Fact Sheets

CMS and Virginia Partner to Coordinate Care for Medicare-Medicaid Enrollees

CMS and Virginia Partner to Coordinate Care for Medicare-Medicaid Enrollees

Overview
On May 21, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that the Commonwealth of Virginia will partner with CMS to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.  

Under the Demonstration, Virginia and CMS will contract with Medicare-Medicaid Plans to coordinate the delivery of and be accountable for covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.

Medicare-Medicaid Enrollees
Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligible individuals” – is a priority for CMS.  Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (Medicare Parts A and B, Part D, and Medicaid).  

Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health and long-term supports and services.  

The Financial Alignment Initiative – Partnerships to Provide Better Care
The new Demonstration seeks to provide Medicare-Medicaid enrollees with a better care experience by evaluating a person-centered, integrated care program that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services.  

In July 2011, CMS announced this opportunity for states and CMS to better coordinate care for Medicare-Medicaid enrollees.  Under the Demonstration, CMS will evaluate the effectiveness of two models:

1. Managed Fee-for-Service Model in which a state and CMS enter into an agreement by which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid; and   
2. Capitated Model in which a state and CMS contract with health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.

Virginia is the sixth state to enter a Memorandum of Understanding (MOU) with CMS to participate in the Demonstration.  CMS continues to work with other states to develop their Demonstration models.  All Demonstrations will be evaluated to assess their impact on the beneficiary’s care experience, quality, coordination, and costs.

The Virginia Demonstration
Virginia has long supported Program of All-Inclusive Care for the Elderly (PACE) sites within the state, and the Commonwealth is now expanding and improving upon these efforts to reach the broader population of Medicare-Medicaid enrollees that have had limited access to the benefits of care coordination to date.

Under this capitated model demonstration, an estimated 78,600 Medicare-Medicaid enrollees in Virginia will have an opportunity for better, more coordinated care.  Virginia and CMS will contract with Medicare-Medicaid Plans (MMPs) that will oversee and be accountable for the delivery of covered Medicare and Medicaid services for Medicare-Medicaid enrollees in 104 localities covering five regions: Central Virginia, Northern Virginia, Western Virginia, Southwest Virginia, and the Tidewater region.

Under the Demonstration, MMPs will be responsible for providing a comprehensive assessment of Medicare-Medicaid enrollees’ medical, behavioral health, long-term services and supports, functional, and social needs.  Medicare-Medicaid enrollees and their caregivers will work with an interdisciplinary care team to develop person-centered, individualized care plans. The Demonstration is designed to offer opportunities for beneficiaries to self-direct services, be involved in care planning, and live independently in the community.

The new Demonstration includes beneficiary protections that will ensure that enrollees receive high-quality care.  CMS and Virginia have established a number of quality measures relating to the beneficiary overall experience, care coordination, and fostering and supporting community living, among many others.  In addition, the Demonstration includes robust continuity of care requirements to ensure that beneficiaries can continue to see their current providers (including those at community health centers) during transitions into the Demonstration health plan.  Ombudsman services will support individual advocacy and independent systematic oversight for the Demonstration, with a focus on compliance with principles of community integration, independent living, and person-centered care.  

All participating plans must first meet core Medicare and Medicaid requirements, state procurements standards and state insurance rules (as applicable).  Every selected MMP must also pass a comprehensive joint CMS-state readiness review.  

Putting the Beneficiary First
Under the Demonstration, care coordination services will be available to all enrollees. MMPs will offer an interdisciplinary care team to ensure the integration of the member’s medical, behavioral health, long term services and supports, and social needs.  The team will be person-centered: built on the enrollee’s specific preferences and needs.

Enrollment will be phased in by region over the next eight months. Beneficiaries residing in the first regions to be phased in (Central Virginia and Tidewater) will be able to opt-in to the new program beginning in February 2014.  Eligible beneficiaries who have not made a choice to opt in or out will be assigned to an MMP through a process that will match beneficiaries with the most appropriate plan for the individual’s health needs.  Beneficiaries will be able to opt-out of the Demonstration or select an alternative MMP plan at any time.

Comprehensive Evaluation
CMS is funding and managing the evaluation of each state Demonstration.  CMS has contracted with an external independent evaluator, RTI International, to measure, monitor, and evaluate the impact of the Demonstrations, including impacts on Medicare and Medicaid service utilization and expenditures.  The evaluation for Virginia’s Demonstration will measure quality, including overall beneficiary experience of care, care coordination, care transitions, and support of community living in Virginia. RTI will develop a unique, Virginia-specific evaluation using a comparison group to analyze the impact of the Demonstration.  

A Transparent Process Supporting Public Input

The Virginia Demonstration is the product of an ongoing planning and development process through which the public helped shape the Demonstration’s design.  Virginia:

• Worked with a diverse group of stakeholders including providers, health plans, nursing facilities, hospitals, state agencies, advocacy groups, associations, and individuals.
• Partnered with CMS to engage with local partners to ensure a broad range of perspectives were captured in the overall Demonstration.
• Hosted numerous public forums to solicit public involvement including statewide calls and public meetings.
• Established public workgroups with external stakeholders to inform Demonstration development and policy.
• Created and maintained a website to facilitate public participation in the Demonstration design and planning process: http://www.dmas.virginia.gov/Content_pgs/altc-enrl.aspx
• Posted its draft proposal for public comment and incorporated the feedback into its Demonstration proposal before officially submitting it to CMS. The proposal was then posted by CMS for public comment.

Additional Information
The Demonstrations will be administered under the Center for Medicare & Medicaid Innovation authority.  Additional information about the Virginia Demonstration, including the MOU, is publicly available at: www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html

Additional information on the ongoing development and implementation of the Virginia Demonstration is available at http://www.dmas.virginia.gov/Content_pgs/altc-enrl.aspx.