Understanding Reached With DMAS on Managed Care

VHCA (1/25/2008)

VHCA has been engaged in discussions with the Department of Medical Assistance Services (DMAS) for well over a year related to efforts by the Department to develop and implement a plan for the integration of acute and long term care – referenced by various names and descriptions including ALTC, the “blueprint” or Medicaid managed long term care.  It is important to note that these discussions focus on a small portion of a typical nursing facility’s Medicaid resident population – specifically, residents that already have Medicaid benefits upon admission.

The latest news related to the DMAS plan highlight a delay in the overall development and implementation schedule that the Department had been working toward.  It now appears that sometime in March of this year DMAS will issue a draft Request for Proposal (RFP) for comments by stakeholders.  Once finalized, this RFP will be sent to managed care organizations (MCOs) for their use in deciding whether to submit a proposal to bid.  The initial rollout of the Medicaid managed long term care plan is not expected to occur for at least a year and most likely will target the Tidewater area as the first phase of implementation.

A key issue that has emerged from our discussions with DMAS, as well as from observations related to the relationships between nursing facilities and managed care organizations in general, is the need to insure that payment for services provided by facilities to beneficiaries covered by managed care plans is received in a timely manner and with a minimal amount of administrative burden.

VHCA recently met with senior DMAS leadership to discuss our desire to eliminate as much of the risk as possible for claims and payments associated with services provided to Medicaid managed care beneficiaries.  Again, these discussions were related to individuals who are admitted to nursing facilities with Medicaid benefits already established.  We believe that this component of a nursing facility’s Medicaid resident population is in the range of 15% to 20% on average.

As described consistently by DMAS, Medicaid managed long term care will never be an issue for all other residents who ultimately receive Medicaid benefits after being admitted as Medicare or private pay and typically go through the spend down process.  For as long as these individuals remain in the nursing facility, they will not be enrolled in managed care and will remain fee-for-service beneficiaries.

We have reached an understanding with DMAS related to claims submission and payment for residents who enter nursing facilities as participants of a Medicaid managed care plan.  We believe that the provisions outlined in the Statement of Understanding will eliminate the vast majority of the risk and concern that has been attributed to working with MCOs.  The key point of this Statement of Understanding is that claims submission and payment will continue to be made to and by DMAS, not the MCO. 

The period of time that a resident will be subject to oversight by the MCO is 60 days.  This time period will commence upon admission regardless of primary payor status at admission.  Once the Medicaid managed care plan resident reaches the 61st day of care in a nursing facility, DMAS will automatically remove them from the managed care plan and enroll them as a traditional fee-for-service beneficiary.

Members are encouraged to review the Statement of Understanding.  Prior to its finalization, VHCA’s Payment for Services Committee reviewed the document and requested several minor changes which have been incorporated and accepted by DMAS.  By design, this document is intended to serve as a conceptual framework for the Department and will be incorporated in their RFP to MCOs later this year.  The Statement of Understanding is not intended to serve as detail procedural level guidance for providers; that guidance will be developed over the next year as the Department works to implement Medicaid managed long term care.