DMAS UPDATE HOUSE APPROPRIATIONS COMMITTEE HHR SUBCOMMITTEE January

DMAS UPDATE HOUSE APPROPRIATIONS COMMITTEE HHR SUBCOMMITTEE January 22, 2020 KAREN KIMSEY, MSW DIRECTOR, Department of Medical Assistance Services

Agenda q Medicaid Overview q Medicaid Expansion Update q DMAS Priorities in the Governor’s 2020 Budget 2

Who Does Medicaid Serve? Children 672, 000 Pregnant Women and Parents 123, 000 Older Adults 76, 000 Individuals with Disabilities 145, 000 Expansion Adults 372, 000 Medicaid plays a critical role in the lives of nearly 1. 5 million Virginians 3

Medicaid Expenditures by Population, Where General Funds are Used (Excludes Expansion Adults) Medicaid Enrollees and Expenditures, SFY 2019 100% 90% 23% 80% 70% 61% 60% 10% 21% Children Pregnant Women and Parents Older Adults Individuals with Disabilities 50% 40% 30% 20% 18% 7% 46% 67% of Medicaid spending is on behalf of older adults and individuals with disabilities (21% of the population). 14% 0% Enrollment Expenditures Funding for these populations is split almost equally between federal dollars and general funds 4 Enrollment and expenditure totals do not include expansion adults or limited benefit members.

Medicaid Expenditures by Population, Including GF and non-GF Medicaid Enrollees and Expenditures, SFY 2019 100% 90% 80% 21% 48% 70% 40% 30% Children Pregnant Women and Parents 60% 50% 9% 20% Older Adults Individuals with Disabilities Expansion Adults 13% 6% 11% 42% 20% 10% 22% 8% 0% Enrollment 5 Expansion enrollment began January 1, 2019. Expenditures There are no general fund dollars spent on expenditures for expansion adults; these are funded with 90 % federal and 10% special funds.

Managed Care Programs 96% of full-benefit Medicaid members are in managed care Medallion 4. 0 1, 101, 000 Members Covered Groups § Serving infants, children, pregnant women, caretaker adults, and newly eligible adults Commonwealth Coordinated Care Plus (CCC Plus) 245, 000 Members § Serving older adults, disabled children, disabled adults, medically complex newly eligible adults § Medicare and Medicaid (fullbenefit duals) Covered Benefits § Births, vaccinations, well child doctor visits, sick doctor visits, acute care, pharmacy, ARTS, behavioral health services, including community mental health rehabilitation services § Excludes LTSS 6 DMAS Monthly Enrollment as of January 1, 2020 § Full continuum of services (same as Medallion) § Long-term services and supports (LTSS) in the community and in nursing facilities and hospice

Medicaid Expansion: Who Is Eligible? Children 0 -18 (family of 3) 205% FPL ($43, 727) Pregnant Women (family of 3) 205% FPL ($43, 727) 80% FPL ($9, 992) 138% FPL ($17, 237) Person With Disability Parents (Family of 3) Childless Adults 33% FPL* ($8, 112) 138% FPL ($17, 237) 138% FPL ($29, 436) age 19 – 64 and not Medicare eligible Pre-Expansion Eligibility 7 *Percent income may vary by locality Expansion Eligibility

Medicaid Expansion: Status Update 372, 000 newly eligible adults are enrolled 325, 000 Medicaid expansion members have received a Medicaid service and 250, 000 have had a general office visit 22, 000 have received care through the Addiction and Recovery Treatment Services (ARTS) program Treatment for other chronic and life-threatening conditions include: Cancer (5, 700); Diabetes (26, 000); Hypertension (46, 000) 8 *Source: DMAS Enrollment and Claims Data as of 1/1/20. Due to natural claims lag, we expect these numbers to continue to rise as claims continue to be submitted.

Expansion Access and Utilization Dashboard 9 http: //dmas. virginia. gov/#/accessdashboard

Medicaid Expansion: Expenditures Update 10

Overview: Current State of the 1115 Waiver On December 3 rd, 2019, in response to Governor Northam’s instructions, DMAS asked the Centers for Medicare and Medicaid Services (CMS) to delay action on portions of the 1115 demonstration waiver related to work requirements and cost sharing in order to allow the state’s new leadership to make a determination about the best next steps for Virginians. Status of 1115 Waiver Components Approved On December 30, 2019, CMS approved the extension of the existing Addiction Recovery and Treatment Services (ARTS) and former foster youth coverage provisions of the 1115 waiver through December 31, 2024. In Progress Negotiations for the housing and employment supports benefit for high-needs Medicaid enrollees is still underway, and once finalized, funding will be requested through the legislature Paused 11 Negotiations for the work and community engagement requirements, monthly premiums, and other “healthy behavior” requirements are on pause at this time, pending the decision of the legislature

