Early Insights from Commonwealth Coordinated Care: Virginia’s Demonstration to Integrate Care and Align Financing for Dual Eligible Beneficiaries
Issue Brief
The five regions where the CCC program is operating are Central Virginia (including Richmond), Tidewater, Northern Virginia, Western/Charlottesville, and the area near Roanoke. Some counties and cities in southwestern and south central parts of the state are excluded from CCC.
Virginia does offer the PACE program (Program of All-inclusive Care for the Elderly) option for a limited number of beneficiaries. PACE is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.
Virginia Department of Medical Assistance Services, presentation by Karen E. Kimsey to the National Health Policy Forum, Improving Care for Medicare-Medicaid Enrollees, Virginia’s Financial Alignment Demonstration, December 6, 2013. Available at: http://www.nhpf.org/uploads/Handouts/Kimsey-slides_12-06-13.pdf. In its October 2014 enrollment report, DMAS reports a modestly lower count (75,300) of eligible beneficiaries.
The Medicaid EDCD Waiver program provides services that help individuals live in their own home or community instead of a nursing home. It is available to individuals 65 years of age and older, and to individuals of any age who have a disability. Individuals who depend on another person for their supports and have medical or nursing needs may be eligible for the EDCD Waiver. The EDCD Waiver offers services such as: adult day health care, agency and consumer-directed personal care, personal emergency response system, agency and consumer-directed respite care, and medication monitoring.
Excluded from the CCC program include those receiving hospice care, individuals with end-stage renal disease, those in home and community-based waiver programs other than EDCD, those in other programs (PACE, Money Follows the Person, Independence at Home), those in state mental hospitals or ICF/DDs, those under age 21, and those eligible for Medicaid for less than three months or based only on spend-down.
The Virginia Department of Aging and Rehabilitative Services (DARS) administers VICAP.
Letters are on the CCC website. The initial welcome and opt-in notice can be found at http://www.dmas.virginia.gov/Content_atchs/altc/mmfa-imme5.pdf. The 60-day passive enrollment notice is at http://www.dmas.virginia.gov/Content_atchs/altc/60DayLetterBeneficiaries.pdf.
Automatic enrollment was delayed one month in Central and Northern Virginia to give plans more time to get established and expand and diversify provider networks.
Automatic enrollment was delayed one month in Central and Northern Virginia to give plans more time to get established and expand and diversify provider networks.
An initial programming glitch caused confusion because the system matched first based on nursing facility residence rather than on current enrollment in a Medicare Advantage plan.
According to DMAS, about 12 percent of those originally estimated to be eligible had lost CCC eligibility because they lost Medicaid eligibility, moved out of the demonstration area, participate in some other exempt program, or are in an exempt facility. These beneficiaries are excluded from the numbers presented in this report.
By late October 2014, two localities in the Western/Charlottesville region and seven in the Northern Virginia region had only one approved MMP. Three localities in Northern Virginia had two plans available and started automatic enrollment in November 2014.
This group is known as “PDP Exclusion Members.” They are Medicare beneficiaries eligible for Part D’s Low-Income Subsidy (LIS) who are assigned to a plan by CMS if they do not select one on their own. In subsequent years, some LIS beneficiaries are reassigned by CMS to a new plan to ensure that they are in a premium-free plan. These reassignments are normally effective in January, so CMS opted to defer assignments to a CCC plan until January 2015 in order to avoid two changes in beneficiaries’ drug coverage within a single year.
Cindi B. Jones, “Estimates of Medicaid Reform Costs and Savings,” presentation to the Medicaid Innovation and Reform Commission, October 21, 2013. http://mirc.virginia.gov/documents/10-21-13/102113_No5_Jones_MIRC.pdf.
These rates are similar to those in Massachusetts, as of November 1, 2014 (27 percent overall and 37 percent in counties with automatic enrollment). Calculated from http://www.mass.gov/eohhs/docs/masshealth/onecare/enrollment-reports/enrollment-report-november2014.pdf.
Data for the period from June 14, 2014 to September 20, 2014 from: Virginia Department of Medical Assistance Services, presentation by Fuwei Guo to the Commonwealth Coordinated Care Advisory Committee, Examples of CCC Data Analytics, October 22, 2014. Available at: http://www.dmas.virginia.gov/Content_atchs/altc/October%2022%202014%20Duals%20Meeting%20Materials.pdf.
Data for the period from June 14, 2014 to September 20, 2014 from: Virginia Department of Medical Assistance Services, presentation by Fuwei Guo to the Commonwealth Coordinated Care Advisory Committee, Examples of CCC Data Analytics, October 22, 2014. Available at: http://www.dmas.virginia.gov/Content_atchs/altc/October%2022%202014%20Duals%20Meeting%20Materials.pdf.
