The Integration of Acute and Long Term Care Services: Status of Phase I and Decisions for Phase II P

1
The Integration of Acute and Long Term Care
Services Status of Phase I and Decisions for
Phase IIPresentation to Stakeholders
Department of Medical Assistance
Services August 21, 2007 Cindi B. Jones, Chief
Deputy Director
2
Presentation Outline
Background for Development of the
Blueprint Community Model PACE Regional
Model Managed Care Organizations Next Steps
3
Demographics Of Recipients In Virginias
Medicaid Program

• The Elderly And Persons with Disabilities
  Represent 30 Percent of Medicaid Program
  Recipients

Note Unduplicated count of recipients in FY 2005
4
Demographics Of Recipients In Virginias
Medicaid Program(continued)

• Yet they account for 71 percent of program
  expenditures

Notes FY 2005 recipient and expenditure data
5
Demographics Of Recipients In Virginias
Medicaid Program(continued)

• Meaning the cost of serving the elderly and
  disabled is substantially greater than the cost
  of care for children

Notes FY 2005 recipient and expenditure data
6
The Blueprint for the Integration of Acute and
Long Term Care 2006 Virginia Acts of the General
Assembly (Item 302, ZZ)

• Completed December 2006, this plan
• explains how the various stakeholders are
  involved in the development and implementation of
  the new program models
• describes the various steps for development and
  implementation of the program models
• includes a review of other States models,
  funding, populations served, services provided,
  education of clients and providers, and location
  of programs and
• describes the evaluation methods that will be
  used to ensure that the program provides access,
  quality, and consumer satisfaction.

7
Blueprint for the Integration of Acute and
Long-Term Care Services
Virginia Department of Medical Assistance
Services December 15, 2006 Found at
http//www.dmas.virginia.gov/altc-home.htm
8
The Blueprint for the Integration of Acute and
Long Term Care(continued)

• DMAS held a series of three meetings on Acute and
  Long Term Care Integration Models and Issues
  (during Summer/Fall 2006)
• First Meeting Provided an overview of Medicaid
  funded acute and long term care services in
  Virginia and across the United States.
• Second Meeting Facilitated a meeting with
  stakeholders so they could provide input on the
  options for developing an integrated acute and
  long term care program in Virginia.
• Third Meeting Heard public comment on the
  integration of acute and long term care.

9
The Case for Integration

• Current System Fee-for-Service and Fragmented
• Primary and Acute Care Services
• Physician
• Hospital
• Pharmacy
• Labs
• Disease Management
• Long Term Care Services
• Nursing Facilities
• Home and Community Based Care Waiver programs (7)
• Case Management

• New System Capitated and Coordinated Care
• Combines acute and long term care services
  (except for certain waiver programs) under one
  capitated rate
• Combines Medicare and Medicaid funding
• ONE CALLALL CARE NEEDS
• Right Services at Right Time

10
Integrated ModelPopulations Covered
All 234,945 Low-Income Seniors and Persons with
Disabilities (ABD)

• Medicaid Only (non-duals) 86,732 clients
• Dont use long term care services (79,045
  clients)
• Use long term care services (7,687 clients)

• Medicaid and Medicare (dual eligibles) 148,213
  clients
• Dont use long term care services (115,152
  clients)
• Use long term care services (33,061 clients)

11
Presentation Outline
Background for Development of the
Blueprint Community Model PACE Regional
Model Managed Care Organizations Next Steps
12
Two Models for Integration- Community Model
PACE

• Community Model Program of All Inclusive Care
  for the Elderly or PACE. Combines Medicaid and
  Medicare funding to provide all medical, social,
  and long term care services through an adult day
  health care center.
• Limited to persons who are nursing facility
  eligible
• Voluntary enrollment
• Sites serve no more than 200 enrollees
• Site receives both a Medicaid and Medicare
  capitated rate and pays for all services
• Phase I Six communities actively pursuing
  PACE6 were awarded start up grants (250,000
  each). Implementation 2007-2008 (see Map on next
  slide).
• Hampton Roads (2)
• Richmond (1)
• Lynchburg (1)
• Far Southwest (2)

