Virginia Acute and LongTerm Care Integration VALTC

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Virginia Acute and Long-Term Care Integration
(VALTC)

• Department of Medical Assistance Services
• Suzanne Gore, Integrated Care Program Manager
• Suzanne.gore_at_dmas.virginia.gov
• Adrienne Fegans, Program Operations Administrator
• Adrienne.fegans_at_dmas.virginia.gov
• April 9, 2008

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VALTC An Opportunity

• First step toward
• bridging Medicare and Medicaid
• and integrating services across
• the spectrum of care.
• Nationally, interest in integrated care is
• gaining momentum.
• 7 other state Medicaid programs currently
• offer some form of integrated care
• Arizona, Florida, Massachusetts,
• Minnesota, New York, Texas, and Wisconsin.
• Hawaii just received approval to
• implement its program.

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What is Acute and Long-Term Care Integration?

• An Opportunity

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VALTC Mission

• To improve the quality of life of Virginias
  Medicaid-enrolled seniors and adults with
  disabilities by empowering them to remain
  independent and reside in the setting of their
  choice for as long as possible through the
  provision of a streamlined primary, acute, and
  long-term care service delivery system that
  offers ongoing access to quality health and
  long-term care services, care coordination, and
  referrals to appropriate community resources.

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Integration of Acute and Long-Term Care

• Main concept Offer primary, acute, and
  long-term care services through a managed care
  program
• To accomplish this, DMAS is integrating
• populations and services previously
• excluded from managed care into
• managed care.

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Localities Included in Tidewater Pilot
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Localities Included in Tidewater Pilot

• Prospective MCOs must contract for all targeted
  populations in the core localities within the
  designated region.
• MCOs may include the provision of services for
  any or all targeted populations in the non-core
  localities
• DMAS, however, must have a minimum of two MCOs in
  each of the core and non-core localities in order
  to implement the program in those areas.

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Populations

• Full benefit dual eligibles (Medicare and
  Medicaid)
• Elderly or Disabled with Consumer Direction
  (EDCD) waiver participants

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Population Summary
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Elderly or Disabled with Consumer Direction (EDCD)

• Home and Community-Based Long-Term Care Services

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Special Populations EDCD Waiver

• Elderly or Disabled with Consumer Direction
  (EDCD) waiver program
• One of seven home and community-based wavier
  programs.
• 13,965 EDCD waiver participants in SFY2007
  statewide. 
• Participants currently enrolled in FFS.
• Enrollment not capped often serves as waiting
  area for other waivers.
• Waiver enrollment is growing.

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New Services EDCD Waiver

• EDCD waiver services
• Adult Day Services,
• Personal Care,
• Respite Care,
• Electronic Monitoring,
• Service Facilitation for Consumer Directed
  Personal and Respite Care
• Assistive Technology,
• Environmental Modifications and
• Transition Services Coordination (offered as a
  carved out).

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New Services EDCD Waiver

• Services vary depending on the individuals
  service plan.
• All EDCD participants must meet the nursing
  facility level of care criteria.
• Participants may meet a higher financial
  eligibility threshold (300 of the SSI payment
  level for one person).
• Depending on income level, participants are often
  responsible to cover a portion of their care
  (patient pay).
• All participants must have an annual assessment
  and service plan update in their preferred
  setting.
• Special Feature
• Consumer Direction - Individual directs his own
  care.

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New Services EDCD Waiver

• Consumer Direction
• Available option for personal care and respite
  care.
• Participants hire their own attendant care
  provider.
• Must be an extenuating circumstance for attendant
  to be a family member.
• Training of attendants by the MCO may be
  encouraged, but not required.
• DMAS will include current PMPM for CD fiscal
  agent in capitation rate.

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Enrollment EDCD Waiver

• Enrollment in VALTC is mandatory.
• Participants may request to opt-out of VALTC if
  enrollment would detrimentally impact the health,
  safety, or welfare of the participant.
• Opt-out requests will be evaluated by a DMAS
  committee on a case-by-case basis to ensure
  appropriate, accessible, and quality care for the
  individual.
• EDCD participants have an expedited enrollment
  process.
• EDCD participants must receive services within 30
  days of enrollment in the EDCD program.

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Dual Eligibles

• Integrating Medicare and Medicaid

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Special Populations Dual Eligibles

• Receive both Medicare and Medicaid.
• Currently participate in FFS.
• Receive majority of care through Medicare.
• Enrollment
• Dual eligibles will be pre-assigned to a VALTC
  MCO based on an algorithm through a 60 day
  pre-assignment cycle.
• Participants are encouraged to select the plan
  that is the best fit for them.
• Participants will have the option to disenroll
  into another plan within the first 90 days of
  participation.

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New Services Dual Eligibles

• Dual eligibles may receive Medicaid coverage for
  the following
• Not included in VALTC capitation rate
• Medicare monthly premiums for Part A, Part B, or
  both (DMAS will pay Medicare Part A and/or Part B
  premiums. Premiums will not be included in the
  capitation rate).
• Included in VALTC capitation rate
• Coinsurance, copayment, and deductible for
  Medicare-allowed services (i.e., crossover
  claims).
• Medicaid-covered services (including certain
  medications), even those that are not allowed by
  Medicare.

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Claims Process Dual Eligible

• VALTC MCOs will receive crossover claims through
  three scenarios
• Participant enrolled in the VALTC Medicaid MCO
  and Medicare fee-for-service
• Participant enrolled in the VALTC Medicaid MCO
  and in a different MCOs Medicare Advantage plan
  or SNP or
• Participant enrolled in the VALTC Medicaid MCOs
  Medicare Advantage plan or SNP.

