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Department of Medical Assistance Services

Medicaid and the Status of
Health Care Reform in Virginia
Cindi B. Jones, Direc...
Presentation Outline
Medicaid 101
New Eligibility System
Status of Medicaid Reforms
Savings for Medicaid Reform: Phase...
Medicaid Enrollment
56.7M

National Medicaid
Enrollment

22.9M

946,000

Virginia Medicaid
Enrollment

291,000

1990

1995...
Who is Eligible for Medicaid?
• Eligibility is EXTRAORDINARILY complex!
• Currently, to qualify for Medicaid, individuals ...
Federally Mandated Minimum
Medicaid Eligibility Levels 2013
140%
120%
100%

133%

133%
100%
75%

80%
60%
40%
20%
0%
Pregna...
2013 Federal Poverty Level (FPL)
Guidelines
Annual Family Income

100% FPL

133% FPL

185% FPL

200% FPL

1

$11,490

$15,...
Virginia Medicaid Eligibility
•
•

The Supreme Court effectively ruled that the Medicaid Expansion was
optional for states...
Virginia Medicaid Expenditures
Top Expenditure Drivers:
$8

 Enrollment Growth: Now
provide coverage to over
400,000 more...
Composition of Virginia Medicaid
Expenditures – SFY 2012
Long-Term Care Expenditures
ID/DD
EDCD

Medical Services by Deliv...
Virginia Medicaid: Enrollment v. Spending
7%
18%

1%
QMB

33%
Non Long-Term Care

7%
10%
3%

Long-Term Care

35%
Caretaker...
Medicaid as a Percent
of Total State Expenditures

SOURCE: National Association of State Budget Officers. The Washington P...
Virginia’s Current Medicaid Program
When Compared to other states:
• Virginia ranks 24th in Medicaid spending
per recipien...
What Services Does Medicaid
Cover?
–
–
–
–
–
–
–

–

Mandatory
Inpatient Hospitalization
Outpatient Hospital Services
Phys...
Medicaid Service Delivery Structure
•
•

14

(Current)
Fee-for-Service
Contracted
Directly administered by the state.
Part...
New Eligibility System: We made it!
• New modernized Eligibility system went
live 10/1 as planned!
• PPACA compliant solut...
New Eligibility System
• Eligibility criteria is checked real-time with
Social Security Administration, IRS,
Homeland Secu...
Application Volume (10/1 – 11/7)
•
•

34,783 applications submitted across multiple
benefit programs
25,241 new Medicaid a...
Virginia Medicaid Reform Goals
Coordinated
Service
Delivery

•DMAS provides a health system where
services are coordinated...
Working with CMS to Implement
Reforms in Virginia
Key CMS Approvals/Support
Medicare-Medicaid Enrollee (dual eligible)
Fi...
Working with CMS to Implement
Reforms In Virginia
– On August 15, 2013, DMAS submitted a concept paper
to CMS, entitled “I...
Working with CMS to Implement
Reforms In Virginia
Request
Assurance Parameters for RapidCycle Innovation Pilots

Value Dri...
Status of Phase 1 Reforms
Title

Progress

Timeline/Target Date

Dual Eligible
Demonstration
Pilot

•

SFY14-16 Total
Savi...
Status of Phase 1 Reforms
Title
Foster Care
Enrollment
into MCOs
SFY14-16 Total
Savings
($13,940,351)

Eligibility and
Enr...
Status of Phase 1 Reforms
Title

Access to
Veterans
Benefits
for
Medicaid
Recipients
SFY14-16 Total
Savings
Minimal at thi...
Status of Phase 2 Reforms
Title

Progress

Timeline/Target Date

Commercial
Like Benefit
Package

•

Weekly discussions wi...
Status of Phase 2 Reforms
Title

Progress Timeline/Target Date

Parameters to
Test
Innovative
Pilots

•

July 2013 (for MC...
Status of Phase 3 Reforms
Title

Progress

Timeline/Target Date
October 2013 - First Phase of DBHDs Study
completed
July 2...
Status of Phase 3 Reforms
Title

