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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Potential Virginia Model: Private
Option for Low-Income Adults
Eligible
Adults
Entry into
Private
Market
Health
Plan
Accountability
Commercial
Benefits
33

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. 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. 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. 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