MCOs- Medicaid managed care merger starts Jan. 1 in Virginia

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[MM Curator Summary]: VA is pulling together their 2 different Medicaid managed care programs.


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Virginia health care providers want the next multi-billion-dollar, Medicaid managed care contract to tackle longstanding complaints about insurers’ practices – but the state and insurers say the imminent merger of the state’s two managed care programs could fix many of those.

On Jan. 1, the state will merge the two programs, which cover virtually all the 1.8 million Virginians whose health care is paid for by the $18.7 billion, joint federal-state system.

It contracts with six insurers, formally called “managed care organizations” or MCOs, to run the plans the two programs offer Medicaid recipients.

But what insurers’ guidelines for their coverage can differ depending on which program their plans come under, even if the insurers have plans for both programs, said Doug Gray, executive director of the Virginia Association of Health Plans.

“I think that’s where a lot of confusion comes up,” he said.

Providers sometimes think they’re dealing with one program when their patients are actually in the other, he said.

On Jan. 1, the new “Cardinal Care” will merge the Medallion 4 managed care plans that serves children, pregnant women and adults – that last category has grown with Medicaid expansion, since in years past only very low income parents qualified – and the Commonwealth Coordinated Care Plus plans that serve older adults who also are on Medicare, children and adults with disabilities, and individuals in long term care.

Cardinal Care won’t change or reduce any existing coverage, the state’s Medicaid agency, the Department of Medical Assistance Services, said.

But looking ahead to the negotiations for a new five-year managed care contract with insures, providers at a DMAS advisory group, said it needed to be written to address their complaints about denials of coverage for specialized services.

The state plans to begin negotiations on a new five-year contract next year and to nail down an agreement by 2024. That contract will succeed the current contract which expires in fiscal year 2026.

It will involve a complicated juggling of the interests of several actors — patients, doctors and other providers some of whom are often at cross-purposes, MCOs — and the state agencies involved with the program — DMAS, which handles the money and sets the rules and the Department of Social Services, which determines which individuals are eligible for coverage.

Providers and insurers clash most often.  

Providers are often ignored when they bring issues to an insurer, said Marcia Tetterton, executive director of the Virginia Association for Home Care and Hospice.

Jennifer Faison, executive director of the Virginia Association of Community Services Boards, said the new contract needs to ensure more accountability over insurers’ utilization review – the process by which the firms decide whether or not a service will be covered.

The kind of work that’s the focus of Virginia’s community services boards — mental health care outside of hospitals – will be a major emphasis in the new contract, Secretary of Health and Human Resources John Littel has said.

This year has already seen a major step up in Medicaid’s mental health coverage with last December’s expansion of coverage for multisystemic therapy, intensive treatment for youth aged 11 to 18; functional family therapy, short term treatment for disruptive youth; 24-hour-a-day mobile crisis response; community stabilization for people recently receiving crisis care and short term residential stays in a crisis stabilization unit.

Craig Conners, director of payer relations at the Virginia Hospital and Health Care Association said standards for when an insurers’ network of doctors, hospitals and other caregivers is deemed adequate needs to be looked, while coordinating care when a patient is discharged is a problem.

Cardinal Care should make it easier to manage gaps in care, the Medicaid agency says, and it will provide care coordination services as needed.

The unification of Medallion 4.0 and Commonwealth Coordinated Care Plus into Cardinal Care should also simplify processes for contracting with providers and their credentialing, the Medicaid agency said.