The next slides discuss the benefits and services provided through Managed Care.
This slide shows a current snapshot of Managed Care enrollment in Virginia. As you can see, the majority of Medicaid enrollees are receiving their services through a Managed Care organization.
Coordination of health careCase managementprovided through licensed registered nurses (RNs) or individuals with appropriate professional clinical expertise. 24 hour nurse hotlineIncreased access to physicians and other providersTargeted services for chronic conditions including Disease Management & Chronic Care Programs Better coordination between DSS and MCOs which will improve outcomes for childrenFamilies may choose to have multiple children in one MCO and with one primary care physician
These services are not readily available or not available at all for the fee-for-service members but are provided for Managed Care enrollees:MCO member ID card, handbook, and provider directoryToll-free member helpline Access to free translation services /language telephone line 24-hour nurse advice lineAccess to assistance with medical issues (case management)Member outreach and health education materialsAccess to credentialed providersNo co-payments
This slides details the carved out services which are not covered through the MCOs but paid through the Medicaid Fee-For-Service Program
In Virginia, we have six Medicaid Managed Care partners operating across the state.As of July 1, 2012managed care is available statewide, althoughnot all six MCOs are available in every area. For information about which Managed Care organizations participate in which localities refer to the Managed Care Resource Guide on the DMAS website.
Children in Foster Care/Adoption Assistance in the Managed Care Central and Tidewater Regions will transition to managed care effective July 1, 2013.This includes the following;Children receiving Medicaid as part of Adoption Assistance;Children placed in Foster Care and residing in Managed Care Central and Tidewater Regions, who are not in Level C residential care;Children in non-custodial placement agreement who are not in Level C residential care; and ***just FYI - don’t share on Webinar***(Parent/guardian retains custody as agreement with LDSS and LDSS serves as the case manager and eligible for same services).Minor children of eligible foster care youth.Residential care are level C / Psychiatric Residential Treatment Facilities***just FYI - don’t share on Webinar***Children with parental agreements ARE NOT considered to be in foster care for Medicaid eligibility purposes. This is an agreement between the child’s parent/guardian and an agency OTHER THAN DSS which is designated by the CPMT (Community Policy and Management Team).
Children will obtain services through fee-for-service (regular Medicaid) until MCO enrollment
Request for changes to MCO can occur at any time during the yearAdoption Assistance parents may contact the Managed Care Helpline directly to request an MCO change.Parents are responsible for requesting MCO changes.The open period for changes to MCOs is unique for FC and AA children. Normally MCO changes are allowed in the first 90 days after the individual becomes a member, at open enrollment time, or with special approval from DMAS.
If Medicaid eligibility is cancelled, the child’s MCO enrollment ends.If Medicaid eligibility is regained within 60 days, child is reinstated in the same MCO on the first of the next available month.DMAS will mail the CW/parent a letter notifying of the re-enrollment.Child may be disenrolled from MCO but remain eligible for Medicaid if placed in a Level C psychiatric residential treatment facility. This process of disenrollment and re-enrollment in Managed Care is coordinated through KEPRO and DMAS and does not require action by the LDSS.
Parents/placement providers will have two ID Cards for each child.Medicaid plastic ID card – received from DSS.MCO ID card – received from MCO.Both cards must be taken to appointmentsParents/CWs will need to choose the best MCO to ensure that their child’s provider(s) participate in the assigned MCO.For parents with questions about MCOs and providers can call the DMAS Managed Care Helpline – 1-800-643-2273
Foster Care/Adoption Assistance Transition to Virginia Medicaid Managed Care
www.dmas.virginia.gov 1Department of Medical Assistance ServicesFoster Care / Adoption AssistanceTransition to Virginia MedicaidManaged CareNational Institute forHealth Care ManagementApril 2013www.dmas.virginia.gov 1Department of Medical Assistance Services
www.dmas.virginia.gov 2Department of Medical Assistance ServicesThe Beginning…
www.dmas.virginia.gov 3Department of Medical Assistance ServicesRichmond Foster Care Pilot Program• The Richmond Foster Care Medicaid PilotProgram was developed in response to arequest from the City to provide morecoordinated care for children in fostercare.• The Virginia Department of MedicalAssistance Services (DMAS) receivedpermission from the federal governmentto move foster care children in the Cityinto managed care health plans.
