments with members.
• Refers recipients to other sources (i.e., Doral
  for dental)
• Keeps records of all calls and complaints.

10
DMAS Oversight of MCOs

• Medical and Utilization Management
• Quality Assurance and Improvement
• Medical Care and Services
• Financial Management the MCOs are at full risk
  for services
• Management Information Systems and Claims
  Processing

• MCO Licensure and Administration
• Outreach and Marketing
• Enrollment and Patient Education
• Network Analysis and Provider Relations
• Member Services and Complaint Tracking
• Encounters
• EQRO Annual Review

11
Contract Modifications

• All health plans sign same standard contract.
• Annual contract revision process.
• Renews each year on July 1st.
• Collaborative process MCO/DMAS open
  discussions.
• Amendments (i.e., program changes) as needed.

12
Questions

• ??
• Questions and comments may be forwarded to us via
• ALTCMCO_at_dmas.virginia.gov