virginia medicaid
TRANSCRIPT
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
7
• 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
8
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
9
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
10
Medicaid as a Percent of Total State Expenditures
11
SOURCE: National Association of State Budget Officers. The Washington Post. Published on June 14, 2011, 7:13 p.m.
Virginia’s Current Medicaid Program
12
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?
13
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)
14
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
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).
17
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
19
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
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.
21
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)
23
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)
24
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
Status of Phase 2 Reforms Title Progress Timeline/Target Date
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
26
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
27
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
Medicare-
Medicaid (Duals)
Coordinated
Care, including
children
July 2018
28
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)
29
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
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
31
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
33
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
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
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 high-performance (Phase 2 Reforms Included) Future Options:
•Premium assistance (similar to capitated payment) •Health Savings Accounts
36
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 • Wellness incentives for all
37