Commonwealth Coordinated Care Update with Initial Medicaid Payment Rates

Despite the fact that there are significant and important ongoing discussions between VHCA, the three contracted Medicare-Medicaid Plans (MMPs) and the Department of Medical Assistance Services (DMAS) to address a range of operational issues, DMAS is continuing its efforts to launch the Commonwealth Coordinated Care (CCC) program in accordance with their enrollment timetable for each of five CCC regions.  These discussions focus on three key areas: service authorizations, claims processing and payment determination (treatment of Medicare bad debts and Medicaid patient pay components), and care coordination. There is no formal mechanism for reporting the status of providers, including nursing facilities, that have contracted with Anthem HealthKeepers, Humana and Virginia Premier. It is our understanding that all three MMPs continue to work aggressively to negotiate and execute provider agreements.

All three MMPs have now finalized their provider manuals.  While it was our understanding that these manuals were intended to serve as key resource documents and guidance for providers, the manuals unfortunately do not contain the level of detail necessary to provide meaningful guidance on a wide range of operational areas.  We continue to urge each VHCA member facility to carefully review all of the information and documents available to them prior to making a decision to execute a specific MMP participation agreement. It is critical that providers have high comfort and trust levels with the agreements and related documents prior to execution.  The ability to negotiate specific contract provisions that are critical to a facility’s goal of delivering high-quality services and the expectation that there be a corresponding receipt of adequate payment is significantly diminished once agreements are executed.  A comparison of key contracting provisions of each MMP’s DMAS-approved contract template is available on the VHCA websitePlease note that this comparison was developed prior to a series of meetings now taking place between DMAS, the MMPs and VHCA members that are intended to standardize the approaches to a variety of operational areas among the MMPs.  The outcome of these meetings will likely modify the contracting provisions referenced in the linked document.

Phase I of the CCC launch includes the Tidewater and Central Virginia/Richmond regions.  The planned implementation timelines are as follows:

Tidewater area:

    March 2014: Voluntary enrollment begins
    April 2014: Services/supports begin for those enrolled
    May 2014: Automatic enrollment begins
    July 2014: Services/supports for those automatically enrolled begins

Central Virginia/Richmond area:

    March 2014: Voluntary enrollment begins
    April 2014: Services/supports begin for those enrolled
    June 2014: Automatic enrollment begins
    August 2014: Services/supports for those automatically enrolled begins

Northern Virginia, Roanoke, Charlottesville areas:

    May 2014: Voluntary enrollment begins
    June 2014: Services/supports begin for those enrolled
    August 2014: Automatic enrollment begins
    October 2014: Services/supports for those automatically enrolled begins

Last week, dual eligible beneficiaries in the Tidewater and Central Virginia/Richmond regions began receiving CCC letters that focus on the voluntary enrollment process.  In some cases, the only known address for the beneficiary is the nursing facility in which that individual resides.  DMAS has provided no formal guidance to VHCA or to our members as to expectations and responsibilities of facilities to advise residents about their options relative to voluntary enrollment or the individual’s right to opt-out of the CCC.  We are unaware of any legal or other requirements for nursing facilities to provide direct counsel to their residents or their family members in connection with CCC enrollment.

CCC enrollment is the responsibility of a third-party enrollment broker, MAXIMUS. MAXIMUS will provide education services about the CCC program to eligible beneficiaries and process enrollment and disenrollment requests received by telephone and mail. MAXIMUS hours of operations for customer service are Monday through Friday 8:30 am to 6:00 pm. Individuals interested in the CCC program may call MAXIMUS at 855.889.5243 or contact them through the website.

CCC also maintains a partnership with the Virginia Insurance Counseling Assistance and Program (VICAP) to assist with beneficiary education. Beneficiaries may connect with a VICAP representative through their local Area Agency on Aging (AAA) or online.

Under the CCC, the three MMPs must honor all existing plans of care and prior authorizations until the authorizations end or 180 days after the beneficiary’s date of CCC enrollment, whichever is sooner. At that time, beneficiaries who are enrolled in the CCC are limited to providers that are part of the MMP’s network. Therefore, if you provide services to an individual who is enrolling in CCC, you will need to participate in the provider network of their chosen MMP to continue providing covered services to them.  Alternatively, individuals who are automatically (passively) enrolled in the CCC have the option of opting-out of the program and may continue to receive services under traditional Medicare and Medicaid fee-for-service arrangements.

An issue identified last week that may have significant implications for dual eligible resident populations in nursing facilities focuses on a provision in the three-way contract between CMS, DMAS and the MMPs that stipulates that beneficiaries with other insurance coverage are not eligible to participate in the CCC.  It is not uncommon for nursing facility residents to have Medicare supplemental insurance policies.  We are seeking clarification on the specific policy types that meet the other insurance coverage criteria; however, DMAS has indicated that traditional Medigap and Tricare policies indeed meet these criteria.  An additional concern related to this provision is that DMAS and its enrollment broker MAXIMUS do not maintain records that identify which dual eligible beneficiaries have supplemental insurance in effect.  Facilities are encouraged to identify residents with this type of coverage and communicate the CCC participation restriction for individuals with this coverage.

DMAS has developed a table of CCC rates for Medicaid services provided under the demonstration between April 1, 2014 and June 30, 2014.  The rate file is available on the DMAS website.

As mentioned in a February 6th CareConnection article, DMAS is hosting Town Hall meetings in each of the five CCC regions in Virginia.  The Town Hall meetings include presentations from DMAS and the CCC partnering organizations, including each of the MMPs.  Town Hall meetings scheduled for the Phase I regions include a Tidewater meeting held on March 5th in Virginia Beach and a Central Virginia/Richmond meeting to be held in Fredericksburg on March 25th.  Information for the Fredericksburg meeting is included below.

Central Virginia/Richmond CCC Region Town Hall Meeting
10:00 am- Provider Session
12:00 pm- Enrollee/Advocate Session
Location: John F. Fick III Center
1301 Sam Perry Blvd., Fredericksburg, VA 22401
Registration Requested at