Commonwealth Coordinated Care Update

Efforts and discussions continue as VHCA members work with leadership from the Department of Medical Assistance Services (DMAS) and representatives of all three health plans contracted to operate Virginia’s dual eligible financial alignment demonstration, the Commonwealth Coordinated Care (CCC) program, to address a number of operational issues that remain unresolved.  Earlier this week, a workgroup assembled to focus on several key claims and payment issues met with DMAS and all three Medicare-Medicaid plans (MMPs).

The discussion topics for the meeting included the status of efforts to test claims submission and payment capabilities for all three MMPs and an assessment of early claims experiences for initial billing for a small number of CCC beneficiaries now receiving services under the opt-in phase of the demonstration in the Tidewater and Richmond/Central regions.  Other key discussion topics included:

  • Status of provider contracting with the three MMPs;
  • Claims submission considerations for nonparticipating providers;
  • The automatic/passive beneficiary enrollment process now underway in Tidewater;
  • Post-payment review activities anticipated to be utilized by each of the MMPs;
  • Difficulties with determining resident enrollment status;
  • Provider payment backup plans and provisions; and
  • Status of efforts by the Center for Medicare and Medicaid Services (CMS) and DMAS to develop “safe harbor” communication guidance for use by nursing facilities in responding to CCC enrollment questions from residents and their families.

Despite the fact that the CCC has now launched in the Tidewater and the Central/Richmond regions, it appears that a significant number of nursing facilities have not finalized provider agreements with one or more of the MMPs.  As it is public information disclosed on each of the MMP websites, each health plan agreed to provide VHCA with a file reporting contracted and non participating (no agreement has been executed to date) nursing facilities as of mid-May.  

Nursing facilities now providing services to CCC beneficiaries that have not contracted with the health plan to which the beneficiary is assigned may still submit claims to the MMP for services delivered as a nonparticipating provider (out of network).  Those facilities are strongly encouraged to contact the MMP and provide tax identification (W-9) and National Provider Identifier (NPI) information prior to submitting claims to avoid the pending of those claims by the health plan.

During this week’s meeting, DMAS Deputy Director Karen Kimsey informed members of the workgroup that a problem has been identified in connection with the “intelligent assignment” algorithm used to assign CCC eligible beneficiaries to one of the three MMPs within the Tidewater region.  Unfortunately, the 60-day notification letters received by approximately half of the eligible beneficiaries in Tidewater will be rerun and a new health plan assignment indicated in a mailing anticipated to occur within the next two weeks.  This corrected communication is likely to create additional confusion for both residents and the nursing facilities now providing their care.  This disclosure by DMAS prompted a renewed discussion about the frustrations that providers are experiencing in connection with determining CCC enrollment status for their residents.  This process now focuses on the DMAS Automated Response System (ARS) which limits beneficiary inquiries to ten individuals at a time.  DMAS has acknowledged that there are shortcomings with this approach and now believes that providers will soon be able to refer to the 270/271 reports to identify MMP assignment for their residents.  Ms. Kimsey indicated that DMAS is awaiting confirmation that the 270/271 report will contain accurate MMP assignment information needed by all providers of services to CCC enrollees including nursing facilities.  

In past CareConnection issues, we’ve reported the challenges and difficulties that member facilities are encountering as they face questions from their residents and family members related to CCC enrollment.  The enrollee’s decision to change MMPs or opt-out of the CCC rests with them or their authorized representative.  We have communicated to DMAS that nursing facilities often assist residents in an informal capacity when they have no family or other legally recognized individual to act on their behalf.  Additionally, there are times when individuals within provider organizations are appointed as guardians to legally act on behalf of residents who are no longer able to make decisions due to cognitive deficiencies.  

During this week’s CCC workgroup meeting, we again stressed the critical need for guidance in this important area.  DMAS responded that they are working to develop resources for providers and expect to have a review draft available in the near future.  In the interim, we strongly encourage that all member facilities refrain from writing or calling the CCC enrollment broker, Maximus with opt-out requests unless acting at the specific direction of the resident who has a physical limitation that prevents them from placing a phone call.  Requests to Maximus to opt-out of the CCC must be initiated by the beneficiary or their responsible party and can only be made via phone call.  Based upon informal guidance from DMAS, in the case where a nursing facility is providing assistance to their resident in connection with contacting Maximus by phone, we suggest that such calls be made for an individual resident and that no attempt is made on the part of the facility to group multiple residents with CCC changes into one call.  The CCC beneficiary toll free help-line operated by Maximus is 855.889.5243.

DMAS has clarified that nursing facilities located outside of the five CCC demonstration regions with residents that have received enrollment letters can assist with notification and requests directly to DMAS (not Maximus) that the beneficiary resides outside of CCC geographic boundaries and should be removed from the beneficiary roster.  Facilities may contact Tammy Whitlock, Director, Division of Integrated Care & Behavioral Services at 804.225.4714 or tammy.whitlock@dmas.virginia.gov for additional instructions.  Please do not send PHI to Ms. Whitlock via email.  Upon contact with her, she will provide members with instructions for securely communicating beneficiary information to her.  We are aware that three counties initially included in one of the five CCC regions have been temporarily removed from the demonstration as a result of the failure of the MMPs to develop an adequate network of providers.  The identified counties are Accomack, Loudoun and Mecklenburg.  Facilities located in those counties may follow the process described above for requesting that residents be removed from the CCC eligible beneficiary roster.

We are working to finalize an education program to be held June 17th and 18th in Richmond.  This day and a half program is being developed to provide member facilities with the latest information needed to successfully transition from the traditional fee-for-service environment for Medicare and Medicaid services provided to dual eligibles to operating under managed care.  Information about this program will be posted at www.vhca.org early next week.  Additionally, we are also planning to offer claims workshops at several locations around the Commonwealth.  These workshops are intended to enhance the skills and capabilities of business office and claims personnel as they prepare for the challenges ahead.