13
PACE IN THE COMMONWEALTH OF VIRGINIA
Map Key
PACE Sentara PACE Mountain Empire
PACE Centra PACE Riverside - Hampton
PACE Riverside - Richmond PACE
Appalachian RFA PACE Northern Virginia

Frederick
Winchester
Manassas Park
Clarke
Loudoun
Falls Church
OPERATIONAL TIMELINE FOR PACE PROVIDERS PACE
Sentara OCT 07 PACE Riverside - Hampton NOV
07 PACE Mountain Empire FEB 08 PACE
Appalachian APR 08 PACE Centra JNE 08 PACE
Riverside - Richmond JNE 08 PACE Northern
Virginia JAN 09
Warren
Arlington
Fauquier
Shenandoah
Alexandria
Fairfax City
Fairfax
Rappahannock
PrinceWilliam
Manassas
Page
Rockingham
Harrisonburg
Culpeper
Stafford
Madison
Highland
KingGeorge
Augusta
Fredericksburg
Greene
Orange
Staunton
Westmoreland
Spotsylvania
Albemarle
Bath
Essex
Waynesboro
Northumberland
Caroline
Louisa
Charlottesville
Lexington
Clifton Forge
Richmond
Fluvanna
King Queen
Buena Vista
Accomack
Covington
Hanover
Goochland
Nelson
Lancaster
Rockbridge
Alleghany
King William
Middlesex
Henrico
Amherst
Buckingham
Powhatan
Botetourt
Richmond
NewKent
Matthews
Cumberland
Craig
Lynchburg
Northampton
Gloucester
Chesterfield
JamesCity
Appomattox
CharlesCity
Roanoke
Amelia
Bedford
Col.Heights
Giles
Salem
Prince Edward
Roanoke City
York
Buchanan
Prince George
Poquoson
Williamsburg
Petersburg
Campbell
Bedford
Montgomery
Surry
Nottoway
Hopewell
Hampton
Dickenson
Bland
Dinwiddie
Newport News
Tazewell
Isle ofWight
Charlotte
Radford
Wise
Norfolk
Lunenburg
Franklin
Pulaski
Sussex
Portsmouth
Russell
Floyd
Norton
Wythe
Virginia Beach
Brunswick
Smyth
Pittsylvania
Franklin
Henry
Suffolk
Lee
Carroll
Emporia
Washington
Chesapeake
Southampton
Danville
Scott
Mecklenburg
Galax
Patrick
Halifax
Grayson
Martinsville
Greensville
Bristol
14
PACE of SENTARALikely First PACE Site in
Virginia

• Successful Pre-PACE program for 10 years
• Has served over 500 recipients since 1996
• Capacity to enroll 130 recipients with
  attendance up to 100 daily
• CMS response date for approval is September 25,
  2007
• Targeted operational date is October 2007

15
PACE of Riverside at Hampton

• Hampton site is a community re-development
  project housed in a building which has been
  vacant for 10 years
• RHS is highly regarded, extremely visible and
  dedicated to the population to be served
• Anticipate an average daily attendance of 90
• CMS has just completed their first 90-day clock
  review of provider application
• Targeted operational date is November 2007

16
PACE of Mountain Empire for Senior Citizens at
Big Stone Gap

• One of two rural PACE sites in the Commonwealth
  has been working on PACE for the past 10 years
  with feasibility study conducted in 1996
• Will make use of telemedicine at this site
• Serving one of the poorest regions of the U.S.
• Most conservative estimates place a sustainable
  program at 124 recipients
• PACE provider application submitted to CMS on
  July 2, 2007 Currently under first 90-day clock
  review by CMS that will end on October 3, 2007
• Construction for new PACE site is slated to begin
  late 2007
• Targeted operational date February 2008

