Commonwealth Coordinated Care Update

On September 24th, the Department of Medical Assistance Services (DMAS) announced in an email message that the agency had approved provider agreements submitted by Virginia Premier Health Plan, Inc. including the plan’s nursing facility agreement.  The message also indicated that DMAS had approved all agreements submitted by HealthKeepers (Anthem/WellPoint) except for the nursing facility agreement.  Finally, the Department indicated that none of the provider agreements submitted by Humana have been approved at this time.  VHCA has obtained a copy of the Virginia Premier agreement and is now reviewing the document.  Virginia Premier officials stress that the approved plan will serve as a template for individual provider agreements and provides the flexibility to incorporate contact provisions that foster innovative and effective approaches for care coordination.

In discussions earlier this week, DMAS officials confirmed that the Centers for Medicare and Medicaid Services (CMS) has still not issued blended Medicare-Medicaid rates to health plans participating in Virginia’s dual demonstration.  Given that participating plans do not know how much they are going to be paid by CMS and DMAS under the Commonwealth Coordinated Care (CCC) demonstration, we encourage our members to delay the execution of provider agreements until the plans are able to provide more payment details.

In connection with our ongoing evaluation of the CCC, DMAS officials recently indicated that the agency and CMS are prohibited under federal laws and regulations from mandating payment provisions to health plans in connection with Medicare services provided within Medicare Advantage contracts.  CMS contends that managed care organizations are functioning as Medicare Advantage plans within the demonstration.  We are continuing to explore options for both CMS and DMAS to require health plans to adhere to fair payment practices with respect compensating providers, including nursing facilities, for Medicare related services delivered to dual eligibles.