CCC Program: Services for Passive Enrollees Effective in Tidewater July 1

The Commonwealth Coordinated Care (CCC) program for Medicare/Medicaid fully dual eligible individuals (Duals) will enter into its first effective coverage of passively enrolled recipients on Tuesday, July 1 in the Tidewater CCC region.  Tidewater and Central Virginia were the first effective regions for CCC beginning this past April, but participation was limited to voluntary enrollment of beneficiaries in this initial implementation phase.  With passive enrollment, all Duals who did not explicitly opt-out of the program, or who are excluded for a limited number of reasons (such as having other third party insurance), have been automatically enrolled in one of the participating Medicare-Medicaid Plans (MMPs) in the Tidewater region (Initial passive enrollment assignment is currently underway in the Central region for coverage effective September 1).  Initial numbers from the Department of Medical Assistance Services (DMAS) indicate approximately 10,600 passively enrolled individuals in Tidewater will begin coverage in their assigned MMP on July 1 (the number of nursing facility residents within this total enrollment number has not yet been formally provided by DMAS to VHCA, but is believed to be slightly less than 1,500 – roughly half of initial estimates for nursing facility residents in Tidewater).

VHCA has been coordinating the discussion of a number of key issues related to nursing facility coverage of CCC participants with both DMAS and the MMPs.  Many of these significant issues, while acknowledged by DMAS and the MMPs, have not yet been resolved.  For example, of significant concern is the revelation that assignment of the Primary Care Physician (PCP) by the MMPs does not appear to have considered the unique requirements for providing services to nursing facility residents.  It appears that many of the PCP assignments have been based on PCP availability generally within their contract with the MMP, as opposed to considering the high-touch needs (in-facility visits, etc.) for the nursing facility population.  Since the PCP is essentially the “gate-keeper”, so-to-speak, to needed acute care services, this is a very significant concern related to the care needs of this extremely frail population.

This problem, along with other on-going concerns, is multifaceted, and nursing facilities share some responsibility in their resolution.  For the PCP issue, it is imperative that facilities in current and future CCC regions share physician/other practitioner lists with their contracted MMPs, and to the extent they can, encourage these providers to consider participation in the MMP networks so that continuity of care can be achieved.  We are actively working with DMAS to consider auto-assignment of the existing facility-utilized physicians as PCPs for residents, but network participation is a major threshold issue in this discussion.  While the 180 day transition period represents a temporary and limited solution to the care needs of the recipient, it provides little solace in the long-term and very little relief for new residents.  

DMAS has promised an on-going commitment to work with VHCA to resolve these CCC program concerns.  Please consider participation with the various workgroup meetings and ad hoc calls; this is the best way to ensure, to the extent we can, that the unique care needs of the population you serve are addressed appropriately, as are your business needs, under the CCC program.