Progress

Timeline/Target Date

All Inclusive
Coordinated Care
for LTC
Beneficiaries
(coo...
Savings Estimates for Medicaid Reform for Virginia: Phase 1
SFY 14 – SFY 16
Total Funds/GF

SFY 2014
Total Funds/GF

SFY 2...
Savings Estimates for Medicaid Reform:
Phase 2
• At this time, there are no additional savings estimates on this Phase
for...
Savings Estimates for Medicaid Reform for Virginia: Phase 3
SFY 14 – SFY 16
Total Funds/GF

•Long Term Care Coordinated Ca...
Estimated Cost and Savings of Medicaid Reform for Virginia
SFY 10 - SFY 22 SFY 2014
Mandatory ACA Provisions: Costs – Stat...
Potential Virginia Model: Private
Option for Low-Income Adults

Eligible

Adults

Entry into
Private
Market

Health
Plan
A...
Potential Virginia Model: Private
Option for Low-Income Adults
Eligible
Adults

Entry into
Private Market

Health Plan
Acc...
Potential Virginia Model: Private
Option for Low-Income Adults
Eligible
Adults

Entry into
Private
Market

Health Plan
Acc...
Potential Virginia Model: Private
Option for Low-Income Adults
Eligible
Adults

Entry into Private
Market

Health Plan
Acc...
Potential Virginia Model: Private
Option for Low-Income Adults
Eligible
Adults

