Opportunities and Threats
Managed
Long
Term
Care
and
Support
Services
Growing Aged, Blind
and Disabled
Population
Increased cost of
delivering institutional
and community based
long‐term care services
Financial Alignment
Demonstrations
Authority in the Affordable Care Act allows CMS to test capitated and
managed fee‐for‐services financial alignment models and seeks to
improve care and control costs for dually eligible Medicare and Medicaid
Virginia was one of the first states to be approved for a capitated
financial alignment demonstration (Managed Long Term & Acute
Care).
Dual Eligibles often have complex health care needs with multiple
chronic disease, low income, inadequate housing and transportation.
The current delivery system is fragmented, and Medicare and Medicaid
often work at cross purposes and impede care coordination.
Medicaid and Medicare have overlapping and sometimes conflicting
benefits and requirements.
Our goals were to create a seamless, integrated service delivery system,
align Medicare and Medicaid rules, improve accountability, produce
savings AND improve long‐term and health care services for a very
vulnerable population.
Managed
Long
Term
Care
and
Support
Services
Virginia’s capitated demonstration, Commonwealth
Coordinate Care, launched in April 2014 – expires
December 2017.
Provider meetings occurred on a regular basis Phase in periods were established
Prior to the launch extensive review occurred
Health plans were selected
Networks “were established”
Three way contracts between the health plans, Virginia Medicaid and Medicare were signed.
Early
Challenges
Overly ambitious timeline for implementation
Program details were still under construction as enrollment started
Confusion among beneficiaries
Some beneficiaries opted in and out of the program multiple
times in one day
Passive enrollment was done with incomplete logic data
Confusion among providers
Letters of intent to participate are not the same as a contract
Credentialing must occur and is a long drawn out process
Welcome letters identify you have been credentialed and are
in network
Early
Challenges
Managed Care Plans lacked experience working with long‐ term care providers
Managed Care Plan contracts did not fit community based care
Unanticipated difficulties with maintaining continuity of care due to beneficiary opting in and out
Low enrollment
Medicaid beneficiaries could not be located
Poor health literacy, English as a second language, cognitive impairments, etc.
Information exchange systems had not been tested
Providers did not have real‐time enrollment information
Beneficiaries did not know their status and failed to re‐ enroll in Medicare Part D
Co‐pays who is on first what is on second
Plan hopping by beneficiaries did not allow for
meaningful health assessment, care plan development
or coordinated services
Case management was nonexistent
Early
Challenges
Health plans faced significant challenges in developing
provider networks
Long term care and support service providers had
limited experience with managed care and vice a versa
Managed care has it’s own language
Managed care organizations are large Dreaded telephone tree and website
Consumer directed care presents challenges
Early
Challenges
Prompt payment was a challenge due to
Transition from API to NPI
Clearing house processing “new” to some
Paper CMS 1500 for many waiver providers delayed payment
Billing p0rtles did not exist
Unclean claims result in non payment
Authorization process in general terms worked well
Continuing
Challenges
Continued concern regarding the lack of care
coordination
Transition protections mask network inadequacies
Increased administrative cost in back office
Billing
Contract maintenance
Chasing unclean claims
VAHC is moving forward with language that would require all
claims to be settled in 30 days – placing the burden on the
What range of services does the provider offer?
What assurances can a provider offer that the right people, with the right training will show up at the right time?
What quality metrics can a provider offer?
How reliable are the caregivers? How is reliability measured?
Pricing. How will prices be negotiated?
Providers are likely to see utilization pressure
Be prepared to drive and demonstrate your outcomes (prove value and cost‐effectiveness)
What
providers
need
to
know
How will consumers be moved into managed care? All at one time or will the
transition occur in phases?
Will all providers continue to provide care during the transition period? Non
par provider reimbursement?
Will providers be required to provide any new or different information during
the transition period?
Will care continue at current levels during the transition period?
Will providers be expected to take on new Medicaid consumers during the
transition period?
What are the reporting requirements during the transition?
Describe when and how consumers can switch payers (process and frequency) How will the claims process change?
Where will claims be sent? State? Health plan?
Audits
How often will the audits occur?
Define the conflict resolution process under the
Medicaid managed care contract
Who, at the health plan, serves as the “tie‐breaker”
when conflicting information is provided?
What
is
Quality
How is quality defined by the health plan? State?
Whose definition wins?
Important to understand how parameters around
quality can lead to an issue of conflicting information
and the necessity of a tie breaker
Define the conflict resolution process under the
Medicaid managed care contract
Who, at the health plan, serves as the “tie‐breaker”
What is the timeframe for submitting a claim?
What is the timeframe for getting a claim paid?
Health plans require “clean claims”—what does that mean?
Who will communicate with consumers? Multiple communications coming from multiple sources can be confusing and frustrating for consumers
Describe the appeals process
Identify any reporting requirements that will be placed on providers by the health plan
What information has to be reported? When? By what method?
Opportunities
Have a list of managed care contacts
Hold meetings Collaboration
Identify best practices
Don’t be afraid to ask for things
Help identify ways to improve care, reduce care, and
provide exceptional services
Create an environment where your organization is a
Contact
Information
Marcia Tetterton, MS, CAE Executive Director
Virginia Association for Home Care and Hospice 3761 Westerre Parkway, Suite B
Richmond, VA 23233 804-285-8636
Fax 804-288-3303 www.vahc.org
