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The purpose of this bulletin is to notify providers of changes to Cardinal Care Managed Care (CCMC) enrollment for youth in Psychiatric Residential Treatment Facilities (PRTFs). Currently, youth who enter PRTFs are excluded from CCMC and are covered by fee-for-service (FFS). Effective November 1, 2025, youth receiving services in PRTFs will maintain enrollment in CCMC: 

• Youth with PRTF admission dates on or after November 1, 2025 will maintain enrollment in their CCMC Managed Care Organization (MCO). 

• Youth in PRTFs with admission dates prior to November 1, 2025 will remain in fee-for-service (FFS) until they are assigned to a MCO on November 18, 2025 and CCMC coverage becomes effective on December 1, 2025.

• Youth in a PRTF who become eligible for Medicaid after admission to a PRTF will have an initial period in FFS while awaiting assignment to a MCO.

• Youth eligible for the Foster Care Specialty Plan (FCSP) will enroll in Anthem Healthkeepers Plus.

• Under certain circumstances, youth are not eligible for CCMC for other reasons and will remain in FFS.

Payment for PRTF services will be carved out of the CCMC contract and covered by FFS.  A forthcoming update to the Residential Treatment Services Manual reflects this change.

For youth enrolled in CCMC:

1. The PRTF per diem, which includes all resident care services, is carved out of the managed care contract and reimbursed through FFS. 

2. The PRTF per diem does not include coverage for certain PRTF required services delivered by facility staff or contractors, including physician services related to assessment and diagnosis, medication management and supervision, drug testing, and psychological professional services. These PRTF required services are reimbursed separately from the PRTF per diem and will also continue to be paid through FFS.

3. Any other health care services not included in #1 or #2 above are covered by the youth’s CCMC MCO, and providers must bill the MCO directly.  Examples include physician specialists; pharmacy services; physical therapy; occupational therapy; laboratory and radiology services; durable medical equipment; supplemental nutritional supplies; vision services; outpatient hospital services;; emergency services and allowable Mental Health Services (such as mobile crisis response and limited overlaps with other services to assist with care coordination - see the Mental Health Services Manual for details). 

4. Non-emergency medical transportation (NEMT) must be arranged through the MCO. 

5. Dental and orthodontic services are covered through the Dental Benefits Administrator, DentaQuest. 

Credentialing and coordination with the CCMC MCOs 

Providers must participate with the youth’s MCO by becoming credentialed and contracted or they must negotiate as an MCO out-of-network provider in order to be reimbursed by the MCO for MCO contracted services as designated above (#3 and #4). Providers must contact the youth’s MCO directly for information regarding reimbursement for services provided through the MCO.   

Ordering, Referring and Prescribing (ORP) Providers must be credentialed with the youth’s MCO in order to ensure claims will be paid to the servicing provider who is billing the service. PRTFs are encouraged to collaborate with the ORPs providers contracted by the facility to ensure credentialing requirements are met. 

Youth in PRTFs will have an assigned CCMC MCO care manager who will assist to coordinate non-PRTF services as well as behavioral health services at discharge. In collaboration with the MCO care manager, the PRTF will maintain primary responsibility for arranging necessary services while the individual is in the facility and for discharge planning.  The MCO care manager should be considered an active treatment team participant, assist with arranging health care services outside of the facility and transportation for family members to the facility.  The MCO care manager will contribute to discharge planning including identifying available service providers in the youth’s community.  The MCO care manager will have primary responsibility for coordinating the youth’s services upon discharge from the PRTF.

See below for a list of contacts for the CCMC MCOs:

Questions related to PRTF service policy can be sent to the Behavioral Health Division at enhancedbh@dmas.virginia.gov.