West Virginia Beneficiaries by Enrollment Group

1
West Virginia Beneficiaries by Enrollment Group
191,316
91,190
60,233
31,144
2
West Virginia Beneficiaries by Expenditures
WEST VIRGINIA MEDICAID BENEFICIARIES AND
EXPENDITURES BY ENROLLMENT GROUP, FFY 2003
100
Elderly (31,144)
90
Blind Disabled (91,190)
80
Adults (60,233)
70
Children (191,316)
60
Source CMS 2082
50
Data from MMIS
System
40
30
Note Beneficiaries are
20
enrollees who received
a Medicaid service.
10
Blind Disabled
0
includes adults,
children, and elderly
who qualify based on a
disability.
3
Recent History of West Virginia Medicaid

• Year Total Expenditures
• FY 2001 1.48B
• FY 2002 1.59B
• FY 2003 1.76B
• FY 2004 1.94B
• Annual growth of 7-9 each year.

4

Recent History of West Virginia Medicaid Conti
nued

• West Virginia has not expanded eligibility
• Rolls have grown by 37,365 or 12 since 2001
• Cost-containment achieved by cutting reimbursement

5
Mission of WVBureau for Medical Services

• To support an enhanced quality of life for
  Medicaid beneficiaries by facilitating access to
  appropriate, high quality, cost effective
  service
• To provide these services in a user friendly
  manner to both consumers and providers
  
• To use the states purchasing power to foster
  excellence in health care quality, efficiency and
  service
  
• To work collaboratively with other partners in
  the health care community to promote
  comprehensive health care
  
• And to focus on the future by promoting
  preventative care and health awareness education.

6
Goals of West Virginia Medicaid Redesign

• Streamline administration
• Tailor benefits to population needs
• Coordinate care, especially for members with
  chronic conditions
  
• Provide members with the opportunity and
  incentives to maintain and improve their health

7
Hallmarks of Redesign

• Prevention
• Personal Responsibility
• Care Management
• Establishment of a Medical Home

8
Development of the West Virginia Medicaid
Redesign

• Steering Committee and Workgroup included staff,
  providers, advocates and consumers
  
• Met publicly
• Will use market analysis for some components
• Public forums on the final application

9
Streamlining Administration

• Reduce 29 eligibility categories to 4
• All mandatory coverage groups and previously
  eligible individuals continue to be covered
  

10
Eligibility

• Simplification of coverage group categories
• Children
• Adults 65 and over
• Adults with Children
• Special Needs Groups
• No expansion groups are proposed

11
Flexible Benefits

• Ensure that participants receive the right care,
  at the right place, at the right time by the
  right provider through care coordination
  
• Use evidence-based medicine to manage services by
  duration, scope and severity
  

12
Electronic Health Information

• Electronic medical records

13
Member Agreements
Member Agreements

• Outlines member rights and responsibilities.
• An educational tool.
• Attached addendums will identify check-ups and
  exams which are appropriate for the members age
  and diagnosis.
  
• Refusal to sign an agreement excludes member from
  the benefits of the Healthy Rewards Account.

14
Healthy Rewards

• A method of providing incentives and
  disincentives for member behavior.
  
• Pilot project to be expanded to all WV Medicaid
  members who are able to partner in their personal
  health decisions.
  
• Intended to foster and reward healthy choices
  among WV Medicaid members.
  
• Fixed amount of credits per quarter per member
  are deposited in the account
  
• Used to cover medical and pharmaceutical co-pays
• Higher co-pays for inappropriate use of ER
• Bonus credits added for meeting health goals
• Can use credits remaining at the end of the year
  to purchase non-covered services
  

15
Medical Home

• A team approach to providing health care and care
  management. Whether involving a primary care
  provider, specialist or sub-specialist, care
  management includes the development of a plan of
  care, the determination of the outcomes desired,
  facilitation and navigation of the health care
  system, provision of follow-up and support for
  achieving the identified outcomes. The medical
  home maintains a centralized, comprehensive
  record of all health related services to provide
  continuity of care.

16
Long Term Care and Care Management
Long Term Care and Care Management

• Single point of entry with a needs assessment
• Placement in most integrated setting
• Resource Management Contract

17
Quality Outcomes and Measurements

• Access
• Service Utilization
• Effectiveness of Care
• Patient Experience
• Safety
• Administrative

18
2005 Deficit Reduction Act

• The DRA changes the face of Medicaid.
• West Virginia is poised to take the lead in
  moving Medicaid from a welfare mentality to a
  model which emphasizes personal empowerment and
  responsibility.