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COMMONWEALTH COORDINATED CARE PLUS
BPROLynne Vest and Laura Epperly
Division of Integrated CareDepartment of Medical Assistance Services
Agenda
CCC Plus Enrollment Update
Dual-Eligible Special Needs Plans
CCC Plus Waiver Update
Care Coordination
Medicaid Expansion
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Commonwealth Coordinated Care Plus
• Medical, behavioral health and long-term services and supports
• Health Plans cover services within at least equal amount, duration, and scope as Medicaid
• Health Plans provide additional benefits and linkages to resources to address social determinants of health
• Very few carved-out services (e.g., dental, school health, and DD Waiver services)
• Care coordination for all enrollees
Managed Long Term Services and Supports
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CCC Plus Populations
Approximately 236,000 individuals, including:
Adults and children living with disabilities
Individuals living in Nursing Facilities (NFs)
Individuals in the CCC Plus Waiver (formerly the Technology Assisted Waiver and Elderly and Disabled with Consumer Direction Waiver)
Individuals in the 3 waivers serving the Developmental Disabilities populations for their non-waiver services
Medically complex individuals eligible through Medicaid Expansion
Governor’s Access Plan members transitioned to CCC Plus on January 1, 2019
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CCC Plus Enrollment
As of 3/22/2019
MCO Tidewater CentralCharlottes-
villeRoanoke
AlleghanySouthwest
Northern VA/ Winchester
Total
Aetna 6,365 10,058 4,534 4,368 4,570 5,379 35,274
Anthem 15,536 17,559 5,760 5,163 4,140 17,200 65,358
Magellan 6,360 5,700 3,262 2,804 2,588 3,578 24,292
Optima 12,885 8,299 7,937 2,941 2,921 3,205 38,188
United 4,992 5,584 2,655 3,633 2,756 7,322 26,942
VA Premier 6,038 10,361 8,015 9,798 7,645 4,336 46,193
Total 52,176 57,561 32,163 28,707 24,620 41,020 236,247
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Members with Medicaid and Medicare
Medicaid
CCC Plus Health Plan
Medicare
Dual Special Needs Plan
Covers Part A, B and prescription drug coverage under D
Or
Traditional Medicare or any Medicare Advantage plan
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Dual Eligible Special Needs Plan
• D-SNP membership is limited to people who qualify for both Medicare and Medicaid (Duals).
• D-SNPs cover Medicare Part A, B and prescription drug coverage under Part D.
• Individuals can, but are not required to, enroll in the same health plan for their Medicare and Medicaid benefits.
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Dual-Eligible Special Needs Plan Enrollment
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Open Enrollment
• DMAS implemented the first open enrollment period for CCC Plus from October 1, 2018 –December 18, 2018. Health plan changes were effective on January 1, 2019.
• A total of 8,411 members changed health plans during open enrollment.
• Of those members, 6,220 called the Enrollment Helpline to change plans and 2,191 used the website.
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Continuity of Care Period
• During transitions between Fee For Service and between health plans,
Member’s can see their current providers for up to 30 days.
• The health plan will honor the service authorizations issued by DMAS
or the DMAS Contractor for the length of the existing service
authorization or 30 days (whichever is sooner).
• The health plan will extend this time frame as necessary to ensure
continuity of care pending the provider’s contracting with the health
plan or the Member’s safe and effective transition to a contracted
provider.
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CCC Plus Waiver Services
• Adult Day Health Care
• Personal Assistance Services
• Private Duty Nursing
• Respite care
• Services Facilitation
Assistive Technology
Environmental Modifications
Personal Emergency Response System and Medication and Monitoring
Transition Services
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EPSDT and CCC Plus Waiver
• Medicaid Memo issued July 11, 2018 indicating that as of September 1, 2018, the following services for members under age 21 must go through EPSDT for authorization:
Personal Care
Private Duty Nursing
Assistive Technology
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EPSDT and CCC Plus Waiver
• As of May 1, 2019, personal care can be authorized through the CCC Plus Waiver for members under age 21
• Private Duty Nursing and Assistive Technology will continue to be authorized through EPSDT for members under age 21
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Personal Care for Members under Age 21
• Effective May 1, 2019, waiver criteria is applied for personal care for member under age 21
• EPSDT forms no longer required for waiver members:
EPSDT Personal Care Services Functional Status Assessment (DMAS-7)
EPSDT Personal Care Program Agency and Consumer Directed Plan of Care (DMAS-7a)
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Requests for CCC Plus Waiver Review
• For members who experienced personal care hour reductions under EPSDT and indicate their needs are not met, the provider may submit a new authorization request to have hours reviewed under the CCC Plus Waiver criteria.
• Reminder: Providers are required to ensure that services are adequate to meet the member’s needs.
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CCC Plus Waiver Resources
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For CCC Plus Waiver Policy-Related Questions: [email protected]
For Consumer-Directed or Service Facilitation Questions or Issues: [email protected]
Care Coordinator Role
Every member is assigned an MCO Care Coordinator who performs the following functions
Plan
• Drive the development of person-centered, individualized care plan
• Include plan to support social determinants of health
Communicate
• Establish collaborative relationships that connect the enrollee, MCO, and providers
Coordinate
• Help navigate the health care system
• Coordinate team of health care professionals
• Support care transitions
Monitor
• Track progress towards goals
• Monitor status to avoid disruption in care
• Update plan of care
Assess
• Conduct/ coordinate Health Risk Assessment
• Identify barriers to optimal health
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Care Coordinators Can Help
Serves as point of contact to ensure members get services and care they need
Available to answer questions about programs for enhanced care planning options and risk management
Helps to resolve barriers to care such as possible network and transportation issues
Ensures appropriate authorizations are in place and that changes occur promptly
Leads the Interdisciplinary Care Team for individualized care planning and transition of care needs
Advocates for members and providers helping members
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Care Coordinator Contact Information
CCC Plus Members are assigned a Care Coordinator to personally assist members and their treating providers
For assistance identifying a member’s Care Coordinator, please contact the assigned health plan directly at:
Aetna Anthem Magellan Optima UnitedHealthCare VA Premier
1-855-652-8249
press #1 and
ask for Care
Coordination.
