Acute and LongTerm Care ALTC Integration

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Acute and Long-Term Care (ALTC) Integration

• MCO Meeting 3
• Hot Topics
• October 10, 2007
• ALTCMCO_at_dmas.virginia.gov

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Meeting Overview

• Hot Topics Meeting
• Enrollment Overview
• Patient Pay for Waiver services
• Role of the Consumer Direction Fiscal Agent
• Medicaid Responsibility for Dual Eligibles
• 10 Minute QAs and Discussion Between Each
  Presentation

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Enrollment

• Suzanne Gore,
• Integrated Care Program Manager

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Dual Eligibles Included in ALTC
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Full Benefit Dual (a.k.a. QMB-Plus)

• Participants who are fully eligible for both
  Medicare and Medicaid.
• Included in the Virginia Administrative Code as
  Qualified Medicare Beneficiaries (QMB) Plus.
• This program will not include individuals who are
  required to spend down income in order to
  Medicaid eligibility requirements.

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Full Benefit Dual (a.k.a. QMB-Plus)

• This program will also not include non full
  benefit dual eligibles such as
• Qualified Medicare Beneficiaries (QMBs),
• Special Low Income Medicare Beneficiaries
  (SLMBs),
• Qualified Disabled Working Individuals (QDWIs),
  or
• Qualified Individuals (QI).
• These are individuals for whom DMAS only pays a
  limited amount each month toward their cost of
  care (e.g., deductibles).

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What does Virginia Medicaid pay for Full Benefit
Dual Eligibles?

• Dual eligibles may receive Medicaid coverage for
  the following
• Medicare monthly premiums for Part A, Part B, or
  both.
• Coinsurance, copayment, and deductible for
  Medicare-allowed services.
• Medicaid-covered services, even those that are
  not allowed by Medicare.
• DMAS is currently completing a rigorous analysis
  of claims paid for dual eligibles.

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Elderly or Disabled with Consumer Direction
(EDCD)

• Home and Community-Based
• Long-Term Care

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Elderly or Disabled with Consumer Direction
(EDCD) Wavier Participants

• Must be determined eligible for the EDCD waiver
  by the participants local department of social
  services.
• Must meet nursing facility criteria and income
  and resource requirements.
• Participants receive Medicaid primary and acute
  care services along with home and community-based
  long-term care services.

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EDCD Waiver Services Included in ALTC

• Adult Day Health Care
• Personal Emergency Response System
• Personal Care (Provided by an agency or consumer
  directed)
• Respite Care (Provided by an agency or consumer
  directed)
• Service Facilitation (to assist individuals who
  wish to consumer direct services)
• Assistive Technology
• Environmental Modifications
• Provider Manual available on the web
  http//websrvr.dmas.virginia.gov/manuals/edcd/edcd
  .htm

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Combo Participants Dual Eligible/EDCD Waiver
Enrollee

• Some individuals are eligible for both Medicare
  and the EDCD waiver.
• These individuals
• will receive a combined
• service package.

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How will a participant become enrolled in ALTC?
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Population Summary (10/04/07)
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Enrollment

• Mandatory enrollment in to Medicaid MCO with
  option to change plans within 90 days.
• Medicare Advantage/Special Needs Plan enrollment
  is voluntary DMAS cannot mandate enrollment.
• Limited good-cause opt-out (to fee-for-service)
  provisions for existing EDCD participants who
  transition to ALTC MCO. Still in draft form, but
  may be allowed only if
• Approved by Disenrollment Review Panel
• If no long-term care or specialty provider
  available within geographic contractual
  standards or
• If severing an existing long-term care provider
  relationship would cause undue hardship on the
  participant.

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Enrollment, continued

• Developing protocol to pre-assign participants to
  MA/SNP if they are already enrolled in one.
• MA/SNP plans will be encouraged to market to
  Medicaid enrollees (based on Medicare
  guidelines).
• DMAS has no existing plans to match existing Part
  D enrollees with ALTC MCO pre-assignment.
  Possible issue to consider.

