Commonwealth Coordinated Care (CCC) Update – Expansion Edition

As we have reported in previous CareConnection articles, the Department of Medical Assistance Services (DMAS) recently approved several localities previously only subject to voluntary enrollment under CCC to move to passive, or automatic, enrollment of recipients eligible for the program.  This move was predicated upon the approval of network adequacy of a second Medicare/Medicaid Plan (MMP) in each of the localities affected.  The specific localities affected, by region, are:

Northern Virginia   Roanoke Region   Western/Charlottesville Region
Arlington Co.   Wythe Co   Staunton
Loudoun Co.        
Alexandria        
Falls Church        

 

 

 

 

 

 

 

With coverage under CCC effective July 1, 2015, eligible recipients in these localities have likely already received their initial CCC plan assignment to one of the two MMPs in each of these localities (Anthem HealthKeepers or Humana).  Once assigned, the MMP begins the process to enroll the individuals in the plan.  Part of this process includes the initial assignment of a Primary Care Physician (PCP) which serves not only as the primary care-giver, but also as the gatekeeper, so-to-speak, for referrals and treatment orders.  Eligible individuals who do not choose to opt-out will receive assigned MMP materials (including their MMP membership card, with PCP designation) approximately 30 days prior to coverage (around June 1st).

If you have followed the discussion of CCC since the coverage under the program began a little over a year ago (in Tidewater and Richmond, with other regions following), you will recall that one of the major issues encountered was the “misassignment” of PCPs to nursing facility residents.  By “misassignment”, we mean assignment of physicians who were unable or unwilling to provide for the unique needs, and statutorily driven care obligations, of the nursing facility residents.  As it turned out, PCPs were unaware that they had taken on this population in their workload, and nursing facilities had not credentialed these practitioners to do so, even if they were actually willing to enter this niche role.

Whenever passive enrollment is implemented, the continuity of care provision is invoked, whereby existing provider relationships and care plans are honored for up to 180 days by the MMP regardless of a provider’s network participation with the MMP.  While this serves to cushion the blow of PCP misassignment, it became abundantly clear that proper alignment of nursing facility medical directors and/or attending physicians to CCC-covered residents made coordination with the MMP much easier.  We strongly recommend you urge your physician providers, as well as other ancillary providers who provide care in your facility, to consider network participation with the MMP.  Again, folks in the other CCC regions have learned the hard way that network participation by these providers can ease the transition significantly.

As far as PCP assignment, both Anthem and Humana have indicated a willingness to consider your list of attending physicians against their network directory to guide the preliminary assignment of the PCP. Unfortunately, there is only a brief window (approximately the next two weeks) of opportunity where this collaboration can make a difference, due to the required timing for sending plan materials, including PCP assignment.

Steps to take to ease the transition:

  1. Check the eligibility status of your residents against the ARS or MediCall systems – DMAS indicates that CCC enrollment status with initial MMP assignment, with an effective date of July 1, 2015, should already be apparent on the eligibility status; and/or, contact Matthew Behrens of DMAS (Matthew.Behrens@dmas.virginia.gov) and request on-going monthly CCC enrollment reports for your facility(ies)
  2. Contact Humana (rmay1@humana.com, wrobinson10@humana.com or Va_Duals_Inbox@humana.com) and/or Anthem (stephanie.labus@anthem.com or Amy.Brunt@amerigroup.com) to provide the current physician(s) providing day-to-day primary care to residents scheduled to move under CCC July 1; the MMPs have indicated a willingness to consider PCP assignment to these practitioners to the extent they are participating in the MMP’s network
  3. Provide other ancillary provider lists (labs, mobile x-ray, pharmacy, etc.) MMP for network participation discussions – encourage those providers to consider network participation.