Entry into
Private Market

Health Plan
Acc...
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  1. 1. Department of Medical Assistance Services Medicaid and the Status of Health Care Reform in Virginia Cindi B. Jones, Director Virginia Department of Medical Assistance Services November 18, 2013 http://dmas.virginia.gov
  2. 2. 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 LowIncome Adults 2
  3. 3. Medicaid Enrollment 56.7M National Medicaid Enrollment 22.9M 946,000 Virginia Medicaid Enrollment 291,000 1990 1995 2000 2005 2010 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 11/27/2013 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. 3 Virginia
  4. 4. Who is Eligible for Medicaid? • 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. 4
  5. 5. Federally Mandated Minimum Medicaid Eligibility Levels 2013 140% 120% 100% 133% 133% 100% 75% 80% 60% 40% 20% 0% Pregnant Women Children 0-5 Children 6-18 Elderly & Disabled 64% * Parents Percent of FPL * National median Medicaid income eligibility level 5 Source: Kaiser Commission on Medicaid and the Uninsured; Sept., 2011 5
  6. 6. 2013 Federal Poverty Level (FPL) Guidelines 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 Family Size 6 Source: 2013 Federal Poverty Guidelines, U.S. Dept. of Health and Human Services 6
  7. 7. Virginia Medicaid Eligibility • • 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 100% 50% 0% Pregnant Women Children 0-5 Current Elig. Children 6-18 Elderly & Disabled Parents Optional Federal Reform Childless Adults 7
  8. 8. Virginia Medicaid Expenditures Top Expenditure Drivers: $8  Enrollment Growth: Now provide coverage to over 400,000 more members than 10 years ago (80% increase) 8 $5 $4 $3 $2 $1 FY12 FY11 FY10 FY09 FY08 FY07 FY06 FY05 FY04 FY03 $0 FY02  Growth in Specific Services: Significant growth in expenditures for Home & Community Based LTC services and Community Behavioral Health services $6 $billions  Growth in the U.S. cost of health care $7
  9. 9. Composition of Virginia Medicaid Expenditures – SFY 2012 Long-Term Care Expenditures ID/DD EDCD Medical Services by Delivery Type Other 2% Waivers 26% 21% $1.7b 13% 39% $1.4b ICF/MR Nursing Facility Long-Term Care Services 34% 43% Medical Services Managed Care Notes: 9 Behavioral Health Dental Services 9% Indigent Care Medicare Premiums 2% 5% 7% Fee-For-Service
  10. 10. Virginia Medicaid: Enrollment v. Spending 7% 18% 1% QMB 33% Non Long-Term Care 7% 10% 3% Long-Term Care 35% Caretaker Adults 55% 8% 2% 21% 10 Enrollment Expenditures Pregnant Women & Family Planning Children
  11. 11. Medicaid as a Percent of Total State Expenditures SOURCE: National Association of State Budget Officers. The Washington Post. Published on June 14, 2011, 7:13 p.m. 11
  12. 12. Virginia’s Current Medicaid Program 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 12
  13. 13. What Services Does Medicaid Cover? – – – – – – – – 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) 13
  14. 14. Medicaid Service Delivery Structure • • 14 (Current) Fee-for-Service Contracted Directly administered by the state. Participants typically fall into these groups: – New enrollees waiting for MCO assignment – Most individuals receiving Homeand 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) • 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)
  15. 15. 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 15
  16. 16. 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
  17. 17. 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). 17
  18. 18. Virginia Medicaid Reform Goals Coordinated Service Delivery •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. Efficient Administration •DMAS is efficient, streamlined, and userfriendly. Tax payer dollars are used effectively and for their intended purposes. Significant Beneficiary Engagement •Beneficiaries take an active role in the quality of their health care and share responsibility for using Medicaid dollars wisely. 18
  19. 19. 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 19
  20. 20. 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 20
  21. 21. Working with CMS to Implement Reforms In Virginia Request Assurance Parameters for RapidCycle Innovation Pilots Value Driven, Commercial-Like Medicaid Program Comprehensive Coordination of LTSS Background Developing a State Plan Amendment or 1115 waiver authority to implement pilots on a rapid-cycle basis outside of Managed Care Further strengthening DMAS’ current MCO contract by establishing value-driven incentive strategies (e.g., wellness). Using a phased in approach to move all LTSS populations and services into a coordinated delivery system. 21
  22. 22. 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) Enhanced Program Integrity SFY14-16 Total Additional Savings ($17,066,946) • • 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 •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
  23. 23. Status of Phase 1 Reforms Title Foster Care Enrollment into MCOs SFY14-16 Total Savings ($13,940,351) Eligibility and Enrollment System SFY14-16 Total Savings (General Funds only) ($22,400,000 – due to 75% FFP for eligibility functions) Progress Timeline/Target Date • • • • • • • 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. • 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) 23
