The Integration of Acute and Long Term Care Services: Health Plan Requirements Presentation to Manag

1
The Integration of Acute and Long Term Care
Services Health Plan RequirementsPresentation
to Managed Care Organizations
Department of Medical Assistance
Services September 10, 2007 Cheryl Roberts,
Deputy Director Program Operations
2
Introduction

• DMAS is recruiting health plan partners for the
  Integration of Acute and Long Term Care (ALTC)
  Program
• Our goal is to procure 2 or more health plans for
  
• Tidewater in Fall 2007 for a summer 2008
  implementation and
• Richmond in Spring 2008 for a winter 2009
  implementation
• While the scope of work has not been completed,
  we want to provide information to support your
  business model and case

3
Basic Requirements

• We are seeking 6 basic requirements for the ALTC
  health plans
• Licensed by the Bureau of Insurance (BOI)
• Certified for MCHIP from the Virginia Department
  of Health
• Accredited by NCQA or URAC will be required to
  comply with HEDIS studies
• Operate (or apply for by January 1, 2008) a
  Medicare Advantage Plan with PDP certification or
  as a Special Needs Plan
• Operate office in Richmond with the authority for
  profit and loss responsibility as well as the
  ability to make program changes
• Accept DMAS rate methodology and full risk
  capitation rates

4
Integrated ModelPopulations Covered
All 234,945 Low-Income Seniors and Persons with
Disabilities (ABD)

• Medicaid and Medicare (dual eligibles) 148,213
  clients
• Dont use long term care services (115,152
  clients)
• Use long term care services (33,061 clients)

• Medicaid Only (non-duals) 86,732 clients
• Dont use long term care services Medallion II
  (79,045 clients)
• Use long term care services (7,687 clients)

5
Integrated ModelPopulations Covered
6
ImplementationTidewater - Summer 2008
7
Implementation Richmond Winter 2009
8
Client Perspective

• The Department wants the enrollee to have a
  streamlined system. We will require plans to
• Have a single card for services
• Coordinate between Medicaid and Medicare whenever
  possible
• Have a single point of entry and customer service
  center as well as care coordination

9
Enrollment

• There are 6 points of entry for the client into
  the program, depending upon the circumstances,
  e.g., from a hospital discharge to a new DSS
  enrollee
• The Department will use an enrollment broker to
  handle all health plan enrollments
• The program will have mandatory enrollment with
  liberal opt-out provisions. There will be an
  annual open enrollment
• The Department will work with the plans to
  encourage the duals to enroll into the respective
  plans Medicare Advantage/SNP plan

10
Networks

• Large percentage of the procurement will be
  focused on provider networks and applicability to
  population, location, services, and utilization
• Networks must consists of
• Acute care services
• Long term care services, to include consumer
  directed and personal care providers
• Social support services
• The network submission should be comprehensive
• The Department will consider Letters of Intent to
  contract. However, for major acute care services,
  executed contact will be required.
• The Department will provide its current provider
  networks

11
Care Coordination

• As seen in Texas, Massachusetts, and Minnesota,
  the Department will require 3 levels of care
  coordination
• Para-professionals to handle care coordination,
  social and program issues
• Clinical professionals to managed intensive high
  risks cases
• Outreach staff or contractor to handle home
  visits
• We expect the program to be high touch for
  example assessments done within 90 days and
  annual assessments for care

12
Marketing and Community Relations

• This program will require the plan to have some
  affirmative marketing strategy
• The Department will work to resolve the marketing
  differences between Medicaid and Medicare
• One of the major components of the program will
  be to obtain consensus, provider and advocate
  approval. As part of this process, the
  Department will connect the plans with different
  interested groups
• In addition, we will want a targeted CAHPS and
  provider satisfaction survey on the project as
  part of the evaluation process

13
Contractors

• The Department will require/encourage plans to
  work with existing DMAS contractors
• This can be transitional or permanent
  relationships to include
• PPL consumer directed fiscal agent
• KePRO prior authorization services
• HMC disease management services
• Doral dental services

14
Quality

• The program focus will be on quality. We are
  looking for improved health outcomes as well as
  prevention of inappropriate hospitalizations and
  improved pharmacy management
• We expect the plans to
• Provide HEDIS studies
• Have disease management and chronic care
  management
• Work with the Department and other plans to
  develop quality projects
• Be willing to have quality scores and studies
  published
• Have demonstrated commitment to quality for the
  population
• Have a Virginia licensed Medical Director

15
Evaluation

• Tidewater and Richmond are pilot projects
• The project will be evaluated by the EQRO (MPRO)
  for contract adherence as well as quality
  measures
• The project also will be evaluated to compare the
  outcomes of enrollees compared to fee-for-service
  counterparts

16
Data and IT Connections

• Plans should be able to accept eligibility data
• Plans must be able to provide encounter data on
  acute as well as long term care services
• Plans should have sufficient IT capability for
  enhancements and testing and reporting

17
System Readiness

• Goal is to implement 08/08/08
• Readiness reviews will be conducted May 2008
• Pre-assignment begins May 2008 August 2008

18
Administrative Flexibility

• We are confident, absolutely sure that we are
  going to miss something as we procure and
  implement
• We need the health plans to have administrative
  flexibility to handle program changes mid year as
  well as case by case flexibility

19
LOIs and Questions

• ??
• Questions and comments may be forwarded to us via
• ALTCMCO_at_dmas.virginia.gov