Commonwealth Coordinated Care Update

Despite a number of unresolved issues and many unanswered questions, the Department of Medical Assistance Services (DMAS) continues to move ahead with efforts to launch the Commonwealth Coordinated Care (CCC) program.  Beginning April 1st, approximately 1,400 dual eligible beneficiaries who voluntarily enrolled in the program began receiving services under the CCC.  According to information shared this week by DMAS, only 50 of these 1,400 individuals are residing in nursing facilities in the Tidewater and Central/Richmond regions of the CCC.

As has been reported previously, automatic or passive enrollment is scheduled to commence in May for all remaining identified dual eligible beneficiaries.  Services for those individuals will begin on July 1, 2014 in Tidewater and August 1st in the Central/Richmond region.

Since late January, VHCA has participated in a series of workgroup meetings facilitated by DMAS with representatives of Anthem HealthKeepers, Humana, Virginia Premier and DMAS staff.  These meetings have focused on operational and financial concerns listed below which were identified and communicated to DMAS in late 2013.

Track #1: Authorizations and reauthorizations requirements

  • Implement common approaches to the referral, verification of benefits, approval of admission and admission into nursing facility/center process
  • Implement common approaches  to the reauthorization process, including frequency, method of communicating necessary information, time frames

Track #2: Payment determination and claims submission and processing (including testing)

  •  Seek common approaches for payment of Medicaid patient pay and Medicare bad debt
  •  Undertake comprehensive walkthrough to reach common approaches to the process surrounding payment for services including billing (claims submission), receipt of funds, patient liability, requests for additional documentation and appeals

 Track #3: Care coordination, quality metrics and monitoring and the remaining clinical/operating issues

  • Explore other key processes anticipated to be used between each of the three health plans and nursing facilities and explore ways to standardize these processes along with related procedures and forms
  • Clearly define care coordination function, including time frames for completion of initial assessments and plans of care, how communicated, how to address differing opinions/recommendations between health plan and SNF, how to maintain regulatory compliance in all aspects of care coordination, how the MDS will be incorporated into the process, role of “on-site” coordinators from health plans 
  • Implement common approaches to the transition/discharge planning process, including authorizations needed for services required in the discharge destination, time frames, “difficult to discharge” patients (needing ALF level of care, etc. or no willing/able caregiver, etc.)
  • Clearly define quality metrics for both SNFs and the MMPs and reach common approaches to monitoring, reporting and use of information


Unfortunately, despite the investment of considerable time and effort on the part of VHCA members and staff, we are unable to report meaningful progress in obtaining the cooperation of the three contracted Medicare-Medicaid Plans (MMPs).  Prior to a workgroup meeting that took place on April 9th, MMPs had offered their meaningful cooperation specifically related to authorization and reauthorization requirements.  During the April 9th meeting, some of the MMPs informed the provider workgroup participants and DMAS staff that they were retracting their offer related to the Track #1 topics outlined above.  We have communicated to both DMAS leadership and to the Secretary of Health and Human Resources office that without the meaningful cooperation of the health plans on this and many other issues providers will find it very difficult to operate effectively within the CCC program.  Additionally, efforts to enable all nursing facilities to commence claims testing with the MMPs are currently stalled due to the failure on the part of health plans to provide clear instructions to providers to submit test claims.  DMAS is attempting to facilitate the communication of claims testing instructions to providers.

In an effort to better understand remaining issues facing member facilities, VHCA will be surveying members early next week to find out which providers have contracted with specific MMPs.  This brief survey will also ask for information about the existence of third party liability insurance coverage within each facility’s resident population (see related article below) for the purpose of projecting the number of beneficiaries that are likely eligible to participate in the CCC program.