Commonwealth Coordinated Care Update

On December 17th, members of the VHCA’s Ad-Hoc Managed Care Committee met with representatives of all three health plans that have been selected by the Department of Medical Assistance Services (DMAS) and the Centers for Medicare and Medicaid Services (CMS) to participate in Virginia’s Commonwealth Coordinated Care program (CCC or dual demonstration). The meeting was structured to allow the committee to meet with the three managed care organizations (MCOs) separately for purposes of discussing the status of efforts by each health plan to address a range of operational issues that are considered essential to the successful coordination of activities and communications between MCOs and nursing facilities.

In addition to representatives of the three health plans (Anthem/HealthKeepers, Humana and Virginia Premier), five DMAS staff members with responsibilities for the CCC also participated in the meeting.  The discussion topics focused on during the meeting included:

  • Specific process and workflow approval for beneficiary admission authorizations;
  • Beneficiary-specific plan of care development, approval, coordination and monitoring;
  • Protocols for beneficiary assessment and transition between skilled level services and long-stay services;
  • Communication flow between local DSS offices, DMAS, health plans and the facility with respect to patient pay liability modifications;
  • Authorization and approval process related to nursing facility to hospital transfers;
  • Authorization and process workflow related to requesting nonemergency transportation; and
  • Acceptance testing related to claims submission to health plans and the edit process in place by plans to establish “clean claim” status.

DMAS staff continues to report that the dual demonstration will launch in January 2014. VHCA remains concerned that the time available for both nursing facilities and health plans to fully address a host of operational issues is insufficient. The Three-Way Contract that was anticipated to be signed in September has still not been executed.  The delay in the contract execution has prevented nursing facilities and health plans from working to resolve operational issues that must be addressed before the demonstration begins.  Additionally, VHCA is very concerned that effective and tested care coordination capabilities that are the focus of the initiative have not been developed.  

As health plans continue their efforts to contract with providers, including nursing facilities, the Provider Agreements for all three MCOs that form the basis of contractual relationships refer heavily to the plans’ Provider Manual for detailed requirements and responsibilities.  During the meeting, the plans indicated that they are still a minimum of six to eight weeks away from having finalized Provider Manuals available for facilities to review.  We continue to encourage our members to carefully evaluate and consider any request to execute Provider Agreements until all important information is made available.

An important outcome of the meeting is an agreement among all participants – providers, health plans and DMAS – that additional meetings are needed to focus on the identification of areas where common processes and requirements can be adopted to avoid additional administrative and operational burdens that otherwise might result from the CCC implementation. A key aspect of such meetings is that representatives from all three MCOs would meet together and with VHCA members along with DMAS staff to work toward an overall objective of standardizing to the extent possible a wide range of practices, requirements and communications that will define the relationships between providers and health plans.  These meetings will likely take place in January and February of 2014.

The CCC program is intended to test a payment and service delivery model to lessen the fragmentation and improve coordination of services for Medicare-Medicaid Enrollees, enhance quality of care, and reduce costs for both the Commonwealth and the federal government.  The demonstration 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.

Earlier this week we received information from DMAS developed as a response to CCC-related questions raised during the November joint meeting of the VHCA/VCAL Regulatory and Quality of Care Committees.  To download and view the question and answer document as a PDF file, please visit our Commonwealth Coordinated Care Resource Library and select the first document Commonwealth Coordinated Care Question and Answer December 2013 (member log-in required).
Finally, we have received an analysis of the unexecuted Three-Way Contract provided by DMAS last week.  This analysis, performed by legal counsel at our request, is expected to be posted for member review in the Commonwealth Coordinated Care Resource Library within the next few days.

Please contact us if you have questions or if you need additional information.