17
PACE of Appalachian Agency for Senior Citizens at
Cedar Bluff

• Second of two rural PACE sites in the
  Commonwealth
• Four counties over 1800 square miles, 676 persons
  per square mile, Per capita income 15,000
• Long history of working to improve the lives of
  the elderly
• Will utilize the Hub and Spoke service delivery
  model of care for PACE participants
• PACE provider application is currently under
  review by DMAS will be sent to CMS Summer 2007.
• Targeted operational date is April 2008

18
PACE of Riverside at Richmond

• RHS will employ an aggressive targeted marketing
  strategy in Richmond
• Challenge in developing in a market with no
  current facilities, programs or services
• 15 months following start-up of the Hampton site
• PACE eligibles in Richmond over 2,500
• Geographic considerations 2 PACE centers within
  5 years
• First center will be operating in Southside
  Richmond
• Targeted operational date June 2008

19
PACE of Centra at Lynchburg

• Began in 2000 from a grassroots citizens group
  concerned with health care for the elderly
• July 2006, Centra Health, local non-profit
  hospital system took over
• Centra has a long-standing history of community
  stewardship
• Centra Health is growing regionally with new
  affiliations with hospitals and health centers
• PACE site will be located in the center of the
  City of Lynchburg in an area that is part of the
  revitalization efforts of Lynchburg
• Targeted operational date June 2008

20
Whats Next with PACE Phase II

• DMAS published a Request for Application (RFA) on
  July 23, 2007 for the development of a PACE site
  for underserved areas of Northern Virginia.
• This site will also be awarded a 250,000
  start-up grant.
• Letter of Intent and questions due August 23,
  2007
• Application deadline September 24, 2007
• Implementation 2008-2009
• Future PACE sites will also be determined through
  RFAs in order to ensure open competition. No
  additional RFAs planned at this time.

21
Presentation Outline
Background for Development of the
Blueprint Community Model PACE Regional
Model Managed Care Organizations Next Steps
22
Two Models for Integration Regional

• Regional Model Could range from a capitated
  payment system for Medicaid (potentially
  integrating Medicare funding) for acute care
  costs with care coordination for long term care
  services, to a fully capitated system for all
  acute and long term care services

23
DMAS Progress on the Expansion of Existing
Managed Care Program

• The Medicaid managed care program, Medallion II,
  will go live in the Lynchburg region beginning
  October 1, 2007. Three managed care
  organizations will cover approximately 14,000
  eligible enrollees.

• This expansion will provide Medallion II coverage
  in all areas of the State except for the deep
  southwest portions of our western border with
  West Virginia

24
Implementation Regional ModelPhase I

• Current System Mandatory managed care for acute
  care needs only49,000 low income seniors and
  individuals with disabilities (Aged, Blind, and
  Disabled) with no Medicare and with no long term
  care services.
• Phase I (September 1, 2007) Managed care
  organization (MCO) enrollees who become eligible
  for home and community-based service waiver
  programs will remain in their MCOs for acute and
  primary medical services. These individuals will
  continue to receive HCBC waiver services through
  the fee for service program.

25
Implementation Regional Model Phase I

• Implementation date is September 1, 2007 CMS has
  approved the 1915(b) waiver modification.
• In the first year, will impact about 500 Medicaid
  only clients who are receiving managed care first
  and now need long term care services.
• Phase I is statewide wherever there are MCOs.
• Populations excluded during Phase I (most of
  these populations are included in Phase II)
• Will not include dual eligibles (Medicaid and
  Medicare)
• Will not include nursing facility residents
• Will not include Technology Assisted Waiver
  clients
• Will not move current LTC waiver clients into
  managed care.

26
Implementation Regional Model Phase I
(continued)

• DMAS conducted several activities to ensure a
  smooth transition to Phase I
• Made changes to information system and to
  recipient and provider communications, amended
  MCO contracts, modified 1915(b) waiver, and
  promulgated regulations
• Met with various stakeholder groups over past
  nine months
• Met with and trained MCOs
• Hiring two part-time transition coordinators to
  assist providers, recipients, and MCOs.

27
Implementation Regional Model Phase II

• The roll out of Phase II will be on a scheduled
  and layered approach over time based on
• Geographic location (pilot first in two areas)
• Populations Included
• Funding sources (Medicaid and Medicare)
• Services Included
• The focus will be what is feasible and will
  ensure a smooth transition for our recipients and
  providers.

