DMAS Reveals Managed Care Plans

VHCA (8/24/2007)

On August 20th, the Virginia Department of Medical Assistance Services (DMAS) held a pubic meeting to share their plan for implementing Medicaid managed care for populations now receiving long term care services under fee-for-services arrangements.  Senior DMAS staff described their Regional Model which could range from a capitated payment system for Medicaid (potentially integrating Medicare funding) for acute care costs with care coordination for long term care services, to a fully capitated system for all acute and long term care services. 

Phase I of the Regional Model to be implemented September 1st calls for mandatory managed care for acute care needs only, currently 49,000 low income seniors and individuals with disabilities (aged, blind, and disabled) with no Medicare and with no long term care services.  This phase will not include services provided to nursing facility residents.

DMAS is currently planning for Phase II of the Regional Model to be rolled out on a geographic basis, one area at a time (every six months) until statewide.  Initial areas to be folded into the plan are Tidewater (13 cities and counties) beginning August 2008, and Richmond (12 cities and counties) beginning January 2009.  According to Cindi Jones, Chief Deputy Director at DMAS, Tidewater and Richmond were selected as the first pilot areas because of their strong health systems, competitive atmosphere, urban environment, and size of their Medicaid populations. 

At the end of Phase II, the goal is to have more than 200,000 low income seniors and persons with disabilities (known as the aged, blind, and disabled) in some form of Medicaid managed care for their acute care needs only and/or long term care needs.  The initial wave of the roll-out for populations in the geographic areas will include both Medicaid only and Medicaid and Medicare (dual eligibles) and nursing facility residents (new admissions only).

The initial waves in Tidewater and Richmond will provide integrated managed care for acute care and long term care services (when needed) to 36,710 new clients including 2,310 new nursing facility residents.  Care provided to these residents will be subject to oversight from the individual’s managed care organization (MCO) for a period of time after admission.  According to DMAS, this allows the MCO an opportunity to move the client back home with community based care services, if appropriate.  Of interest to both VHCA and our members is the fact that the time frame suggested during the August 20th meeting of 120-180 days is significantly longer than time frames previously mentioned.  This issue will be one of the key items discussed in early September as VHCA meets formally with DMAS to share questions and concerns related to the plans outlined for the Regional Model.

DMAS indicates that to have truly integrated acute and long term care services, both the Medicaid and Medicare funding (through a Medicare Advantage Plan or a Special Needs Plan) need to be combined within the administration of one Managed Care Organization.  However, due to the timing of federal requirements for Special Needs Plans (or SNPs), DMAS will need to start the initial wave with a Medicaid only integrated model for acute and long term care services.

The Request for Proposals for the Integrated Managed Care Program, to be sent later this year to potential MCOs, will require that all participating health plans be classified as a Medicare Advantage and/or SNP or are working/applied for the classification.

From the initial discussions with DMAS late last year related to their acute and long term care integration plan, the association has struggled to understand what benefit the Department contemplates for overlaying managed care on top of the current system of providing and funding long term care services.  Now, nearly ten months later, this key question remains unanswered.  In addition to this critical issue, VHCA has indicated to DMAS that the profession can not support this plan until a number of key questions are answered to our satisfaction.  In late June, DMAS provided partial responses to our questions.  Generally, the responses provided by DMAS fail to persuade us that Medicaid managed care for long term care is in the best interest of either our Medicaid residents or the providers that deliver care to them.  To review both the questions and the DMAS responses please visit the VHCA website.

For Medicaid beneficiaries receiving care outside of nursing facilities, DMAS sights care coordination through intensive care management for long term care service clients with a 24-hour/7 days a week access line and disease management (if applicable).  DMAS believes that once the Medicare Advantage Plans or SNPS are in place, the Medicare/Medicaid clients will have coordinated Medicare services also.  These plans may add enhanced services, such as dental care, vision, and hearing.

Also discussed during the August 20th meeting was the fact that Medicaid managed acute and long term care enrollment will be mandatory with opt-out provisions (first 90 days, annual enrollment period, or if meet established good cause).  Medicare managed acute and long term care (Special Needs Plans or Medicare Advantage Plans) enrollment is voluntary and based on Medicare rules.  In order to reduce disruption of care, DMAS will be developing the capability to ensure that the Medicaid and the Medicare plans are the same MCO.

VHCA will continue to meet with DMAS and monitor all discussions taking place related to the development of the Regional Models.  All updates and new information will be provided electronically to members as it becomes available.  To view a copy of the slides used by DMAS during the August 20th meeting go to the VHCA website.