www.dmas.virginia.gov 4Department of Medical Assistance ServicesAuthority for Pilot Program• In 2011, the Virginia General Assembly andthe Governor formally endorsed a pilotproject with the City of Richmond Departmentof Social Services to meet the health careneeds of children in foster care through themanaged care delivery system.• Item 297 MMMM1.b. of the 2011Appropriations Act required the Departmentto allow on a pilot basis, foster carechildren, under the custody of the City ofRichmond Department of Social Services, tobe enrolled in Medicaid managed care(Medallion II).
www.dmas.virginia.gov 5Department of Medical Assistance ServicesRichmond Foster Care Pilot Program• Workgroup developed of SMEs serving theRichmond area to make the transition assmooth as possible– 1 Department of Medical Assistance Services– 1 Department of Social Services– 120 Local Department of Social Services – alllocally driven– 6 Managed Care Organizations– Numerous Advocacy Groups– Numerous Child Placement Agencies
www.dmas.virginia.gov 6Department of Medical Assistance ServicesRichmond Foster Care Pilot Program• December 1, 2011 - Implementation– Foster care children under the custody of theCity of Richmond Department of SocialServices and who are not in residential care– Non-custodial children who are not inresidential care– Minor children of eligible foster care children– Excluded children receiving adoptionassistance
www.dmas.virginia.gov 7Department of Medical Assistance ServicesStatewide Transition• The Richmond Foster Care Pilot Programhas been successful.– Pilot program enhanced communicationbetween state and local agencies and themanaged care plans.– Pilot program enhanced communicationbetween local eligibility workers and caseworkers.– MMIS eligibility system has been cleaned up sothat children are correctly identified is systemas well as have correct addresses.
www.dmas.virginia.gov 8Department of Medical Assistance ServicesStatewide Transition• Virginia General Assembly and theGovernor approved for the managed carestatewide expansion of children in fostercare and receiving adoption assistance.• Virginia is implementing the statewidetransition this year in two phases.
www.dmas.virginia.gov 9Department of Medical Assistance ServicesWhy Managed Care?
www.dmas.virginia.gov 10Department of Medical Assistance ServicesManaged Care Enrollment• Statewide Medicaid Enrollmentfor children as of March 2013:–Managed Care 89%–Fee-for-Service 11%
www.dmas.virginia.gov 11Department of Medical Assistance ServicesAnticipated Improvements• Coordination of health care• Case management• 24 hour nurse hotline• Increased access to practitioners• Targeted services for chronic conditions• Better coordination• Choice of primary care providers
www.dmas.virginia.gov 12Department of Medical Assistance ServicesComparison of Member ServicesMedicaid Fee-For-Service(FFS)• Medicaid ID Card• Recipient helpline(not toll-free)• Member handbook• No co-payments for under 21Managed Care Organization(MCO)• MCO member IDcard, handbook, and providerdirectory• Toll-free member helpline• Access to free translation services/language telephone line• 24-hour nurse advice line• Access to assistance with medicalissues (case management)• Member outreach and healtheducation materials• Access to credentialed providers• No co-payments
www.dmas.virginia.gov 13Department of Medical Assistance ServicesMCO Carved Out Services• Community Mental HealthRehabilitative Services– Intensive In-Home Services forChildren and Adolescents– Therapeutic Day Treatment forChildren and Adolescents– Day Treatment/PartialHospitalization– Psychosocial Rehabilitation– Crisis Intervention– Intensive Community Treatment– Crisis Stabilization Services– Mental Health Support Services– Case Management– Level A & B Group Homes• Mental Retardation CommunityServices– Case Management Services• Private Duty Nursing for HCBSwaiver enrollees• Substance Abuse TreatmentServices– Substance Abuse Crisis Intervention– Substance Abuse Intensive Outpatient– Substance Abuse Day Treatment– Opioid Treatment– Substance Abuse Case Management• Dental (Smiles For Children)• School Health Services• Specialized Infant Formula forChildren Under Age 21• Health Department LeadInvestigations• Early Intervention Services• Personal Care services
www.dmas.virginia.gov 14Department of Medical Assistance ServicesVirginia Managed Care Partners• Anthem HealthKeepers Plus• Amerigroup• CoventryCares of Virginia• Optima Family Care• Virginia Premier Health Plan• MajestaCare
www.dmas.virginia.gov 15Department of Medical Assistance ServicesWho will be transitioning toManaged Care?