28
Implementation Regional Model Phase
II-Geographic Location

• On a geographic basis, the roll out will be one
  area at a time (every six months) until statewide
  
• Tidewater August 8, 2008initial wave
• 13 cities and counties
• Richmond January 2009initial wave
• 12 cities and counties
• Northern August 2009
• Surrounding counties Winter 2010
• Rural Summer 2010/Winter 2011
• Tidewater and Richmond were selected as the first
  pilot areas because of their strong health
  systems, competitive atmosphere, urban
  environment, and size of their Medicaid
  population.

29
Implementation Regional Model Phase
II-Geographic LocationInitial Wave
30
Implementation Regional Model Phase
II-Populations

• At the end of Phase II, the goal is to have more
  than 200,000 low income seniors and persons with
  disabilities (known as the Aged, blind, and
  disabled) in some form of Medicaid managed care
  for their acute care needs only and/or long term
  care needs.
• The roll-out for populations in the geographic
  areas will include
• Medicaid only and Medicaid and Medicare (dual
  eligibles)-initial wave
• Nursing Facility Clients (new admissions
  only)-initial wave
• Home and Community Based Care Waiver Clients
• Existing and new Elderly and Disabled with
  Consumer Direction and AIDS waiver
  clients-initial wave
• Later, existing and new Mental Retardation, Day
  Support, Developmental Disabilities, Alzheimer's,
  Tech waiver clients for acute care needs only
  (could be put in Phase I option at any time)

31
Implementation Regional Model Phase
II-Populations

• The initial waves in Tidewater and Richmond will
  provide integrated managed care for acute care
  and long term care services (when needed) to
  36,710 new clients
• Medicaid and Medicare (dual eligibles) 30,398
  clients
• Nursing Facility Clients (new admissions only)
  2,310 clients (for a specific period of time)
• Existing and new Elderly and Disabled with
  Consumer Direction and AIDS waiver clients
  4,002 clients

32
Implementation Regional Model Phase II-Funding

• To have truly integrated acute and long term care
  services, both the Medicaid and Medicare funding
  (through a Medicare Advantage Plan or a Special
  Needs Plan) need to be combined within the
  administration of one Managed Care Organization.
• However, due to the timing of federal
  requirements for Special Needs Plans (or SNPs),
  DMAS will need to start the initial wave with a
  Medicaid only integrated model for acute and long
  term care services.
• The Request for Proposals for the Integrated
  Managed Care Program will require that all
  participating health plans be classified as a
  Medicare Advantage and/or SNP or are
  working/applied for the classification.

33
Implementation Regional Model Phase II-Services

• Medicaid managed acute and long term care
  services
• All current Medicaid state plan primary and acute
  care services, including mental health and
  transportation services
• Excluded are the state plan option mental health
  services that are currently carved out
• All Elderly and Disabled with Consumer Direction
  waiver services, including adult day health care,
  personal care aide (both agency and
  consumer-directed), personal emergency response
  systems and medication monitoring, and up to 720
  hours per year of respite care (both agency and
  consumer-directed). Environmental modifications,
  assistive technology, transition services, and
  transition coordination will be added with Money
  Follows the Person in May 2008.
• All HIV/AIDs waiver services, including personal
  care aide (both agency and consumer directed),
  private duty nursing, nutritional supplements,
  respite care (up to 720 hours per year), and case
  management. Transition services, personal
  emergency response systems and medication
  monitoring, assistive technology, and
  environmental modifications will be added with
  Money Follows the Person in May 2008.

