12VAC30-121 Medicare-Medicaid Demonstration Waivers

NOTICES OF INTENDED REGULATORY ACTION

Vol. 32 Iss. 1 - September 07, 2015

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 121

Notice of Intended Regulatory Action

Notice is hereby given in accordance with § 2.2-4007.01 of the Code of Virginia that the Board of Medical Assistance Services intends to consider promulgating 12VAC30-121, Medicare-Medicaid Demonstration Waivers and amending 12VAC30-50, Amount, Duration, and Scope of Medical and Remedial Care Services. The purpose of the proposed action is to create the Commonwealth Coordinated Care program, which enables individuals who are eligible for both Medicare and Medicaid services (dual eligibles) to receive acute, primary, and long-term care services in a coordinated managed care system.

The dual eligible population is of particular interest for a managed care program because the participants represent some of the most vulnerable citizens who typically have extensive medical, behavioral health, social, and long-term care needs. In the Commonwealth, dual eligibles are currently excluded from managed care because Medicare, being their first payer of services, covers their acute care services. Also, managed care organizations did not originally cover long-term care services (neither nursing facility services nor home and community-based services). These dual eligible persons have been receiving acute and long-term care services in Medicaid's fee-for-service system.

As a result of being in the fee-for-service system, no single health care provider or entity is responsible for coordinating all of these individuals' care, resulting in an inefficient system that is cumbersome for the individuals with misaligned benefit structures and opportunities for cost shifting. This system has likely led to unnecessary hospital admissions, unnecessary use of nursing facilities, and the mismanagement of medications.

Integrating primary and acute care services with long-term care and behavioral health services into one delivery system will streamline the delivery of services by offering ongoing access to quality health and long-term care services, care coordination, and referrals to appropriate community resources. This will also empower the Commonwealth's full dual eligible beneficiaries to remain independent, residing in settings of their choice for as long as possible.

The Social Security Act (§ 1932(a)) permits the combining of Medicare and Medicaid services to dual eligible individuals under the authority of a Financial Administration Demonstration Waiver. The goal of this action is to provide integrated care to dual eligible individuals who are currently excluded from participating in managed care programs. This change will enable these participants to access their primary, acute, behavioral health, and long-term care services through a single managed delivery system, thereby increasing the coordination of services across the spectrum of care.

Commonwealth Coordinated Care (CCC) Program participants will include adult full benefit dual eligible individuals (ages 21 and older), including full benefit dual eligible individuals in the Elderly or Disabled with Consumer Direction (EDCD) Waiver and full benefit dual eligible individuals residing in nursing facilities. Individuals who are required to "spend down" income in order to meet Medicaid eligibility requirements will not be eligible. The CCC Program also will not include individuals for whom DMAS only pays a limited amount each month toward their cost of care (e.g., deductibles only) such as: (i) qualified Medicare beneficiaries (QMBs); (ii) special low income Medicare beneficiaries (SLMBs); (iii) qualified disabled working individuals (QDWIs); or (iv) qualified individuals (QIs).

The proposed regulatory action will allow DMAS to combine certain aspects of managed care, long-term care, and Medicare into one program. The program is expected to offer participants care coordination, which will, it is anticipated, improve their quality of care. To accomplish this, DMAS is including certain populations and certain services previously excluded from managed care into a new managed care program. This new managed care program is being offered on a voluntary basis in five regions of the Commonwealth: Central Virginia, Tidewater, Northern Virginia, Charlottesville/Western, and the Roanoke region. The program has been phased in on a regional basis over the first 12 months of the program, starting with the Central Virginia and Tidewater regions. Eligible individuals were notified of the opportunity to enroll during March 2014 and the first opportunity for enrollment was effective on April 1, 2014. The remaining three regions were phased in later in 2014.

Covered services will include the following:

1. All Medicare Parts A, B, and D services (including inpatient, outpatient, durable medical equipment (DME), skilled nursing facilities (NFs), home health, and pharmacy);

2. The majority of Medicaid State Plan services that are not covered by Medicare, including behavioral health and transportation services;

3. Medicaid-covered EDCD Waiver services: adult day health care, personal care (consumer and agency directed), respite services (consumer and agency directed), personal emergency response system (PERS), transition coordination, and transition services;

4. Personal care services for persons enrolled in the Medicaid Works program;

5. Nursing facility services; and

6. Flexible benefits that will be at the option of participating plans.

The agency does not intend to hold a public hearing on the proposed action after publication in the Virginia Register.

Statutory Authority: § 32.1-325 of the Code of Virginia; §§ 1932 and 1915(c) of the Social Security Act.

Public Comment Deadline: October 7, 2015.

Agency Contact: Matthew Behrens, Project Manager, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone [phone], FAX [phone], or email [e-mail].

VA.R. Doc. No. R15-3786; Filed August 10, 2015, 8:46 a.m.