Commonwealth Coordinated Care: MCO Contracting

Due to the significant potential impact for our members, we are repeating this article from last week's CareConnection.  The Department of Medical Assistance Services (DMAS) along with the Centers for Medicare and Medicaid Services (CMS) recently announced that they have 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 five demonstration regions.  A 10-day protest period is now underway to allow unsuccessful health plans to appeal the DMAS/CMS decision.

We are aware that at least two of the three selected plans are attempting to obtain signed provider agreements with nursing facilities within the Demonstration regions and were doing so even prior to last week'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 next week to discuss significant issues yet to be resolved by DMAS and CMS.  Based upon the outcome of that meeting, we will update members with additional information and educational resources.

We understand that several of the MCOs are assigning July dates that the signed agreements 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.