Virginia medicaid

Cindi B. Jones, Director

Virginia Department of Medical Assistance Services

November 18, 2013

http://dmas.virginia.gov

Department of Medical Assistance Services

Medicaid and the Status of Health Care Reform in Virginia

Presentation Outline

Medicaid 101

New Eligibility System

Status of Medicaid Reforms

Savings for Medicaid Reform: Phase 1-3

Cost/Savings for Affordable Care Act

Potential Virginia Model for Low-Income Adults

2

1990 1995 2000 2005 2010

Virginia Medicaid Enrollment

Medicaid Enrollment

11/27/2013 3

National Medicaid Enrollment

22.9M

56.7M

Note: For the purposes of this presentation, the term “Medicaid” is used to represent both Virginia’s Title XIX Medicaid and Title XXI CHIP programs. Source: National Medicaid Enrollment - 2010 Actuarial Report On The Financial Outlook For Medicaid . Office of the Actuary, Centers for Medicare & Medicaid Services, and the U.S. Department of Health & Human Services Virginia Medicaid Enrollment – Virginia Department of Medical Assistance Services, Average monthly enrollment in the Virginia Medicaid and CHIP programs, as of the 1st of each month.

291,000

946,000

Who is Eligible for Medicaid?

4

• Eligibility is EXTRAORDINARILY complex!

• Currently, to qualify for Medicaid, individuals must:

– Meet financial eligibility requirements; AND

– Fall into a “covered group” such as:

• Aged, blind, and disabled;

• Pregnant;

• Child; or

• Caretaker parents of children.

• Currently, Virginia Medicaid does not provide medical assistance for all people with limited incomes and resources.

Federally Mandated Minimum Medicaid Eligibility Levels 2013

133% 133%

100%

75%64%

0%

20%

40%

60%

80%

100%

120%

140%

Pregnant

Women

Children

0-5

Children

6-18

Elderly &

Disabled

Parents

Percent of FPL

5

*

* National median Medicaid income eligibility level

Source: Kaiser Commission on Medicaid and the Uninsured; Sept., 2011 5

6

2013 Federal Poverty Level (FPL) Guidelines

Family Size

Annual Family Income

100% FPL

133% FPL

185% FPL

200% FPL

1 $11,490 $15,528 $21,257 $22,980

2 $15,510 $20,629 $28,694 $31,020

3 $19,530 $25,975 $36,131 $39,060

4 $23,550 $31,322 $43,568 $47,100

5 $27,570 $36,669 $51,005 $55,140

Source: 2013 Federal Poverty Guidelines, U.S. Dept. of Health and Human Services 6

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• The Supreme Court effectively ruled that the Medicaid Expansion was optional for states

• This ruling causes the expansion to be a policy choice for Virginia, as opposed to a federal mandate

Virginia Medicaid Eligibility

0%

50%

100%

PregnantWomen

Children0-5

Children6-18

Elderly &Disabled

Parents ChildlessAdults

Current Elig. Optional Federal Reform

Virginia Medicaid Expenditures

Top Expenditure Drivers:

Enrollment Growth: Now provide coverage to over 400,000 more members than 10 years ago (80% increase)

Growth in the U.S. cost of health care

Growth in Specific Services: Significant growth in expenditures for Home & Community Based LTC services and Community Behavioral Health services

$0

$1

$2

$3

$4

$5

$6

$7

$8

FY

02

FY

03

FY

04

FY

05

FY

06

FY

07

FY

08

FY

09

FY

10

FY

11

FY

12

$b

illio

ns

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Composition of Virginia Medicaid Expenditures – SFY 2012

Notes:

43%

Dental 2% Medicare Premiums

7%

Indigent Care 5%

Behavioral Health Services

9%

34%

Nursing Facility

ICF/MR

EDCD

ID/DD

Other Waivers

Long-Term Care Expenditures

21% 26%

13% 39%

2%

$1.7b

$1.4b

Managed Care Fee-For-Service

Medical Services by Delivery Type

Long-Term Care

Services Medical Services

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Virginia Medicaid: Enrollment v. Spending