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Scenario A Participant enrolled in the VALTC
Medicaid MCO and Medicare fee-for-service

• Providers submit claims through their standard
  Medicare claims process.
• GHI processes the Medicare liability and pays the
  provider for the Medicare portion of the claim.
• GHI then sends the crossover remittance to First
  Health Services (the DMAS fiscal agent).
• First Health Services pays the provider for any
  VALTC Medicaid carved out service.
• First Health Services then sends the remittance
  to the applicable VALTC MCO for payment of any
  remaining Medicaid liability (e.g. crossover
  payment).
• The VALTC MCO processes the remittance and pays
  the provider any further amount owed.

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Scenario B Participant enrolled in the VALTC
Medicaid MCO and in a different MCOs Medicare
Advantage plan or SNP

• Providers submit claims to the proper Medicare
  Advantage Plan or SNP and that plan pays the
  provider for the Medicare portion of the claim.
• Next, the provider submits the remittance to the
  VALTC MCO.
• The VALTC MCO pays the remaining Medicaid
  liability of the claim.
• If liability remains for a carved out service,
  the provider resubmits the claim to First Health
  Services for payment of the carved out service.

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Scenario C Participant enrolled in the VALTC
Medicaid MCOs Medicare Advantage plan or SNP

• Providers submit claims to the proper Medicare
  Advantage Plan or SNP and the VALTC plan pays the
  provider for both the Medicare and Medicaid
  liability.
• If liability remains for a carved out service,
  the provider resubmits the claim to First Health
  Services for payment of the carved out service.

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Care Coordination
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Care Coordination

• VALTC will include the following levels of care
  coordination
• Standard care coordination
• For all participants (both dual eligibles and
  EDCD participants)
• Expanded care coordination for individuals
  enrolled in the EDCD waiver
• Required EDCD care coordination
• Optional EDCD care coordination

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Standard Care Coordination

• Care coordination for all participants (dual and
  EDCD)
• Access to a 24 hour/7 days a week nurse
  help-line
• Customer service line
• Offer referrals to Medicare services and appeals
  when appropriate and
• Provide information on program options.
• Referral of participants to appropriate community
  resources.

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Expanded Mandatory Care Coordination for EDCD

• All EDCD participants must take part in these
  activities.
• Performance of annual level of care
  re-evaluations and service plan updates to ensure
  necessity of EDCD services and to identify unmet
  medical or social needs
• Coordination with social service agencies (e.g.
  local departments of health and social services)
  
• Participating in discharge planning (to include
  nursing facility discharge), when appropriate, to
  ensure awareness of and access to community based
  services
• Providing a point person for recipients and
  caregivers
• Monitoring of services provided and
• Maintaining and monitoring individual service
  records.

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Expanded Optional Care Coordination for EDCD

• MCOs must offer these services, however
  participation by the member is optional.
• Setting up appointments
• Setting up transportation
• Shepherding medical/LTC information between
  providers and
• Coordination with Medicare services if individual
  is enrolled in MCOs Medicare plan.

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Nursing Facility Coverage
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Nursing Facility Coverage

• Sixty days of a nursing facility stay is covered
  under VALTC.
• Participants must be referred by their MCO.
• Participants must meet nursing facility criteria.
  
• Sixty day coverage does not include step-down
  care.
• DMAS will pay the nursing facilities directly and
  adjust capitation payments accordingly.

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Nursing Facility Coverage 60 Day Clock

• If a Medicaid beneficiary enters a nursing
  facility under a Medicare Part A stay, the 60-day
  clock for continued VALTC MCO enrollment will
  begin upon entry to the nursing facility.
• The 60 day clock stops after the individual is
  discharged from the nursing facility and placed
  in
• a community setting.
• Upon completion of the 60-day
• period, if the beneficiary remains
• in the nursing facility, he/she will
• be excluded from VALTC.

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Differences between VALTC and the existing DMAS
Managed Care Program
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How is VALTC Different Than Medallion II?

• VALTC will cover populations previously excluded
  from managed care.
• VALTC will offer care coordination for EDCD
  participants.
• VALTC will include new long-term care services.
• VALTC will include consumer directed services.

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How is VALTC Different Than Medallion II?

• VALTC MCOs will process Medicare crossover
  claims.
• VALTC participants have greater health care
  needs.
• VALTC participants have the opportunity to enroll
  in Medicare Advantage plans.

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Implementation Advisory Group

• Beginning summer 2008.
• Membership will include representatives from
  participating MCOs and DMAS staff members.
• Collaborative to provide training, clarify
  requirements, identify challenges, and resolve
  implementation issues.
• Planned topics include
• Long-term care services- including consumer
  direction
• Long-term care quality measures
• Dual eligible claims processing
• Screening, eligibility criteria, and enrollment
• Care coordination

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Next Steps

• Adrienne Fegans

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Contracting Timeline
 
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Requirements to Contract for VALTC

• Financial, management, and administrative
  capabilities
• Quality improvement and utilization management
  processes
• Network of providers with appropriate demographic
  placement and specialties

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Requirements to Contract for VALTC

• Informational programs for enrollees and consumer
  protections
• Ability to process information and data, and
  render appropriate reports quickly, efficiently,
  and completely
• HIPAA confidentiality requirements

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Thank you!

• We look forward to working with you on this
  initiative.
• Questions?