www.dmas.virginia.gov 16Department of Medical Assistance ServicesWho will move to Managed Care?• Effective July 1, 2013 for Central andTidewater managed care regions;– Children receiving Medicaid as part of AdoptionAssistance– Children placed in Foster Care who are not inLevel C residential care– Children in non-custodial placementagreements who are not in Level C residentialcare– Minor children of eligible foster care youth
www.dmas.virginia.gov 17Department of Medical Assistance ServicesWho is Excluded from MC Expansion?• Children who are hospitalized at time ofenrollment• Children placed in Level C residentialtreatment care• Children who are also covered under othercomprehensive insurance• Children in Medicaid home and communitybased waivers• FYI - July 1st expansion will only include thoseFC/AA children residing in a Central orTidewater locality– FC children must also be in the custody of a Centralor Tidewater LDSS or CPA
www.dmas.virginia.gov 18Department of Medical Assistance ServicesMC Expansion Timeline – Phase I• May 18, 2013 - MCO Pre-assignmentsoccur• First week of June 2013 - Pre-assignmentletters received by LDSS Case Worker(CW) for foster care or adoptive parent• June 18, 2013 – Last day for CW/adoptiveparent to request MCO change beforeassignment to MCO
www.dmas.virginia.gov 19Department of Medical Assistance ServicesMC Expansion Timeline – Phase I• June 18, 2013 - MCO assignmentprocessing occurs– MCOs mail ID card, handbook and providerdirectory to parents/placement providers• July 1, 2013 - MCO enrollment begins– Must go to doctor that is part of MCO network• Phase II – October 1, 2013– Will follow similar timeline beginning August2013.
www.dmas.virginia.gov 20Department of Medical Assistance ServicesChanging MCOs – Foster Care• Request for changes to MCO can occur atany time during the year– Foster care parents/placement providers mustcontact the Case Worker at the LDSS or CPA torequest an MCO change– Only the Case Worker is authorized to contactthe Managed Care Helpline to request thechange• Foster care parents/placement providerscannot make changes to the youth’s MCO
www.dmas.virginia.gov 21Department of Medical Assistance ServicesChanging MCOs – Adoption Assistance• Request for changes to MCO can occur atany time during the year– The Adoptive parent may contact the ManagedCare Helpline directly to request an MCOchange• Adoptive parent is responsible forrequesting MCO changes
www.dmas.virginia.gov 22Department of Medical Assistance ServicesLoss of Coverage• If Medicaid eligibility is cancelled, thechild’s MCO enrollment ends.• If Medicaid eligibility is regained within 60days, MCO reinstated on the first of thenext available month.• Child may be disenrolled from MCO butremain eligible for Medicaid if placed in aLevel C psychiatric residential treatmentfacility. The child will be re-enrolled inManaged Care once released.
www.dmas.virginia.gov 23Department of Medical Assistance ServicesImpact on Families/Providers
www.dmas.virginia.gov 24Department of Medical Assistance ServicesImpact on Families/Providers• Parents/placement providers will have twoID cards for each child.– Medicaid plastic ID card – received from LDSS.– MCO ID card – received from MCO.– Both cards must be taken to appointments.• Parents/CWs will need to choose the bestMCO to ensure that their child’sprovider(s) participate in the assignedMCO.
www.dmas.virginia.gov 25Department of Medical Assistance ServicesManaged Care Implementation• Systems Updates for Eligibility Records• Training and Communications• Transition/Continuity of Care• Rate Setting
www.dmas.virginia.gov 26Department of Medical Assistance ServicesManaged Care Experience• Seamless Integration with Membershipand Processes• Minimal Access and Care Management Issues• Preparation for 2013 Expansions
www.dmas.virginia.gov 27Department of Medical Assistance ServicesLessons Learned• Trainings critical among various agenciesinvolved (state agencies, localDSSs, managed care plans)• Cross training to educate DSS on managedcare, health plans on foster care/ adoptionassistance processes, etc.• Information infrastructure needs established• Including families/placement providers inprocess• Need for review of utilization data todetermine trends and special caremanagement needs
www.dmas.virginia.gov 28Department of Medical Assistance ServicesThank youAnthem HealthKeepers PlusKatina GoodwynProgram DirectorVirginia Dept. of Medical Assistance ServicesAshley Harrell, Acting ManagerMaternal and Child Health DivisionTammy WhitlockSenior Programs Advisor