Virginia

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State Demonstration to Integrate Care for Dual Eligible Individuals

Virginia’s duals demonstration proposes to cover full benefit Medicare-Medicaid enrollees (age 21 and older), older persons and persons with physical disabilities, nursing facility residents, and persons who receive services through the Elderly or Disabled with Consumer Direction (EDCD) Waiver. Persons with intellectual/developmental disabilities who are not in the EDCD Waiver are excluded from the program. Assisted living services, intellectual/developmental disability services, and PACE programs will be carved out. The state targeted January 2014 for initial implementation in four regions, utilizing voluntary enrollment with opt out. The demonstration will use a capitated-managed care model. (Source: CMS and Truven Health Analytics, The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update, July 2012)
Demonstration Proposal
State Website on Duals Demonstration

On May 21, 2013, then-Governor Bob McDonnell announced that Virginia has signed a Memorandum of Understanding (MOU) with CMS to implement its Medicare-Medicaid Enrollee Financial Alignment Demonstration, aimed at coordinating care for more than 78,000 Virginians currently enrolled in Medicare and Medicaid. Under this initiative, branded as Commonwealth Coordinated Care, Virginia and CMS will enter into a contract with health plans for the delivery of coordinated services and supports to enrollees. Eligible individuals include older adults and individuals with disabilities, including those receiving long-term services and supports, and who live in designated regions around the Commonwealth. The regions include the areas surrounding: Central Virginia/Richmond, Charlottesville, Tidewater, Roanoke and Northern Virginia. (Source: Press Release, May 21, 2013) Memorandum of Understanding

On December 4, 2013, the state and CMS entered into a three-way contract with health plans for the delivery of coordinated services and supports to enrollees. (Source: NSCLC Dual Eligible State Profiles website, March 2014)
Three-Way Contract (12/4/2013)

In March 2014, Virginia began voluntary opt-in enrollment in Commonwealth Coordinated Care; and passive enrollment began May 1, 2014. Residents must be dual eligibles and at least 21 years old to participate in the demonstration. Residents can opt out or withdraw from the plan at any time. (Source: Newsleader.com website; HMA Weekly Roundup, 6/18/2014)

In August 2014, Virginia released a Commonwealth Coordinated Care Update. As of August 1, 2014, there were 11,176 Virginians enrolled in the CCC program. This includes 2,825 individuals who have opted in to the
CCC program across the five CCC regions. On September 1, 2014, approximately 13, 000 individuals are scheduled to auto-enroll in CCC in the Central Virginia area. (Source: State Medicaid website)
Commonwealth Coordinated Care Update (8/2014)

In September 2014, Virginia released a Commonwealth Coordinated Care Update.  As of September 1, 2014, there were 20,824 Virginians enrolled in the CCC program.  This includes 3,266 individuals who have opted into the CCC program across the five CCC regions.  Approximately 10,000 individuals are scheduled to auto-enroll in CCC on October 1, 2014 in the Charlottesville and Roanoke regions.  (Source:  State Medicaid website)
Commonwealth Coordinated Care Update (9/2014)

Effective October 6, 2014, Virginia Premier CompleteCare – a health plan in the Commonwealth Coordinated Care (CCC) duals demonstration program - has entered into an agreement with Magellan Healthcare, Inc. to implement a behavioral health management program to promote quality improvement for services provided to Virginia Premier CompleteCare members.  (Source:  Virginia DMAS website; Virginia Premier CompleteCare website)

On May 17, 2015, the Daily Press Media Group reported that Virginia’s Commonwealth Coordinated Care (CCC) program, a pilot program to provide managed care for dual eligible Virginia residents, has experienced a larger than expected drop in enrollments, threatening the program’s projected $44 million in savings. More than 40 percent of the 66,000 residents eligible for CCC have opted out of the program. Virginia health officials expect the program to become mandatory in the next few years. (Source: dailypress.com, 5/17/2015)

