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.

1. Intermediary changes outside of open enrollment as aligned with section J (below) will present the same challenges to service providers as outlined above.
   J. Consistent with 42 CFR 438.56(d), DMAS must permit an enrollee to disenroll at any time for cause.
2. Throughout this emergency regulation it is stated that the MCOs should “report data to the Department of Medical Assistance Services, the Attorney General of Virginia or his authorized representative, or the State Medicaid Fraud Control Unit”. This data should be publicized to inform provider choice and stakeholder knowledge of the managed care process and quality of the MCO organizations. Included information for public reports of managed care contracting data should be inclusive of items such as data, claims reports, and quality studies performed by the MCOs.

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

1. In this regulation, it is stated that MCO’s may deny service due to “moral or religious objections”. However, the MCOs are also accountable for maintaining services that are not “less restrictive than the department”. This stipulation presents the possibility of conflict between what the department is to provide versus the moral or religious restrictions that may be presented by a contracted MCO. There is a general inquiry of what “moral or religious objections” may be presented by the Commonwealth’s contracted MCOs regarding waiver services and medically necessitated procedures or provisions.

Referenced Commentary by VAC Section

1. 12VAC30-120-620. MCO responsibilities; sanctions
   1. A.3. –States that the contracted MCOs shall “maintain record of written policies and procedures”. As a contracted consumer directed service facilitation company we have been unable to identify these records through communication with the MCOs or their websites.
   2. A. 8. –“Cost sharing” obligations shall not be set forth on enrollees except as designated by  regulation “set forth in 12VAC30-20-150 and 12VAC30-20-160 and as described in the CCC Plus contract”. What potential “cost sharing” is there? (For example, as discussed in conference with DMAS representatives there is concern that PCP visits necessitated by the simultaneous designation of EPSDT services for PCA for those under the DD waiver, CL and FIS, may require exceptional medical visits outside of what is covered by EPSDT covered well visits and coordinated costs for PCP appointments to complete the DMAS 7 and associated documentation for this service or to receive copies of records.)
   3. D. - "The MCO's coverage rules for contract covered services shall also ensure compliance with federal EPSDT [FPA1] coverage requirements for enrollees younger than 21 years of age." As this section states in cooperation with applicable CMS EPSDT rules, it is presumed that all HCBS waivers with consumer directed PCA services would be affected. At this time, there has been an adjustment to the DD waivers (CL and FIS) regarding personal care attendant supports following the guidelines of the June 30th Medicaid memo. However, this has not yet been applied to the CCC Plus waiver (combined EDCD and TA effective July 1). At what time will EPSDT rules be implemented upon the CCC Plus waiver and what estimated time for prior notice will be given to providers and medical professionals? Time to prepare operationally and inform those that will be affected is necessary to maintain quality care, responsible provision of service facilitation and trustworthy relationships.
      1. Further concern has been expressed to DMAS and continues as the EPSDT criteria is more restrictive toward children and waiver services are less applicable or available to children so that they may maintain their medically necessary waivers. Additionally, there is an identified lack of service providers available to children or disability even when the potential for waiver service is extended to the child population. A lack of providers that cater to children should be taken into consideration under the exceptional criteria for “individual consideration” while the Commonwealth departments should continue to actively encourage and establish provision of services and an array of provider choice across all demographics of the Commonwealth (disability, economics, culture, geography, etc.).
2. 12VAC30-120-640. State fair hearing process.[FPA2] _As the MCOs begin to establish relationships with enrollees and service providers it is hoped that the enrollee and their planning team, including the individual, family, medical professionals, paid and unpaid supports and service providers, are regarded as experts. Any denial of waiver and medical services managed by the MCOs should be reviewed by DMAS to ensure quality care of medically necessary services, equal standards and support of 12VAC30-120-620 wherein MCOs are stipulated to not be less restrictive than the department. Data reports on denials, absent of identifying information, should also be made public for stakeholder review to ensure consistency of services that are not less restrictive than the department and to support informed provider choice of those MCOs that are abiding by the department’s contractual agreement.
   1. B. “It is presumed that appellants will receive the MCOs final internal appeal decision 5 days after the MCO mails it.”  & J.2. “For continuation of benefits for an internal appeal with the MCO, the enrollee or representative must file the appeal before the effective date of action or within 10 calendar days of the mail date of the MCO's notice of action.[FPA3] ”_This proposed time for enrollees to initiate an appeal following denial is extremely limited and should be extended to 30 days after the MCO mails the denial. While enrollees have a time frame of 120 days to appeal final decisions of the MCO and initiate a state fair hearing process. 30 days from the mailing of an initial denial from the MCO allows the enrollee enough time to consider action, become familiar with the appeal process, collect supportive documentation and establish representation from professionals or support groups that can provide experienced direction in appeals. Enrollees and families are often their own advocates and unfamiliar with the appeal process. To support self-advocacy and determination the enrollees and their families should be afforded a reasonable amount of time to prepare and initiate appeals.
   2. J.5._” If the final resolution of the appeal or state fair hearing is adverse to the enrollee, that is, upholds the MCO's adverse benefit determination, the MCO may recover the costs of services furnished to the enrollee while the appeal and the state fair hearing was pending[FPA4] , to the extent they were furnished solely because of the pending appeal.”_This regulation is potentially exploitative of people with disabilities and minimal financial resources who necessitate the support of waiver services for their health, safety and inclusion at home, work, school and in their community alternative to institutional care.
3. 12VAC30-120-650. Appeal timeframes.
   1. G. “An extension of the 120-day period for filing a request for appeal may be granted for good cause shown. Examples of good cause include the following situations:”_As the Commonwealth of Virginia contains a large military community, an additional “good cause” grant should be extended to military families, single or dual parent, that may be deployed or otherwise ordered to serve and subsequently be delayed in receiving denial notices with appeal time frame restrictions.
   2. I. 4._”Following a hearing, the hearing officer orders an independent medical assessment as described in 12VAC30-120-670 H 1”._ 12VAC30-120-670 H 1 we are unable to identify this section of the Va Code for cross walk review between this emergency regulation and established state code.

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?