1-855-323-
4687 Press
#4
TTY 711
1-800-424-4524 757-552-8398 OR
Toll Free:1- 866-
546-7924
Members: 1-866-622-
7982
Providers: 1-877-843-
4366
1-877-719-
7358
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Regional Transition Coordinator
Each health plan has Regional Transition Coordinators
Available to answer questions about transitions of care
Participate in discharge planning for Members transitioning from acute institutional settings to lower levels of care, including Long Stay Hospitals, Nursing Facilities, and the community
Upon notification of a hospital admission or discharge, work closely with member's CC to communicate hospital admission/discharge to the PCP and community-based providers
Helps to problem solve difficult placements
Supports local Care Coordinators
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Transportation
CCC Plus Reservations Phone Number Type of Transportation
Aetna Better Health of Virginia (800) 734-0430 Option 1 All ages and all levels of service
Anthem HealthKeepers Plus (855) 325-7581 All ages and all levels of service
Magellan Complete Care of Virginia (877)790-9472 All ages and all levels of service
Optima Health Community Care (855) 325-7558 All ages and all levels of service
United Healthcare Community Plan
Regions 2,4,5
(Central,
Roanoke/Alleghany/Southwest)
(844) 604-2078 All ages and all levels of service
United Healthcare Community Plan
Regions 1,3,6
(Tidewater, Charlottesville/Western
Northern/Winchester)
(888) 258-0521 All ages and all levels of service
Virginia Premier Elite Plus (877) 719-7358 All ages and all levels of service
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Implementation of Common Core Formulary in the CCC Plus Managed Care Program
• CCC Plus health plans adopting a Common Core Formulary
• Uniform drug coverage for CCC Plus enrolled Medicaid members
• Health Plans required to cover all ‘preferred’ drugs on Virginia Medicaid’s PDL May add drugs to formulary
May not remove drugs or place additional restrictions
• Does not apply to Medicare and Medicaid beneficiaries Drug benefits governed by Medicare Part D guidelines
• Medicaid Memo dated July 17, 2017
https://www.virginiamedicaidpharmacyservices.com/
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Office of the State Long-Term Care Ombudsman:Role of the CCC Plus Advocate
CCC Plus Advocates can help with:
• Enrollment and Disenrollment
• Continuity of Care
• Access to covered benefits, urgent needs, prescription drugs, behavioral health care and long-term services and supports
• Timeliness of Plan Responses to Member Questions and Needs
• Questions about Bills, Care Coordination, and Plan Benefits
• Information and Assistance with Grievances and Appeals
Office of the State Long-Term Care OmbudsmanDepartment for Aging & Rehabilitative Services
1-800-552-5019 TTY Toll-free 800-464-9950www.ElderRightsva.org
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Medicaid Expansion: Overview of Adult Coverage
• The rules have changed. Virginians who may have applied for
Medicaid in the past and been denied may be eligible
beginning January 1, 2019.
• Up to 400,000 more Virginia adults will enroll in quality, low-
and no-cost health coverage.
• For example, under the new rules, eligible populations may
include childless adults and individuals who work, as well as
caretaker adults and disabled individuals who may not have
qualified previously for reasons such as excess income and/or
excess resources, etc.
New coverage began 1/1/2019; individuals should apply now!24
Who is Eligible?
Adults ages 19 – 64, not Medicare eligible
Income from 0% to 138% Federal Poverty Level
New eligibility rules will provide quality, low- and no-cost health care coverage to up to 400,000 men and women
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Income Eligibility Guidelines
Adults may be eligible if they make less than:
Who is Eligible?
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New Adult Coverage Uses Current Health Plans
Coverage will be provided for most individuals through the Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus) managed care programs
Medicaid’s six current health plans will serve the new adult members
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“Medically Complex” Enrollees
“Medically Complex” members will be enrolled in the CCC Plus managed care program, which will provide enhanced care coordination services
Medicaid Application Question
• Applicant responds to a “Yes/No” question at time of the initial Medicaidapplication.
• If Applicant marks “Yes,” then the member will receive a screening by their health plan to validate.
Individuals Receiving LTSS
• Individuals who receive services in a nursing facility or one of the Home and Community Based Services (HCBS) waivers are automatically considered “medically complex.”
• Individuals who receive LTSS will also receive a medically complex screening by their health plan, as part of the overall health assessment process
“Medically Complex” includes individuals with a complex behavioral or medical condition and level of care impairment, which may be established by:
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How to Apply for Medicaid Coverage
Local Department of Social Services (LDSS)
Cover Virginia Call Center
1-855-242-8282(TDD: 1-888-221-1590)
Online Application Portal (Common Help)
commonhelp.virginia.gov
VDSS Enterprise Call Center
1-855-635-4370
The “Marketplace” (healthcare.gov)
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