Transcript State of West Virginia Medicaid Waiver Proposal

West Virginia Beneficiaries
by Enrollment Group
West Virginia Medicaid Beneficiaries
By Enrollment Group, FFY2003
Thousands
191,316
Number of Beneficiaries
200
150
91,190
100
51.17%
60,233
50
31,144
24.39%
16.11%
8.33%
0
Elderly
Blind & Disabled
Adults
Beneficiary Group
Children
West Virginia Beneficiaries
by Expenditures
WEST VIRGINIA MEDICAID BENEFICIARIES AND
EXPENDITURES BY ENROLLMENT GROUP, FFY 2003
100%
90%
80%
8.33%
21.00%
24.39%
70%
60%
16.11%
44.16%
50%
40%
30%
20%
Elderly (31,144)
Blind & Disabled (91,190)
Adults (60,233)
Children (191,316)
Source: CMS 2082
Data from MMIS
System
7.48%
51.17%
27.36%
10%
0%
Beneficiaries
Expenditures
Note: Beneficiaries are
enrollees who received
a Medicaid service.
Blind & Disabled
includes adults,
children, and elderly
who qualify based on a
disability.
Barriers to Managing
the Medicaid Program
Categorical eligibility groups
All or nothing benefits packages
Cost-sharing rules which limit beneficiary
participation
Mandatory services i.e. NEMT
No means to incentivize participants to maintain
and/or improve their health
State responsibility for cost of care for Dual Eligibles
Lack of a comprehensive electronic medical record
for beneficiaries limits the ability to manage patient
care
The West Virginia Model
Not a Rolls Royce for a few but a
West Virginia made Toyota for many
Personal Responsibility Agreement
Base eligibility on income rather than on
category
Eliminate Waivers
Tailor Benefits
Cost Sharing
Manage All Aspects of Care
Pay for Performance
Personal Responsibility
Participants sign an agreement acknowledging that they
are partners with the taxpayers of WV.
The taxpayers pay for their medical care and in return
participants agree to:
a) to comply with medical protocols (i.e., keep doctors
appointments, take their medications as prescribed)
b) help to control program costs by reviewing EOBs
c) share in program costs through co-pays, premiums
d) engage in healthy lifestyles
e) if they choose not to adhere to the agreement then
they will pay higher copays or premiums
Tailored Benefits
Ensure that participants receive the right
care, at the right place, at the right time by
the right provider
Eliminate waivers
Use evidence-based medicine to manage
services by duration, scope and severity
Cost Sharing for Eligibility
Eligibility based upon Federal Poverty Level
rather than upon category (following the
Arizona model)
Sliding fee scale for co-pays and premiums
established so that more people can be
covered
Managing Care
Like the private sector, participants are
members of an HMO for a full year
Expand disease state management to
include long-term care, the disabled, and
the medically fragile
Use comprehensive electronic medical care
to manage care – including Medicare drug
benefit information for dual eligibles
Pay for Performance
Base reimbursement rates for health
maintenance organizations based on health
outcomes
Pay PCCM providers based on health
outcomes – may include bonuses
Reward participants based on improved
health (i.e., weight loss, stop smoking,
et cetera)
Financing and Timeline
Reinstate match rate from 2004 (75.36%)
until waiver is implemented
Upon implementation, use 2005 as the
base year convert to per capita rate
(Medicaid expenditures/# of enrollees) with
health expenditure index inflation going
forward (similar to clawback calculation)
Implement waiver July 1, 2006