Governor’s 2020 Budget Overview Maternal and Other Population Health Initiatives Proposals to Improve Behavioral Health and Substance Use Disorder Services Proposals to Improve Long Term Support Services Ensuring Medicaid Is Paying for Value 12

Governor’s Introduced Budget Maternal and Other Population Health Initiatives FY 2021 FY 2022 GF NGF $1, 114, 936 $2, 120, 272 $2, 116, 376 $3, 930, 412 Increase FAMIS MOMS access to treatment for a substance use disorder (Item 313 WWW) $307, 500 $626, 900 $356, 775 $662, 550 Home Visits: Implement a home visiting benefit for pregnant women at risk and postpartum women at risk of poor health outcomes (Item 313 BBBB. 1 &2. ) $1, 054, 300 $3, 514, 556 $11, 750, 159 $34, 216, 923 Extend FAMIS MOMS eligibility from 60 days to 12 months postpartum (Item 313 AAAA) 13

Governor’s Introduced Budget Maternal and Other Population Health Initiatives FY 2021 GF FY 2022 NGF GF NGF Eliminate 40 Quarter Work Requirement for Legal Permanent $1, 172, 091 Residents (Item 313 XXX) $6, 519, 419 $3, 289, 890 $9, 548, 955 Justice Involved: Provide services for individuals who are Medicaid eligible and have pending release from incarceration within 30 days (Item 313 FFFF) $11, 398, 558 $465, 440 $16, 404, 809 14 $347, 803

Governor’s Introduced Budget Proposals to Improve Behavioral Health and Substance Use Disorder Services FY 2021 Funding for the Enhancement of Behavioral Health Services (Item 313 YYY) FY 2022 GF NGF $3, 028, 038 $4, 127, 378 $10, 273, 553 $14, 070, 322 Implementation January 2021 Multi-Systemic Therapy Functional Family Therapy Assertive Community Treatment 15 Implementation July 2021 Comprehensive Crisis Services Partial Hospitalization Intensive Outpatient

Governor’s Introduced Budget Proposals to Improve Behavioral Health and Substance Use Disorder Services FY 2021 Incentive DSH payments to support increased TDO utilization in private acute care hospitals (Item 313 RR. 3) FY 2022 GF NGF $0 $32, 523, 924 • Current DSH: $26 million, $13 million existing GF • New TDO incentive: $32 million, $16 million needed in revenue from Provider Rate Assessment • This proposal uses an incentive of $5, 400 per Medicaid TDO admitted to a hospital, starting July 1, 2020. • Leaves existing DSH payment methodology unchanged. • Requires no GF dollars. 16

Governor’s Introduced Budget Proposals to Improve Behavioral Health and Substance Use Disorder Services FY 2021 FY 2022 GF NGF Expand the Preferred Office. Based Opioid Treatment (OBOT) model to allow for all Substance Use Disorders (Item 313 ZZZ) $421, 476 $620, 156 $1, 273, 633 $1, 873, 300 Increase rates for outpatient services provided by licensed mental health providers to the equivalent of 110 percent of 2019 Medicare rates (Item 313 EEEE) $2, 374, 698 $4, 370, 186 $2, 458, 479 $4, 488, 751 $486, 951 $2, 293, 826 Funding for Medicaid costs associated with the implementation of STEP-VA 17

Governor’s Introduced Budget Proposals to Improve Long Term Support Services FY 2021 FY 2022 GF NGF Proposed funding for DOJ Settlement Agreement, including more than 1, 100 new DD waiver system slots (Item 313 J) $16, 985, 260 $24, 828, 805 Rate increases for DD waiver system services (Item 313 DDDD) $3, 639, 663 $3, 748, 853 Rate increases for skilled and private duty nursing services (Item 313 #69 g, Governor’s amendment) $2, 578, 387 18

Governor’s Introduced Budget Ensuring Medicaid Is Paying for Value FY 2021 Episodic Care: Innovative payment models aimed at incentivizing high quality maternity care and care for other health conditions (Item 313 CCCC) MCO Contract Changes: Implement 14 Contract changes outlined in Item 313 E. 2. 19 FY 2022 GF NGF $151, 915 $174, 266 $249, 415 $271, 766 $2, 226, 600 $2, 428, 350