55%

21%

3%

2%

10%

8%

7%

35%

18% 33%

7%1%

Enrollment Expenditures

QMB

Non Long-Term Care

Long-Term Care

Caretaker Adults

Pregnant Women & Family Planning

Children

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Medicaid as a Percent of Total State Expenditures

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SOURCE: National Association of State Budget Officers. The Washington Post. Published on June 14, 2011, 7:13 p.m.

Virginia’s Current Medicaid Program

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When Compared to other states:

• Virginia ranks 24th in Medicaid spending per recipient.

• Virginia ranks 48th in Medicaid spending per capita.

• No coverage for childless adults

What Services Does Medicaid Cover?

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Mandatory

– Inpatient Hospitalization

– Outpatient Hospital Services

– Physicians’ Services

– Lab & X-Ray Services

– Home Health

– Nursing Facility Services

– Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services for Children

– Non-Emergency Transportation

Optional – Prescription Drugs – Eyeglasses & Hearing Aids (Children Only) – Organ Transplants – Psychologists’ Services & other Behavioral

Health Services – Podiatrists’ Services – Dental Services (Children Only) – Physical, Occupational and Speech

Therapies – Rehabilitative Services – Intermediate Care Facilities for Individuals

with Intellectual Disabilities – Case Management (only through select

HCBS waivers) – Emergency Hospital Services – Hospice – Prosthetic Devices – Home and community based care, such as

Personal Care (only through HCBS waivers)

Medicaid Service Delivery Structure (Current)

Fee-for-Service • Directly administered by the state.

• Participants typically fall into these groups:

– New enrollees waiting for MCO assignment

– Most individuals receiving Home- and Community-Based services

– Individuals in LTC settings

– Individuals with other insurance

– Dual eligibles (Medicaid and Medicare enrollees) (moving to MCOs in 2014)

– Foster Care Children (moving to MCOs this 2013-2014)

Contracted • MCO: Managed care

organizations provide care to beneficiaries through contracts with the state. The MCOs do not provide certain services. These services are referred to as being “carved out.” (E.g., community mental health and dental for children)

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New Eligibility System: We made it!

• New modernized Eligibility system went

live 10/1 as planned!

• PPACA compliant solution

• Approved by Centers for Medicare &

Medicaid Services (CMS)

• New Medicaid eligibility criteria

• Income based on IRS MAGI methodology

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New Eligibility System

• Eligibility criteria is checked real-time with

Social Security Administration, IRS,

Homeland Security

• Cases coordinated real-time with the

federal Exchange

• New Cover Virginia call center open;

enables citizens to apply for Medicaid by

phone

• All 122 Local DSS offices are on-line

16

Application Volume (10/1 – 11/7)

• 34,783 applications submitted across multiple benefit programs

• 25,241 new Medicaid applications CommonHelp portal

Cover Virginia call center

Local DSS offices

• On par with typical new Medicaid application volume before ACA launched

• More than 1,000 applications transferred to the federal exchange

• No applications received from the federal exchange – feds not ready (More than 7,000 waiting).

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Virginia Medicaid Reform Goals

•DMAS provides a health system where services are coordinated, innovation is rewarded, costs are predictable, and provider compensation is based on the quality of the care.

Coordinated

Service Delivery

•DMAS is efficient, streamlined, and user-friendly. Tax payer dollars are used effectively and for their intended purposes.

Efficient Administration

•Beneficiaries take an active role in the quality of their health care and share responsibility for using Medicaid dollars wisely.