According to 2010 data, 0.7 percent of Virginia duals were in Medicare Advantage Special Needs Plans for dually eligible beneficiaries (dual SNPs), and 0.3 percent were in PACE plans. No duals were in comprehensive Medicaid managed care plans. Marsha R. Gold, Gretchen A. Jacobson, and Rachel L. Garfield, “There is Little Experience and Limited Data to Support Policy Making on Integrated Care for Dual Eligibles,” Health Affairs 31(6):1176-1185, June 2012.
Networks were approved for a second plan in six additional cities and counties in early 2015. Beneficiaries not yet enrolled or opted out in those localities received their passive enrollment letters by May 1, 2015, with their coverage effective on July 1, 2015. As of April 2015, there were still nine cities or counties without two approved plans where passive enrollment is not authorized.
See Contract Between United States Department of Health and Human Services Centers for Medicare & Medicaid Services In Partnership with The Commonwealth of Virginia Department of Medical Assistance Services and (Health Plans) Issued: December 4, 2013. Section 2.7.5. Available at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/VirginiaContract.pdf.
Vulnerable subpopulations include: Individuals enrolled in the EDCD Waiver; Individuals with intellectual/developmental disabilities; Individuals with cognitive or memory problems (e.g., dementia or traumatic brain injury); Individuals with physical or sensory disabilities; Individuals residing in nursing facilities; Individuals with serious and persistent mental illnesses; Individuals with end stage renal disease; and, Individuals with complex or multiple chronic conditions. See Contract Between United States Department of Health and Human Services Centers for Medicare & Medicaid Services In Partnership with The Commonwealth of Virginia Department of Medical Assistance Services and (Health Plans) Issued: December 4, 2013. Section 2.7.2.3. Available at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/VirginiaContract.pdf.
See Contract Between United States Department of Health and Human Services Centers for Medicare & Medicaid Services In Partnership with The Commonwealth of Virginia Department of Medical Assistance Services and (Health Plans) Issued: December 4, 2013. Section 2.7.5. Available at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/VirginiaContract.pdf.
These policies are similar to those in other states, though more comprehensive than some in terms of making provisions for enrollees if they change plans, and for allowing enrollees to remain in any nursing facility. The period for maintaining current providers generally ranges from 90 to 180 days in other demonstrations, though some allow certain groups of enrollees – such as those receiving home and community-based LTSS – to maintain current providers for up to one year.
Virginia Department of Medical Assistance Services, presentation by Tammy Whitlock to the Commonwealth Coordinated Care Advisory Committee, Virginia Update, July 17, 2012. Available at: http://www.dmas.virginia.gov/Content_atchs/altc/October%2022%202014%20Duals%20Meeting%20Materials.pdf.
The Ombudsman Office is located in the Department of Aging and Rehabilitative Services.
Virginia Department for Aging and Rehabilitative Services, presentation by Susan Johnson to the Commonwealth Coordinated Care Advisory Committee, Ombudsman Program Update, October 22, 2014. Available at: http://www.dmas.virginia.gov/Content_atchs/altc/October%2022%202014%20Duals%20Meeting%20Materials.pdf.
Virginia Department of Medical Assistance Services, presentation by Gerald A. Craver to the Commonwealth Coordinated Care Advisory Committee, Program Evaluation Update, October 22, 2014. Available at: http://www.dmas.virginia.gov/Content_atchs/altc/October%2022%202014%20Duals%20Meeting%20Materials.pdf.
Cindi B. Jones, “Estimates of Medicaid Reform Costs and Savings,” presentation to the Medicaid Innovation and Reform Commission, October 21, 2013. http://mirc.virginia.gov/documents/10-21-13/102113_No5_Jones_MIRC.pdf. Reductions in federal funds are based on Virginia’s 50 percent Federal Medical Assistance Percentage (FMAP).
“Commonwealth Coordinated Care CY 2014 Rate Report,” November 25, 2013. http://www.dmas.virginia.gov/Content_atchs/altc/cntct-mmfa_cr1.pdf.
A further adjustment is made to reflect the split of “nursing home eligible” beneficiaries between those in nursing facilities and those in the community at the time of enrollment into each plan. Because care in a facility is more costly, this adjustment ensures that a plan is not penalized if more of its passive enrollees or fewer of those opting out are in facilities at the time of enrollment.
There is a lagged adjustment in payment rate amounts reflecting each plan’s mix of nursing home eligible enrollees in nursing facilities versus the community. The intent is to maintain an incentive to keep nursing eligible enrollees in the community while capturing some savings for the state.