34
Implementation Regional Model Phase II-Services

• Medicaid managed acute and long term care
  services (continued)
• Nursing Facility Care (for a short period of
  time, such as 120-180 daysto be discussed with
  nursing facility providers in the development of
  the RFP)
• This allows the MCO an opportunity to move the
  client back home with community based care
  services, if appropriate.
• Additional services
• Care Coordination intensive care management for
  long term care service clients
• 24-hour/7 days a week access line
• Disease management (if applicable)

35
Implementation Regional Model Phase II-Services

• Home and Community Based Care Waiver Services
  Excluded
• Mental Retardation, Day Support, Developmental
  Disabled
• These waivers have waiting lists
• Technology Dependent
• This waiver is the most expensive
• Alzheimer's Assisted Living Waiver
• Numbers too small at this time
• Medicare Managed Care Services Once the
  Medicare Advantage Plans or SNPS are in place,
  the Medicare/Medicaid clients will have
  coordinated Medicare services also. These plans
  may add enhanced services, such as dental care,
  vision, and hearing.

36
Implementation Regional Model Phase II- Other
Decisions

• Enrollment
• Medicaid Managed Acute and Long Term Care
  Enrollment will be mandatory with opt-out
  provisions (first 90 days, annual enrollment
  period, or if meet established good cause)
• Medicare Managed Acute and Long Term Care
  (Special Needs Plans or Medicare Advantage
  Plans). Voluntary and based on Medicare rules.
• In order to reduce disruption of care, DMAS will
  be developing ways to ensure that the Medicaid
  and the Medicare plans are the same provider.
• Federal Authority
• 1915 (b) and (c) combination waiver will allow
  for mandatory enrollment

37
Implementation Regional Model Phase II- Other
Decisions

• Managed Care Organizations
• Choose through Request for Proposal (RFP) process
  with a minimum of two plans for each region
• Health plans must have Medicare Advantage or SNP
  or working toward it
• Must have health plan accreditationURAC/NCQA
• Out of state plans can bid if licensed in
  Virginia and can fully demonstrate that they can
  meet the RFP requirements

38
Implementation Regional Model Phase
II-Capitation Rates

• Specific details regarding the populations and
  services that will be included are required to
  develop appropriate rate cells and service
  categories.
• Most of the historical fee-for-service (FFS) data
  required to develop capitation rates was gathered
  previously for the PACE program. The base data
  will be FFS data.
• Additional data will be needed for some services
  that are not currently included, such as case
  management services.

39
Implementation Regional Model Phase
II-Capitation Rates

• Base FFS data will be trended forward to the
  contract period.
• Adjustments to the base FFS data will have to be
  developed regarding managed care savings and the
  effect of enrollment in Medicare Advantage plans.
• Risk adjustment methods should be explored to
  ensure that health plans receive capitation
  dollars that reflect the relative health status
  of the enrolled population. Actual
  implementation of this method is unlikely in the
  first one or two years of the program.

40
Presentation Outline
Background for Development of the
Blueprint Community Model PACE Regional
Model Managed Care Organizations Next Steps
41
Regional Model Phase II Next Steps

• Will include stakeholder input throughout the
  development and implementation of Phase II
• DMAS has made presentations and met with several
  groups separately throughout the past year
• Need to schedule a series of stakeholder meetings
  to provide input to the Request for Proposals
• Nursing facilities/hospitals
• Home Care Providers (pharmacy, DME, home health,
  personal care, rehabilitation)
• Mental Health/Mental Retardation/Substance
  Abuse/Developmental Disabilities
• Consumers and Advocates
• Managed Care Organizations

42
Regional Model Phase II Next Steps

• Timeframes available for stakeholder meetings
• Wednesday, 9/5/07, from 10a.m.-noonHold for
  NFs/Hospitals
• Thursday, 9/6/07, from 2 p.m.-4 p.m.
• Monday, 9/10/07, from 10 a.m.-noon
• Tuesday, 9/11/07, from 2 p.m.-4 p.m.
• Monday, 9/17/07, from 10 a.m.-noon
• Tuesday, 9/18/07, from 10 a.m.-noon
• Wednesday, 9/26/07, from 2 p.m.-4 p.m.

43
Regional Model Phase II Next Steps

• Request for Proposal will be released in Fall
  2007
• DMAS will submit 1915 (b) and (c) waivers to CMS
• The next presentation will discuss more specifics
  of DMAS implementation plan