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Questions on Enrollment?

• Cheryl Roberts

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Post Eligibility Treatment of Income Patient Pay

• Elderly or Disabled with Consumer Direction
  (EDCD) Waiver
• Karen Packer, Senior Policy Analyst

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Patient Pay

• Federal Regulation
• State Option
• Process
• Example
• Communication

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Federal Regulation

• 42 CFR 435.726 Post-eligibility treatment of
  income of individuals receiving home and
  community-based services furnished under a
  waiver Application of patient income to the cost
  of care.

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Federal Regulation 42 CFR 435.726

• The agency (Medicaid) must reduce its payment for
  home and community-based services provided to an
  individual by all that remains after deducting
  the following amounts, in the following order,
  from the individuals total income

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Federal Regulation 42 CFR 435.726

• Maintenance needs that the state may set
  personal maintenance allowance
• Allowance for spouse
• Allowance for dependent family members
• Incurred non-covered medical expenses
• Medicare and health insurance premiums,
  deductibles, or copays
• Necessary medical care not covered by Medicaid

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State Option

• The state may set amount for personal maintenance
• In 2006, Virginia increased basic personal
  maintenance allowance from 100 SSI payment
  (currently 623) to 165 SSI payment (currently
  1028).
• Special earning allowance amount depends on
  number of hours employed.
• Guardian fees, if any, up to 5 of monthly
  income.
• Personal maintenance allowance cannot exceed 300
  SSI (1,869).

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Process

• Screener sends DMAS-96 verifying level of care
  for EDCD waiver is met to local department of
  social services and service provider.
• Service provider sends DMAS-122 verifying begin
  date of services to local department of social
  services.
• Local department of social services sends
  DMAS-122 to service provider verifying
  eligibility and the amount of patient pay.

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Example- Process

• October 1, 2007 Individual applies for
  Medicaid and is screened for EDCD waiver services
  
• October 20, 2007 Screener sends copy of DMAS-96
  to local department of social services and to
  service provider
• October 24, 2007 Local department of social
  services determines eligibility using LTC rules
• If eligible, patient pay is calculated by
  subtracting personal maintenance allowance,
  spousal allowance, dependent family allowance,
  and non-covered medical expenses from
  individual's gross income. Remainder is patient
  pay.
• October 31, 2007 Worker enrolls individual in
  MMIS, and sends notice of approval and patient
  pay obligation to individual and completed
  DMAS-122 to provider

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Example- Calculation

• 1500 Gross Income
• - 1028 Personal Maintenance Allowance
• - 300 Health Insurance Premium
• 170 Patient Pay Amount
• Participant pays patient pay amount to provider
  with the most billable hours.

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Communication

• Communication is critical
• Applicant
• Screener
• Local department of
• social services
• Service provider

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Patient Pay - ALTC Options and MCO Questions

• Cheryl Roberts

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Patient Pay Personal Maintenance Allowance
(PMA) for waiver services

• Option 1 Maintain status quo
• Provider providing majority of services collects
  the PMA from participant.
• MCO reduces amount paid to provider by the PMA.
• Option 2 Allow MCO to collect patient pay
  however they choose
• Directly from the participant or through the
  provider.
• Option 3 Increase rate to 300 SSI
• DMAS is looking into raising the PMA to 300 of
  SSI and this may remove this issue entirely.

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Consumer Direction Role of the Fiscal
Intermediary

• Paula Van Meter, Contract Monitor

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Consumer-Directed Services

• Medicaid recipient, enrolled in a Medicaid waiver
  may employ their own attendant to meet their
  personal care, respite care or attendant care
  needs.
• DMAS pays wages to attendant through contract
  with Public Partnerships, LLC (PPL).
• In September 2007, 3078 Medicaid recipients
  received consumer-directed services.
• Wages for attendants are 11.14 for Northern
  Virginia and 8.60 for the rest of the state.

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Public Partnerships, LLC (PPL)

• What do they do?

