Action | CCC Plus - Part 1 |
Stage | Emergency/NOIRA |
Comment Period | Ended on 8/9/2017 |
3 comments
One policy that goes into effect in August 2017 is the huge Medicaid/Medicare upheaval known as Commonwealth Coordinated Care Plus which affects every population that I currently work with. Most importantly, it affects the adults with ID and DD that I work with daily and has caused much chaos due to the uncertainty surrounding the differences in coverage that are vital to these individuals lives who already receive so little. All remaining Medicaid populations and services such as community-based and home-based services along with LTC services will be mandated to utilize CCC Plus. During the CCC pilot program last year, potential enrollees (you had to have Medicaid and Medicare) had the option to choose from three different insurance companies. The information that wasn't widely distributed was the fact that there was an "opt out" option for individuals at this time. Individuals had a choice and that has since been taken away by this mandated inclusion. CCC Plus seeks to provide cost-effective, coordinated and managed care system of delivery within 280 days of its enactment. When describing why this change is needed, this regulatory action is described as needed for the welfare, safety and health of citizens that receive long-term services and supports from Medicaid so they can receive higher quality of care and care coordination. Jargon like person-centered, high-touch and improving quality with a managed care model and breaking free of a fee-for-service delivery system are but distractions. But let me ask, how is this person-centered when the person(s) it impacts have no choice? The argument for the emergency behind its implementation is that currently long term services and supports are not sustainable as the rates of those requiring Medicaid rises. There is no indication as to how the quality of services will be improved. This is a better managed way to save money by placing "Big Brother" on the forefront to ensure that one extra dime isn't taken from the greedy hand of state and federal public assistance if it isn't warranted by care coordination. Care coordination is a fancy way of describing the magnifying glass with which these MCOs will be holding down on those who are mandated to be a part of CCC Plus to ensure they don't receive one appointment or service past what is minimally needed. Public participation is encouraged in relation to cost and benefit alternatives, impacts and ideas on the development of CCC Plus yet not one person has left a comment? Is there even a point? This is happening whether or not this is commented upon. What is the most absurdly ironic happenstance regarding this regulatory action is that it seeks to provide a higher quality of care but also incorporates more control on budget predictability. We can all agree that individuals receiving Medicaid and/or Medicare (soon to be CCC Plus) don't have much in the way of disposable funds. The last sentence of the Town Hall Agency Background Document states "may decrease disposable family income depending upon which provider the recipient chooses for the item or services provided." What this really means is "stay in network or you're screwed." No matter how much fancy jargon, service quality promotion, or emergency propaganda the state spouts about this mandated change, one thing is for certain: it is NOT person-centered, it limits vulnerable populations even moreso than before, it provides more stringent guidelines on in-network healthcare and takes advantage of marginalized populations by forcing them to seek out of network care on their own dime.
As a professional who works with individuals who receive Medicaid benefits, I strongly oppose this new mandated managed care program known as CCC Plus. According to the information provided on Virginia.gov, it claims to be person-centered. However, I am unsure how this can be true if individuals will have to leave their existing doctors and choose one from a limited list of providers. I cannot see how providing less choice can be person centered.
Additionally, not enough information and data has been released to effectively determine if this program will actually save the Commonwealth money. Unlike a fee for service model, the CCC Plus model pays a certain amount to providers on a monthly basis to provide care. If individuals who have Medicaid are not using services, that money is being collected by providers and not spent on patient care. I feel that more research needs to be done before implementation.
I have seen first hand the effects of privatization of Medicaid in Virginia. Magellan in the Southwest Virginia Region has created nothing more than unrealistic rules and regulations aimed at reclaiming funds during audits as well as adding more forms and documentation requirements that do nothing more than limit the face-to-face care a professional can provide to an individual.
If Virginia truly wants person centered care, they would look at the needs of the people rather than their bottom line.
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Intro
Moms In Motion/At Home Your Way, service facilitation provider, is responding to the emergency text for the CCC Plus managed care program that Virginia’s Department of Medical Assistance Services has adopted by direction of the Commonwealth’s General Assembly to manage health care costs and service care coordination. We hope our commentary is and suggestions are confsidered during the phased implementation and in the final regulation. Additionally, we propose inquiry for further interdisciplinary and interagency, with input from people utilizing services within CCC Plus managed care, discussion requiring immediate attention as well as clarification in this emergency regulation.