  24. 24. Status of Phase 1 Reforms Title Access to Veterans Benefits for Medicaid Recipients SFY14-16 Total Savings Minimal at this time Behavioral Health Services SFY14-16 Total Savings ($133,960,168) Progress Timeline/Updates • 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 • December 2013: Implement strengthened regulations to improve integrity and quality • December 2013: Implement new Behavioral Health Services Administrator (Magellan) 24
  25. 25. Status of Phase 2 Reforms Title Progress Timeline/Target Date 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) 25
  26. 26. Status of Phase 2 Reforms Title Progress Timeline/Target Date Parameters to Test Innovative Pilots • July 2013 (for MCOs):Program implemented to establish the baseline target • Quality Payment and Incentives July 2014: quality withholds begin • 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 26
  27. 27. Status of Phase 3 Reforms Title Progress Timeline/Target Date October 2013 - First Phase of DBHDs Study completed July 2014 –ID/DD Waiver Renewal Due/ Redesign; second phase of DBHDS study to be complete • All HCBC Waiver Enrollees in Managed Care for Medical Needs • • ID/DD Waiver Redesign July 2015- Additional revisions to the ID/DD Waiver systems implemented as needed • October 2014 • Home and community-based waiver services remain out of managed care and provided through fee-for-service 27
  28. 28. Status of Phase 3 Reforms Title Progress Timeline/Target Date All Inclusive Coordinated Care for LTC Beneficiaries (coordinated delivery for all LTC services) July 2016 Statewide MedicareMedicaid (Duals) Coordinated Care, including children July 2018 28
  29. 29. 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 •80% enrollment in program •Enhanced Program Integrity •Foster Care to Managed Care •Ehhr – 75% enhanced FFP for eligibility and enrollment functions (GF savings) •Behavioral Health Regulations Changes (27,597,465)/ (13,798,733) (44,028,619)/ (22,014,310) (17,066,946)/ (8,533,473) (13,940,351)/ (6,970,176) (1,412,218)/ (706,109) (1,412,218)/ (706,109) (5,688,982)/ (2,844,491) (2,440,351)/ (1,220,176) (17,166,356)/ (8,583,178) (28,186,175)/ 14,093,088) (5,688,982)/ (2,844,491) (5,750,000)/ (2,875,000) (9,018,891)/ (4,509,446) (14,430,226)/ (7,215,113) (5,688,982)/ (2,844,491) (5,750,000)/ (2,875,000) (22,400,000)/ (22,400,000) (6,000,000)/ (6,000,000) (8,200,000)/ (8,200,000) (8,200,000)/ (8,200,000) (133,960,168)/ (66,967,577) (20,737,969)/ (10,367,532) (54,615,905)/ (27,304,419) (58,606,294)/ (29,295,626) (214,964,930)/ (118,669,959) (231,396,084)/ (126,885,536) (36,279,520)/ (21,138,308) (36,279,520)/ (21,138,308) (91,421,243)/ (49,807,088) (102,441,062)/ (55,316,998) (87,264,167)/ (47,724,563) (92,675,502)/ (50,430,230) Totals for Phase 1 •50% Duals enrollment •80% Duals enrollment 29
  30. 30. 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. 30
  31. 31. Savings Estimates for Medicaid Reform for Virginia: Phase 3 SFY 14 – SFY 16 Total Funds/GF •Long Term Care Coordinated Care All HCBS in Managed Care for Acute and Medical needs only (implemented in SFY 2015) SFY 2014 Total Funds/GF SFY 2015 Total Funds/GF SFY 2016 Total Funds/GF 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 31
  32. 32. Estimated Cost and Savings of Medicaid Reform for Virginia SFY 10 - SFY 22 SFY 2014 Mandatory ACA Provisions: Costs – State Funds Mandatory ACA Provisions: Savings – State Funds Total Mandatory ACA Provisions: State Funds Total Mandatory ACA Provisions: Federal Funds Optional ACA Provisions (with Expansion): Costs – State Funds Optional ACA Provisions (with Expansion): Savings – State Funds Total Optional ACA Provisions (with Expansion): State Funds Total Optional ACA Provisions (with Expansion): Federal Funds Net ACA Impact with Optional Expansion – State Funds Net ACA Impact with Optional Expansion – Federal Funds SFY 2015 SFY 2016 $1,017m $46.7m $84.3m $80.1m ($1,159)m ($82.8m) ($57.9m) ($109.8m) ($142)m ($36.1m) $26.4m ($29.7m) $847m $45.5m $78.7m $101.6m $1,603m $9.7m $22.4m $24.9m ($1,323)m ($61.7m) ($137.4m) ($144.3m) $280m ($52.1m) ($115.0m) ($119.4m) $22,346m $771.4m $2,220m $2,417m $137m ($88.1m) ($88.6m) ($149.1m) $23,193m $816.9m $2,299m $2,519m Source: Virginia Department of Medical Assistance Services, December 7, 2012 32
  33. 33. Potential Virginia Model: Private Option for Low-Income Adults Eligible Adults Entry into Private Market Health Plan Accountability Commercial Benefits 33
  34. 34. Potential Virginia Model: Private Option for Low-Income Adults 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. 34
  35. 35. Potential Virginia Model: Private Option for Low-Income Adults Eligible Adults Entry into Private Market 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 35
  36. 36. Potential Virginia Model: Private Option for Low-Income Adults Eligible Adults Entry into Private Market Health Plan Accountability Commercial Benefits • Assured access to providers- statewide coverage • Full financial risk using a capitated payment • Ability to financially incent high-quality and highperformance (Phase 2 Reforms Included) Future Options: •Premium assistance (similar to capitated payment) •Health Savings Accounts 36
  37. 37. Potential Virginia Model: Private Option for Low-Income Adults Eligible Adults Entry into Private Market Health Plan Accountability 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 37 • Wellness incentives for all
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