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Definitions Glossary

• Consumer Medicaid Recipient Medicaid Enrollee
  Employer
• Provider Attendant Employee
• If a consumer is unable to direct their own care
  and be their own employer, someone else may be
  the Employer Employer of Record

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What does PPL do as a fiscal intermediary for the
Medicaid Recipient?

• Act on their behalf to
• process all payroll documentation
• make any necessary payments
• represent the employer/employee when necessary
  (i.e. answer questions about payroll taxes,
  attend unemployment hearings)
• retire accounts when no longer in
  consumer-directed services
• With the following entities
• Internal Revenue Service
• Virginia Department of Taxation
• Virginia Employment Commission

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what else?

• Obtain and retire the Federal Employer
  Identification Number.
• Collect and process all enrollment paperwork,
  such as I-9, Verification of Employment.
• Process criminal history checks and central
  registry checks to assure attendant meets
  Virginia regulations, notify recipient of failure
  to pass check.
• Process all timesheets for attendants within
  authorized service amounts.

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there is more

• Edit timesheets for overlapping days, times and
  services
• Pay attendants via check or direct deposit
• Process any payroll deductions (liens,
  garnishment summons, patient pay, etc)
• Complete employment verifications
• Answer customer service calls
• Keep up with all state and federal forms and laws
• Etc, etc

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What does PPL do as a fiscal intermediary for
DMAS?

• Ensure the Medicaid Recipients needs are met as
  described above
• Process authorization files received from DMAS
• Ensure attendants enrolled meet Virginia
  Administrative Code (VAC) requirements, such as
  over 18 years old
• Process all criminal history checks with Virginia
  State Police to assure compliance with VAC
  requirements (Central Registry checks are
  completed with Dept. of Social Services.)
• And more

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Consumer Direction

• Cheryl Roberts
• Role of PPL in the ALTC Program
• Questions?

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Consumer Direction (CD)

• DMAS would like to maintain PPL as fiscal
  intermediary for all CD services.
• But also give the MCOs the ability to coordinate,
  authorize, and review consumer directed services.
• There is opportunity for expanded efficiency,
  quality, and oversight in CD services.

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Proposed Breakdown of CD Services

• Medical Services
• (MCO)
• MCO responsible for authorization and oversight
  of CD services
• Reviews approved services and role as an
  employer with participant (currently provided
  by service facilitators)
• Reimburses for CD attendant services (for
  personal care and respite) via invoice from PPL.
• CD attendant and service facilitation services
  included under capitation rate

• Administrative Service
• (DMAS)
• DMAS pays PPL administrative PMPM
• PPL Provides
• Payroll Set-up
• Payroll Processing
• Filing of Tax and Social Security Contributions
• Assists participants with Forms
• Sends claim information to MCO

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Coverage for Medicare Beneficiaries

• Dan Sullivan, Systems Analyst

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Types of Medicare Coverage

• Fee-for-service
• Medicare Advantage (MA) Plan
• Special Needs Plan

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Whats Covered?

• Medicare premiums (will most likely be paid by
  DMAS)
• Coinsurance and deductible
• Copayment for enrollees in a Medicare HMO
• Medicaid covered services not covered by Medicare
• Medicaid is the payer of last resort

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Medicaids Reimbursement of Medicare Claims

• Total payment not to exceed Medicaid allowed
  amount.
• Will pay for coinsurance and deductible up to
  Medicaid allowed less other payments.
• Medicaid liability can be 0 claim is denied.

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Crossover Claim Example
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Pharmacy Benefits

• No Crossover claims for pharmacy claims.
• Part D coverage established for FFS claims
• If Part D covered, claim is denied
• If not covered by Part D, paid

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Dual Eligibles.Questions?

• Cheryl Roberts

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Wrap-up

• Please submit questions, comments, or suggestions
  by Friday, October 12 to ALTCMCO_at_dmas.virginia.gov
  .
• Next meeting October 31 from 1-3 p.m.
• Thank you!