General Commentary
Regarding 12VAC30-120-610, during the initial enrollment of all CCC plus managed care program eligible individuals beginning July 1st through January 1st, there is an appropriated 90 day continuity of care period with an initial 90 days to change plans. During the initial 90 days, individuals are allotted the ability to change their plans, yet there is no system established for service providers to be able to accurately check eligibility and managed care enrollment. Waiver service providers are accountable for assuring eligibility prior to submitting any service authorization to the managed care organization. However, the VAMMIS portal is only updated by the 18th of each month for the month for up to 10 individuals at a time when service providers necessitate accurate enrollment and eligibility statuses in real time. For providers like Moms In Motion/At Home Your Way, this is an ineffective system when servicing over 4,000 individuals. Not only are providers inefficiently able to identify the enrollees managed care provider but also their Medicaid eligibility. During the CCC pilot program, we realized several issues with verifying eligibility and managed care enrollment which caused several instances of lapses in service. While our agency regularly checks VAMMIS for Medicaid eligibility, it is impossible to review four thousand plus individuals daily. VAMMIS is also not reliable as there is a delay between an individual notifying DMAS or the enrollment broker and the request being submitted and updated in VAMMIS portal. This presents an operational difficulty to submitting “clean claims” to the appropriate managed care organization but may also affect honoring the initial service authorization start date especially when service authorizations are initially submitted to the incorrect managed care organization under no fault of the participating provider due to delayed eligibility checks within the current system. The availability of running an active/live report for eligibility and MCO enrollment for a large number of enrollees will be extremely necessary during the initial enrollment, open enrollment, enrollment into an MCO after 60 days of nursing or intensive care facility admission, and intermittently through the year for those that are enrolling or who have met the exceptional criteria for cause to dis-enroll.
Moms In Motion/At Home Your Way is in support of the CCC Plus managed care program stipulation that the contracted MCOs are not to be less restrictive than the department as stated in 12VAC30-120-620. MCO responsibilities; sanctions under subsection C.
Immediate attention to the disruption of consumer directed service authorizations for the initial region phase in for the Tidewater region enrollees is required. During the move of service authorizations from Kepro to the individual MCOs, it has been identified that service authorizations have been ended and for several enrollees no longer showing in the portal for Public Partnerships, the fiscal agent. A number of enrollees have received letters from DMAS stating that their service authorizations have ended as of 7/31, one day prior to the 8/1 phase in of Tidewater. For families that depend on medically necessitated waiver services, this error threatens the safety, health and stability of the lives for enrollees and their families. Additionally, employers of record effected by this error have no assurance of service authorizations to schedule their attendants. Likewise, attendants are left with uncertainty of their employment and with this uncertainty are likely to quit their work for the enrollee further threatening the safety, health and stability of the enrollee and their family. Immediate action by the Department of Medical Assistance Services is necessary to correct this error and to ensure that subsequent regions do not realize this same error. As a service facilitation agency, Moms In Motion/ At Home Your Way believes in quality customer service and maintaining our integrity. This error presents understandable confusion and frustration to the individuals and families that we serve who turn to us for answers and problem solving. This issue is beyond our capacity to solve but we are confident that DMAS will implement an immediate resolution and assure that the transfer from Kepro to the MCOs will not disrupt the vital waiver services that individuals and families depend on daily.
Individuals, families and their paid providers will ultimately be affected by any identified or subsequently experienced issues with the implementation of the CCC Plus managed care program plan. Responsible, effective and efficient processes and procedures should be established prior to implementation to ensure the health and safety as well as continuity of care for those that rely on Medicaid waiver services. Prevention of delays in service authorizations is imperative to the continued coverage of Medicaid waiver services necessary to ensure the health and safety of the enrollee. In the instance of consumer directed services, the reliability of a paid attendant’s care is largely affected by the employer of record’s assurance of approved authorization and subsequent schedule to the paid attendant(s). Any delays in service authorization presented by changes in waiver processes as altered by the implementation of managed care will ultimately disrupt the consistency and continuity of care for the enrollee with consumer directed services as the attendant is not assured hours until approved while the enrollee presents medical need for waiver services that they have chosen under the freedom of provider and service choice. Collaboration in regulatory changes should be established with representation across all service providers and the Commonwealth departmental representatives as well as input from the state’s stakeholders in current and future regulatory changes from the state and federal level.
General Statements for MCOs and DMAS
Referenced Commentary by VAC Section
4. 12VAC30-120-660. Prehearing decisions.
A. 2.c._”The action being appealed was not taken by the MCO”_We are requesting clarification of this reasoning. Does this mean that the appeal process will be dismissed when the MCO never acted upon a denial?