Significant Beneficiary

Engagement 18

Working with CMS to Implement Reforms in Virginia

Key CMS Approvals/Support

Medicare-Medicaid Enrollee (dual eligible) Financial Alignment

Significant Reforms to the Managed Care Organization Contracts

Fast Tracking Reviews of Eligibility and Enrollment Changes

Additional Required Medicaid Reforms

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Working with CMS to Implement Reforms In Virginia

– On August 15, 2013, DMAS submitted a concept paper

to CMS, entitled “Implementing Medicaid Reform in Virginia: A summary of planned reforms for review by the Centers for Medicare and Medicaid Services and interested stakeholders”

– Contents • Purpose • Overview of the Medicaid Program • Existing Federal Authority for the Virginia Medicaid Program • Reforming Virginia’s Medicaid Program • Next Steps for Virginia

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Working with CMS to Implement Reforms In Virginia

Request Background

Assurance Parameters for Rapid-Cycle Innovation Pilots

Developing a State Plan Amendment or 1115 waiver authority to implement pilots on a rapid-cycle basis outside of Managed Care

Value Driven, Commercial-Like Medicaid Program

Further strengthening DMAS’ current MCO contract by establishing value-driven incentive strategies (e.g., wellness).

Comprehensive Coordination of LTSS

Using a phased in approach to move all LTSS populations and services into a coordinated delivery system.

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Status of Phase 1 Reforms Title Progress Timeline/Target Date

Dual Eligible

Demonstration

Pilot SFY14-16 Total

Savings

50% enrollment

($27,597,465)

80% enrollment

($44,028,619)

• July 2013: Negotiations started with identified

health plans

• August 2013: Began Readiness Reviews with

plans

• September 2013: Contracting, Rates

• October 2013: Completed desk and on-site

Readiness Reviews with plans

• January 2014: Regional phased-in enrollment

begins

Enhanced

Program

Integrity

SFY14-16 Total

Additional Savings

($17,066,946)

•Continued Enhancement Highlights:

1. 145 referrals to MFCU at the OAG

2. Prevented over $363M in improper

payments (over past two fiscal years)

3. $461,654 in restitution and imprisonment in

some cases for fraudulent eligibility

4. Eight separate contracts to monitor and

audit provider payments 22

Status of Phase 1 Reforms

Title Progress Timeline/Target Date

Foster Care

Enrollment

into MCOs

SFY14-16 Total

Savings

($13,940,351)

• Tidewater: September 1, 2013 (LIVE);

• Central VA: November 1, 2013;

• NOVA: December 1, 2013;

• Charlottesville: March 1, 2014;

• Lynchburg: April 1, 2014;

• Roanoke: May 1, 2014; and,

• Far Southwest: June 1, 2014.

Eligibility and

Enrollment

System SFY14-16 Total

Savings (General

Funds only)

($22,400,000 – due to

75% FFP for

eligibility functions)

• October 2013 – New VaCMS eligibility system

went live for new Medicaid/FAMIS applications;

Now taking Medicaid/FAMIS applications using

new financial requirements MAGI

• January 1, 2014 – Additional eligibility rules

required to begin (e.g., coverage up to age 26 for

foster care youth)

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Status of Phase 1 Reforms Title Progress Timeline/Updates

Access to

Veterans

Benefits

for

Medicaid

Recipients

SFY14-16 Total

Savings

Minimal at this

time

• Assisting veterans to obtain benefits and avoid

Medicaid expenditures when services are more

appropriately funded by the Federal Government.

• To establish the program -DMAS, VDVS and VDSS

have together developed an MOU, interagency

data transfer and internal procedures to get the

program up and running.

