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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Virginia – 8426-06 « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS


MOU Signed: May 21, 2013
3-way contract issued Dec. 4, 20131
Demonstration Duration: 3 years
April. 1, 2014 to Dec. 31, 20172
Target Group:
Includes:  an estimated 78,600 full benefit dual eligible beneficiaries age 21 and older in 104 localities grouped into 5 regions are eligible to enroll; PACE and Independence at Home enrollees may participate if they disenroll from their current program
Excludes:  dual eligible beneficiaries with other comprehensive coverage, those served in a state mental hospital, state hospital, ICF/DD, residential treatment facility or long stay hospital (nursing facility residents are included), § 1915(c) HCBS waiver participants (other than the Elderly or Disabled with Consumer Direction waiver), hospice patients, those with end stage renal disease at the time of demonstration enrollment, those on a Medicaid spend down, those who are eligible for Medicaid for less than 3 months, those whose only Medicaid eligibility is retroactive, and enrollees in the Virginia Birth-Related Neurological Injury Compensation Program or the Money Follows the Person Program
Geographic Area:
104 localities in 5 regions:3
-Central Virginia:  Amelia, Brunswick, Caroline, Charles City, Chesterfield, Cumberland, Dinwiddie, Essex, Goochland, Greensville, Hanover, Henrico, King and Queen, King George, King William, Lancaster, Lunenburg, Mecklenburg, Middlesex, New Kent, Northumberland, Nottoway, Powhatan, Prince Edward, Prince George, Richmond Co., Southampton, Spotsylvania, Stafford, Surry, Sussex, Westmoreland, Colonial Heights, Emporia, Franklin City, Fredericksburg, Hopewell, Petersburg, Richmond City
-Northern Virginia:  Arlington, Culpepper, Fairfax County, Fauquier, Loudoun, Prince William, Alexandria, Fairfax City, Falls Church, City of Manassas, Manassas Park
-Tidewater:  Accomack, Gloucester, Isle of Wight, James City County, Mathews, Northampton, York , Chesapeake, Hampton, Newport News, Norfolk, Poquoson, Portsmouth, Suffolk, Virginia Beach, Williamsburg
-Western/Charlottesville:  Albemarle, Augusta, Buckingham, Fluvanna, Greene, Louisa, Madison, Nelson, Orange, Rockingham, Charlottesville, Harrisonburg, Staunton, Waynesboro
-Roanoke:  Alleghany, Bath, Bedford County, Botetourt, Craig, Floyd, Franklin County, Giles, Henry, Highland, Montgomery, Patrick, Pulaski, Roanoke County, Rockbridge, Wythe, Bedford City, Buena Vista, Covington, Lexington, Martinsville, Radford, Roanoke City, Salem
Enrollment will be conducted in two phases.  Each phase will include an initial voluntary enrollment period, followed by passive enrollment in which the remaining beneficiaries in the target population will be automatically enrolled
In Phase I (Central VA and Tidewater), voluntary enrollment will be effective no sooner than April 2014 (as revised).4  Initial passive enrollment for remaining Phase I beneficiaries will be effective July 2014.5  The dates for advance notice have not been updated since CMS and the state decided to delay enrollment.  Phase II (Western/Charlottesville, Northern VA, and Roanoke) also will have voluntary and passive enrollment periods, but the dates have not been updated to reflect the delay subsequent to the MOU.  Beneficiaries subject to Medicare drug plan reassignment effective January 2014 will not be passively enrolled in 2014.
Beneficiaries may opt of the demonstration prior to passive enrollment and thereafter on a monthly basisVirginia’s § 1932(a) state plan amendment has been approved by CMS and provides for voluntary enrollment in Medicaid managed care.6  The state also must amend its § 1915(c) waivers affected by the demonstration in the next update or scheduled renewal, whichever is sooner
Passive enrollment intelligent assignment will prioritize the following:  (1) beneficiaries in NFs will be assigned to a plan with that NF in-network; (2) beneficiaries in HCBS waiver will be assigned to plan that includes current adult day health care provider in-network; (3) if more than one plan includes NF or adult day health care provider, assignment to the plan in which beneficiary has been assigned in the last 6 months; (4) other beneficiaries will be assigned to a plan to which they have been assigned in the last 6 months
Financing: Capitated with savings percentage (1% in year one, 2% in year two, 4% in year three) applied upfront to baseline Medicare and Medicaid contributions, except that savings in year three will be reduced to 3% if 1/3 of plans experience losses exceeding 3% of revenue in all regions in which those plans participate in year one based on at least 20 months of data;7 capitation rate quality withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)
Medicare baseline for capitated payments: Same as California8
Medicare risk adjustment: Same as California
Medicaid baseline for capitated payments: Historical state spending for state plan and HCBS waiver services trended forward
Medicaid risk adjustment: Rating categories with financial incentives for HCBS over institutional care9 and member enrollment mix adjustment to account for plans with greater proportion of high risk/high cost beneficiaries and to account for the relative risk/cost differences of major sub-populations (e.g. nursing facility residents and beneficiaries receiving HCBS)
Risk sharing: Required minimum medical loss ratio of 90%
Care Delivery Model: Commonwealth Coordinated Care plans will provide care management services to coordinate medical, behavioral health, substance use, LTSS, and social needs
Participating Health Plans: Humana Health Plan, VA Premier Health Plan, HealthKeepers
Benefits: Includes all Medicare and Medicaid state plan services and Elderly or Disabled with Consumer Direction § 1915 home and community-based waiver services except Medicaid targeted case management services and case management services for beneficiaries in assisted living (hospice patients are excluded from the demonstration target population); in limited cases, dental services will be carved out of the demonstration; plans have discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of Care: Beneficiaries retain access to current providers for 180 days from demonstration enrollment; beneficiaries retain access to services in existing plans of care and prior authorizations until authorizations expire or 180 days from demonstration enrollment, whichever is sooner, except that beneficiaries in nursing facilities at the time of demonstration implementation may remain as long as they continue to meet level of care criteria, unless they prefer to move to another facility or the community
Ombuds Program: Virginia intends to support an independent ombuds outside of the state Medicaid agency to advocate and investigate on behalf of demonstration enrollees, safeguard due process, identify systemic problems, and gather and report data.  Virginia has been awarded CMS funding to support its ombuds program.10
Stakeholder Engagement: Plans must establish an independent beneficiary advisory committee that provides input to the governing board and includes beneficiaries with disabilities in the plan governance structure
Notice:  same as California (single integrated notice)
Timeframe to request initial appeal:  same as Illinois (60 days)
Internal health plan appeal:  same as Illinois (initial appeal must be filed with health plan) except that appeals are to be resolved in 30 days (standard) or 72 hours (expedited)
External Medicare appeals:  same as California
External Medicaid appeals:  beneficiary may request fair hearing within 60 days of plan appeal decision; to be resolved within 90 days of hearing request in year 1, 75 days in year 2, and 30 days in year 3
Appeals where Medicare and Medicaid services overlap:  to be defined in 3-way contract; will automatically be sent to IRE, and beneficiary also may request fair hearing; plan to be bound by decision most favorable to beneficiary
Continued benefits pending appeal:  same as Massachusetts (health plans must provide continuing benefits for all prior approved Medicare Parts A and B and Medicaid services while health plan appeals are pending;  beneficiaries may request continuation of previously authorized services for Medicaid appeals while fair hearings are pending
Medicare Part D:  same as California (existing Medicare Part D appeals process continues to apply)
Texas Washington (managed FFS model)