DMAS Announces MCO Awardees for Commonwealth Coordinated Care

Late today, we received information from the Department of Medical Assistance Services (DMAS) that the agency, in conjunction with the Centers for Medicare and Medicaid Services (CMS), has selected three managed care organizations (MCOs or health plans) to participate in Virginia’s dual demonstration – Commonwealth Coordinated Care.  The awardees are Anthem HealthKeepers, Humana and Virginia Premier.  Each of these three health plans will compete in all demonstration five regions.  A ten-day protest period now begins to allow unsuccessful health plans to appeal the DMAS/CMS decision.

We are aware that at least four MCOs are attempting to contract with nursing facilities within the Demonstration regions even prior to today’s DMAS award announcement.  Based on some of the language in the proposed contracts members have reported to VHCA, it appears additional clarification and detail is still needed from DMAS and the MCOs in several key areas.  VHCA’s Managed Care Committee will be meeting with DMAS staff July 10th to discuss significant contracting elements between health plans and nursing facilities.  Based upon the outcome of that meeting, we will update members with additional information and educational materials.

We understand that several of the MCOs are assigning July dates that the signed contracts are due back to the plans. VHCA queried Karen Kimsey, DMAS Deputy Directory for Complex Care Services, about the appropriateness of this timeframe.    Ms. Kimsey indicated that “It is premature for MCOs to require signed contracts with providers for participation in the Commonwealth Coordinated Care program at this time.  DMAS anticipates that contracting efforts between health plans and nursing facilities would likely occur in the next two to three months subsequent to the Department’s initial discussions with MCOs surrounding efforts to develop the three-way contracts with plans and CMS.”

In light of this guidance from DMAS, we caution VHCA member nursing facilities to carefully evaluate requests by MCOs to form contractual relationships with MCOs until we have had an opportunity to provide members with additional information from DMAS.

Following the conclusion of the 10-day protest period, DMAS and CMS intend to begin MCO readiness reviews and draft the three-way (CMS/DMAS/MCO) contract.  During August and September, DMAS and CMS plan to finalize Medicaid capitated rates to MCOs and finalize and execute the three-way contracts. The Demonstration is currently scheduled to begin on February 1, 2014 and continue until December 31, 2017, unless terminated earlier in accordance with provisions of the executed Memorandum of Understanding (MOU).  

The Commonwealth Coordinated Care program will operate in five specific geographic regions within the Commonwealth – Northern Virginia, Central Virginia (including Richmond), Tidewater, Western/Charlottesville and Roanoke.  In those regions, the population that will be eligible to participate in the Demonstration will be limited to individuals ages 21 years and older at the time of enrollment who are entitled to benefits under Medicare Part A, enrolled under Medicare Parts B and D, receive full Medicaid benefits including individuals enrolled in the Elderly or Disabled with Consumer Direction (EDCD) Waiver and those residing in nursing facilities.

The dual demonstration will evaluate the effect of an integrated care and payment model on serving both community and institutional populations.  In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except for specific exclusions identified in the MOU, participating MCOs will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations as well as program specific and evaluation requirements, as will be further specified in a three-way contract to be executed among the health plans, DMAS and CMS.

While very little information exists in the way of practical operating and payment details about the Commonwealth Coordinated Care program, key planning considerations for nursing facilities located within one of the five Demonstration regions include the following:

•    Any willing nursing facility provider may participate in the Demonstration as long as they are willing to accept the payment rates offered by the MCO.
•    MCOs must pay nursing facilities for Medicaid-related services no less than equivalent fee-for-service rates in effect.
•    The MOU officially removes the requirement for a qualifying three-day acute hospital stay in order for a beneficiary to qualify for skilled services coverage in a nursing facility