• Now transferring quarterly data match files with

federal government to link applicants with federal

services when available

Behavioral

Health

Services SFY14-16 Total

Savings

($133,960,168)

• December 2013: Implement strengthened

regulations to improve integrity and quality

• December 2013: Implement new Behavioral

Health Services Administrator (Magellan)

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Commercial

Like Benefit

Package

• Weekly discussions with CMS for transition to a

Commercial (“alternative”) benefit package in 2014

• July 2014: Managed Care Benefit Package Contract

Revision to implement commercial benefit package

Cost

Sharing and

Wellness

• July 2013 Managed Care Changes

•Chronic Care and Assessments (2013)

•Wellness Programs (2013)

•Maternity Program Changes (2013)

Limited

Provider

Networks

and Medical

Homes

• July 2013 Managed Care Changes

• Medallion Care Partnership System (MCSP)

• October 2013: Addition of Kaiser Health Plan

(medical home model)

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Quality

Payment and

Incentives

• July 2013 (for MCOs):Program implemented to

establish the baseline target

• July 2014: quality withholds begin

Parameters to

Test

Innovative

Pilots

• Summer 2013: Provided claims data to GMU to

assist with VCHI pilots

• August 15, 2013: Sent proposal to CMS

• September 2013: Ongoing conversations with

CMS & conversations with VCHI regarding

potential pilots

• October 2013: Workgroups established with

CMS to establish authority

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Status of Phase 3 Reforms

Title Progress Timeline/Target Date

ID/DD Waiver

Redesign • October 2013 - First Phase of DBHDs Study

completed

• July 2014 –ID/DD Waiver Renewal Due/

Redesign; second phase of DBHDS study to

be complete

• July 2015- Additional revisions to the ID/DD

Waiver systems implemented as needed

All HCBC Waiver

Enrollees in

Managed Care for

Medical Needs

• October 2014

• Home and community-based waiver services

remain out of managed care and provided

through fee-for-service

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All Inclusive

Coordinated Care

for LTC

Beneficiaries

(coordinated

delivery for all LTC

services)

July 2016

Statewide

Medicare-

Medicaid (Duals)

Coordinated

Care, including

children

July 2018

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Savings Estimates for Medicaid Reform for Virginia: Phase 1

SFY 14 – SFY 16 Total Funds/GF

SFY 2014 Total Funds/GF

SFY 2015

Total Funds/GF SFY 2016

Total Funds/GF

•Dual Eligible Demonstration Pilot

•50% enrollment in program (27,597,465)/ (13,798,733)

(1,412,218)/ (706,109)

(17,166,356)/ (8,583,178)

(9,018,891)/ (4,509,446)

•80% enrollment in program (44,028,619)/ (22,014,310)

(1,412,218)/ (706,109)

(28,186,175)/ 14,093,088)

(14,430,226)/ (7,215,113)

•Enhanced Program Integrity (17,066,946)/

(8,533,473) (5,688,982)/ (2,844,491)

(5,688,982)/ (2,844,491)

(5,688,982)/ (2,844,491)

•Foster Care to Managed Care (13,940,351)/

(6,970,176) (2,440,351)/ (1,220,176)

(5,750,000)/ (2,875,000)

(5,750,000)/ (2,875,000)

•Ehhr – 75% enhanced FFP for eligibility and enrollment functions (GF savings)

(22,400,000)/ (22,400,000)

(6,000,000)/ (6,000,000)

(8,200,000)/ (8,200,000)

(8,200,000)/ (8,200,000)

•Behavioral Health Regulations Changes

(133,960,168)/ (66,967,577)

(20,737,969)/ (10,367,532)

(54,615,905)/ (27,304,419)

(58,606,294)/ (29,295,626)

Totals for Phase 1

•50% Duals enrollment (214,964,930)/ (118,669,959)

(36,279,520)/ (21,138,308)

(91,421,243)/ (49,807,088)

(87,264,167)/ (47,724,563)

•80% Duals enrollment (231,396,084)/ (126,885,536)

(36,279,520)/ (21,138,308)

(102,441,062)/ (55,316,998)

(92,675,502)/ (50,430,230)

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Savings Estimates for Medicaid Reform: Phase 2

• At this time, there are no additional savings estimates on this Phase for current populations. Savings for commercial like reforms for current population are already included in the capitated payment for the MCOs. MCOs are also at full risk.