Managed LTSS Program

On June 2, 2015, the Virginia Department of Medical Assistance Services (DMAS) announced its intention to move most of the state’s remaining Medicaid fee-for-service (FFS) population into managed care in 2016 and 2017, including: dual eligibles not enrolled in the Commonwealth Coordinated Care Program (CCC); and individuals receiving full Medicaid and LTSS through an institution or HCBS waiver.  Individuals on ID, DD, and DS waivers will continue to receive HCBS through Medicaid FFS. (Source: DMAS, 6/2/2015)
DMAS Stakeholder Letter (5/18/15)

On October 5, 2015, the state of Virginia released a fact sheet regarding the state’s proposed MLTSS program. According to the fact sheet, populations that will be included in the Virginia MLTSS program are 50,000 dual eligibles who receive full Medicaid benefits, 20,000 non-dual eligibles that receive LTSS, and Commonwealth Coordinated Care (CCC)—the state’s dual eligible demonstration—participants  when the demonstration ends in December 2017. Implementation will be phased starting in 2017.  Individuals with intellectual/developmental disabilities will receive acute care through health plans, but will receive HCBS services through fee-for-service. The MLTSS program aims to improve quality, access and efficacy of LTSS delivery. (Source:  Fact sheet 10/5/2015)

Virginia’s Section 1115 demonstration waiver is currently posted for public review and comment through January 6, 2015. The waiver seeks to implement two programs, a Medicaid MLTSS program, and a Delivery System Reform Incentive Payment (DSRIP) initiative. If approved, the Section 1115 waiver would operate from January, 2017 through December, 2022. The proposed MLTSS program would be fully integrated, including physical, behavioral and substance use, as well as LTSS benefits. The MLTSS program will be statewide but executed at the regional level. The VA MLTSS program will incorporate three 1915(c) HCBS waivers: the Alzheimer’s waiver, the technology assisted waiver, and the elderly and disabled with consumer direction waiver. ID/DD individuals and day support waivers will not be included.  The MLTSS program will mandatorily enroll an estimated 46,000 dual eligibles excluded from Commonwealth Coordinated Care (CCC), the state’s financial alignment demonstration; 18,000 members in nursing facilities; and 66,000 dual eligibles that have enrolled or opted out of CCC. VA plans to issue an RFP in the spring of 2016, and a phased implementation schedule commencing in January 2017. (Source: Public Comment DocumentHMA Roundup 12/16/2015)

On January 19, 2016, the Virginia Department of Medical Assistance Services (DMAS) formally submitted its section 1115 demonstration waiver application to CMS. The purpose of the waiver is twofold: to implement Medicaid managed long-term services and supports (MLTSS), as well as a delivery system reform incentive (DSRIP) program. The MLTSS initiative aims to build upon the state's dual eligible demonstration, Commonwealth Coordinated Care (CCC). DMAS is looking for authority to mandate enrollment of eligible populations into MLTSS. In addition, two 1915(c) HCBS waiver populations will be enrolled into the program, the Elderly or Disabled with Consumer Direction (EDCD) and Technology Assisted Waiver (Tech), in order to streamline administration for the state. Virginia's MLTSS program will provide services across the continuum of care including physical, behavioral, HCBS as well as institutional services. DMAS estimates approximately 129,500 individuals will be eligible for MLTSS, which will be enrolled in phases from March 1, 2017, through January, 2018.  (Source: VA 1115 Waiver Application 1/19/2016)

According to HMA Weekly Roundup, Virginia is set to reprocure its Medicaid managed care program, which is called Medallion 3.0, in 2016. Medallion 3.0 covers approximately 740,000 beneficiaries, including pregnant mothers, children, parents up to 52 percent of the FPL, waiver recipients needing acute care services, as well as the aged, blind, and disabled (ABD) population. As a component of the new procurement, however, the ABD population will be shifted into the state’s proposed MLTSS program. (Source: HMA Roundup 4/6/2016)