• Phase 2 Reforms includes: commercial like benefits and service limits, cost sharing and wellness, coordination with behavioral health, limited provider networks and medical homes, quality payment incentives, administration simplification, and parameters to test pilots.

• Phase 2 Reforms and additional savings are more likely with the expansion of the private option to uninsured adults from 0 – 133% FPL.

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Savings Estimates for Medicaid Reform for Virginia: Phase 3

SFY 14 – SFY 16 Total Funds/GF

SFY 2014 Total Funds/GF

SFY 2015

Total Funds/GF SFY 2016

Total Funds/GF

•Long Term Care Coordinated Care

All HCBS in Managed Care for Acute and Medical needs only (implemented in SFY 2015) Not applicable

Savings TBD Savings TBD

All Long Term Care Services in Coordinated Care (Implemented in SFY 2017)

Not applicable

Not applicable

Not applicable

Complete Duals Statewide, including children (Implemented in SFY 2019)

Not applicable

Not applicable

Not applicable

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Estimated Cost and Savings of Medicaid Reform for Virginia

SFY 10 - SFY 22 SFY 2014 SFY 2015 SFY 2016

Mandatory ACA Provisions: Costs – State Funds $1,017m $46.7m $84.3m $80.1m

Mandatory ACA Provisions: Savings – State Funds ($1,159)m ($82.8m) ($57.9m) ($109.8m)

Total Mandatory ACA Provisions: State Funds ($142)m ($36.1m) $26.4m ($29.7m)

Total Mandatory ACA Provisions: Federal Funds $847m $45.5m $78.7m $101.6m

Optional ACA Provisions (with Expansion): Costs – State Funds $1,603m $9.7m $22.4m $24.9m

Optional ACA Provisions (with Expansion): Savings – State Funds ($1,323)m ($61.7m) ($137.4m) ($144.3m)

Total Optional ACA Provisions (with Expansion): State Funds $280m ($52.1m) ($115.0m) ($119.4m)

Total Optional ACA Provisions (with Expansion): Federal Funds $22,346m $771.4m $2,220m $2,417m

Net ACA Impact with Optional Expansion – State Funds $137m ($88.1m) ($88.6m) ($149.1m)

Net ACA Impact with Optional Expansion – Federal Funds $23,193m $816.9m $2,299m $2,519m

Source: Virginia Department of Medical Assistance Services, December 7, 2012

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Potential Virginia Model: Private Option for Low-Income Adults

Eligible

Adults

Entry into Private Market

Health Plan

Accountability

Commercial Benefits

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Eligible

Adults Entry into

Private Market Health Plan

Accountability Commercial

Benefits

• In Virginia, it is estimated that 395,000 uninsured adults earn less than 133% of the federal poverty level (FPL).

•At an estimated 69% take up rate, that would include coverage for roughly 248,000 adults.

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Eligible

Adults


Health Plan Accountability

Commercial Benefits

• Contracted enrollment broker facilitates enrollee’s health plan selection • Choice of available health plans • Mandatory enrollment in a health plan •Future Option:

•Plan selection via the Health Insurance Marketplace

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Eligible

Adults



Commercial Benefits

• Assured access to providers- statewide coverage • Full financial risk using a capitated payment • Ability to financially incent high-quality and high-performance (Phase 2 Reforms Included) Future Options:

•Premium assistance (similar to capitated payment) •Health Savings Accounts

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Eligible

Adults



Commercial Benefits

•Use of Virginia’s Approved Benchmark Plan: Anthem Key Care 30 Benefit Package (the largest small group plan in Virginia) •Medicaid payment rates •Provide wraparound services:

•Transportation to medical providers with limits •Community behavioral health services

•Beneficiary Responsibility: •Cost sharing for enrollees with income over 100% FPL • Wellness incentives for all

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Virginia medicaid

Health & Medicine

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