The Virginia Department of Medical Assistance Services (DMAS) released the request for proposals (RFP) for the state’s statewide managed long term services and supports (MLTSS) program, which will begin phased enrollment in the summer of 2017. In addition to covering members who are aged, blind, and disabled (ABD), the MLTSS initiative will eventually replace the state’s dual eligible demonstration, Commonwealth Coordinated Care (CCC), when it sunsets near the end of 2017. MLTSS MCOs will manage the following services: LTSS, primary, acute, behavioral, and care coordination. In addition, all MCOs will be required to operate a Dual-Eligible Special Needs Plan (D-SNP) within two years from when the contracts are awarded. Following a mandatory preproposal conference on May 10, 2016, proposals will be due by June 30, 2016, with notice of intent to award issued by December 9, 2016. (Source: HMA Weekly Roundup 5/4/2016; RFP 4/29/2016)  

The Virginia Department of Medical Assistance Services (DMAS) has announced the MCOs selected to manage the state’s MLTSS program, which include the following:

  • Optima Health;
  • Humana;
  • Magellan Complete Care of Virginia;
  • Anthem HealthKeepers Plus;
  • Virginia Premier Health Plan;
  • Aetna Better Health of Virginia; and
  • UnitedHealthcare.
Of the MCOs selected, all of them previously served the state’s Medallion 3.0 managed care program for traditional Medicaid aside from UnitedHealthcare and Magellan Complete Care of Virginia. All of the beneficiaries enrolled in the state’s dual eligible demonstration, Commonwealth Coordinated Care, will be transitioned into the MLTSS program commencing in 2018. (Source: HMA Weekly Roundup 9/28/2016; HMA Weekly Roundup 10/5/2016)

In December, 2016, the Virginia Joint Legislative Audit & Review Commission (JLARC) released a report on managing spending in Virginia’s Medicaid program. The report notes that although per beneficiary spending remained mostly level over the 2011-2015 period, overall general fund expenditures have grown an average of 8.9 percent over the past 10 years. In fiscal year 2015, Virginia spent $2.35 billion on LTSS. JLARC offers a number of legislative and executive recommendations that pertain to LTSS in the state. Legislative recommendations include:

  • Directing the Department of Medical Assistance Services (DMAS) to establish a core training curriculum for screeners of LTSS applicants, and amendment of the Code of Virginia to add a new requirement that all screeners be certified and trained;
  • Directing DMAS to look into the LTSS screening process performed by hospitals in order to prevent avoidable institutional placement; and
  • Directing DMAS to establish a stricter profit cap for the Medallion managed care program, as well as the state’s upcoming MLTSS program.

JLARC also recommends the following executive actions:

  • Development of a consistent LTSS functional screening framework, including testing of its reliability;
  • Implementation of a blended capitation rate for MLTSS; and
  • Utilization of improved data and program analysis in order to enhance MCO oversight. (Source: JLARC Report 12/2016) 

On February 9, 2017, the Virginia Department of Medical Assistance Services (DMAS) announced the six companies awarded contracts under the state’s MLTSS program, Commonwealth Coordinated Care Plus. All of the MCOs awarded will operate in regions 1-6 for the program. The six MCOs chosen are:

  • Aetna Better Health of Virginia;
  • Anthem HealthKeepers Plus;
  • Magellan Complete Care of Virginia;
  • Optima Health;
  • United Healthcare; and
  • Virginia Premier Health Plan. (Source: Notice of Award 2/9/2017) 

August 1, 2017, was the official start date of Virginia’s statewide MLTSS program, Commonwealth Coordinated Care (CCC) Plus. CCC Plus will serve an estimated 214,000 Virginians with complex needs. The program is launching regionally, with the Tidewater regional going into effect on August 1; CCC Plus will be fully implemented statewide by January 1, 2018. (Source: DMAS 8/1/2017) 

A new Medicaid spending projection from the Virginia Department of Medical Assistance Services (DMAS) estimates that the implementation of the state’s new MLTSS program, Commonwealth Coordinated Care Plus (CCC Plus), will help bend the state’s cost growth curve. DMAS projects that the Medicaid spending growth rate will be 2.5 percent for the first year of the program, and 3.4 percent for the second—down from a rate of 7.8 percent for this fiscal year. Implementation of the program is expected to be complete by January 2018. (Richmond Times-Dispatch 11/6/2017)