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Entry of Managed Care Organizations (MCOs) for the Medicaid/FAMIS Programs in the Roanoke and Alleghany Regions

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Effective Date:

All Providers and Managed Care Organizations (MCOs) Participating in the Impacted Localities/Surrounding Areas in the Virginia Medical Assistance Programs
Cynthia B. Jones, Director Department of Medical Assistance Services


The purpose of this memorandum is to inform you of the entry of Managed Care Organizations (MCOs)  for the Medicaid/FAMIS programs in the Roanoke and Alleghany Regions. The Department of Medical Assistance Services (DMAS) is pleased to announce that, effective January 1, 2012, Amerigroup Community Care, Anthem HealthKeepers Inc., MajestaCare-A Health Plan of Carilion Clinic, Southern Health CareNet, Optima Family Care, and Virginia Premier Health Plan will be administering health care services to Medicaid and FAMIS managed care eligible members in the following localities:


Alleghany County

Covington City

Highland County

Radford City

Bath County

Craig County

Lexington City

Roanoke City

Bedford City

Floyd County

Martinsville City

Roanoke County

Bedford County

Franklin County

Montgomery County

Rockbridge County

Botetourt County

Giles County

Patrick County

Salem City

Buena Vista City

Henry County

Pulaski County

Wythe County


Managed care eligible members in the Roanoke and Alleghany regions will have a choice of six health plans offering a wide range of enhanced services not available under the MEDALLION PCCM program.


Medicaid’s MCO program began on January 1, 1996, as a managed care initiative of the Virginia Medical Assistance Program. As a result of multiple expansions, the current managed care program now covers Medicaid and FAMIS populations in 119 localities across the Commonwealth of Virginia. Expansion of  the managed care program has resulted in significant health outcome achievements that are detailed in the Virginia Managed Care Performance Report 2009-2010, which may be viewed at




MCO expansion in Roanoke/Alleghany region means that the MEDALLION PCCM and the Client Medical Management (CMM) program will end on October 31, 2011, and will no longer be an option for



members in the localities listed above. All Medicaid managed care eligible individuals in the affected localities, who were formerly enrolled in the MEDALLION PCCM program, will be returned to fee-for- service Medicaid on November 1, 2011 to December 31, 2011. Effective January 1, 2012, managed care eligible individuals residing in the Roanoke and Alleghany region will be enrolled in one  of  the six  MCOs.  Existing Virginia Premier Health Plan members will not be impacted by this transition  unless they want to select another MCO during their open enrollment or renewal period for FAMIS members.


Each MCO is responsible for the development of its provider network. Providers are strongly encouraged  to contract with at least two or more MCOs. This will allow you to continue serving the Medicaid and FAMIS managed care population. It will be helpful to your patients to advise them of the MCOs with which you are contracting so that they may continue to be seen by your practices.


If you have not already been contacted by one of the MCOs, DMAS encourages providers to begin the contracting and credentialing process. Please be aware that credentialing may take up to 90 days. If you wish to contract with the MCOs, please call:

Amerigroup Community Care                                               1-703 286 3972

Anthem HealthKeepers Plus offered by HealthKeepers Inc.      1-540-853-5077

Southern Health CareNet                                                                                                            1-866 240-4345, Ext 6739

MajestaCare-A Health Plan of Carilion Clinic                     1-855-606-4304

Optima Family Care                                                               1-804-510-7434

Virginia Premier Health Plan                                                                                                                  1-800 727-7536, Option 6


To assist in the transition process, DMAS will be providing the MCOs with Medical Transition Reports. These reports will reflect individuals receiving certain medical services such as durable medical  equipment, pregnancy services, and dialysis, among others. This information will assure that service authorizations, etc., are transferred to the MCOs without disruption.


Providers will be able to identify members enrolled in an MCO by their member ID card. Members may call the MCO to request replacement cards, if needed.  If a Medicaid or FAMIS member seeks services,  you should always ask for their MCO member ID card and plastic Medicaid ID card. It is the provider’s responsibility to verify coverage before each visit. FAMIS members in MCOs are responsible for co- payment for some services. Individuals enrolled in MCOs will carry a card bearing the name of Amerigroup Community Care, Anthem HealthKeepers Plus, Southern Health CareNet, MajestaCare-A Health Plan of Carilion Clinic, Optima Family Care, or Virginia Premier Health Plan. All MCO ID cards include the member’s Virginia Medicaid ID number.


MCO Carved-Out Services and Services that Exclude Individuals from MCO Participation


MCO Carved-Out Services


There are a few Medicaid/FAMIS covered services that are “carved-out” of the MCO contracts. For MCO enrolled individuals, coverage for carved-out services is handled through the fee-for-service program. The Medicaid and FAMIS MCO contracts regarding carved-out services differ. Benefits by program are described in the respective MCO contracts, available on the DMAS website at: These services are also highlighted  in  the table below.



MCO Carved-Out Service

These services are carved-out of the MCO contracts and are

reimbursed through DMAS fee-for-service, in accordance with DMAS established coverage criteria and guidelines.

Medicaid Covered



Community Mental Health Rehabilitation Services (CMHRS) Reference Chapter IV of the CMHRS Manual at:



Home and Community Based Care Waiver Services



Early  Periodic  Screening  Diagnosis  and  Treatment                                                                                                  (EPSDT)

Personal Care



Specialized Nutritional Supplements For Children Under Age 21



Early Intervention (EI) Services for children enrolled in the

EI Program



School Health Services



Lead Investigations through Local Health Departments



Dental Services



*FAMIS  coverage  for  CMHRS  is  limited  to   the  following  services:     Intensive In-Home, Therapeutic Day Treatment (Non-Hospital Based), Mental Health Crisis Intervention, and

Case Management For Children At Risk of and/or Experiencing Serious Emotional Disturbance.


Individuals Excluded from Managed Care Participation

There are certain groups of Medicaid and FAMIS members who are exempt from MCO participation. These individuals will continue to be served through Medicaid’s fee-for-service program and include, but are not limited to, individuals in nursing facilities, and individuals who have Medicare and/or other comprehensive group or individual health insurance. Additionally, there are also some  services  that require a Medicaid enrollee to be excluded from managed care participation. Exclusionary  services include:


  • Inpatient care (hospitalized) under fee-for-service coverage at the time of MCO enrollment (includes inpatient acute, psychiatric, EPSDT psychiatric, and inpatient rehabilitation settings). Individuals who are admitted as fee-for-service members, and who subsequently become enrolled with the MCO prior  to discharge from an inpatient setting, will be excluded from MCO participation until after they are discharged. MCO enrollment will not occur until the first of the month following the month in which the individual is discharged. DMAS’ managed care staff is notified by area hospitals at  the end  of  each month regarding all Medicaid individuals who have not been discharged by the last day of the month. Hospitals follow the process described on the DMAS website at
  • Admission to a state owned mental hospital beyond the TDO timeframe.
  • Admission to an approved residential level C treatment facility (under age 21 only).
  • Admission to a nursing facility or hospice (in accordance with Medicaid regulations).
  • Authorized services for treatment foster care case management (TFC-CM).

Providers should continue treatment of these individuals following DMAS coverage criteria  and  guidelines without interruption.


Medicaid members may contact the Managed Care HelpLine at 1-800-643-2273 or find more information on Managed Care on the DMAS website at



FAMIS members should contact FAMIS at 1-866-873-2647 for assistance with choosing an MCO or visit the website for more information.



DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and  electronic  copies  of  remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: If you have any questions regarding the Virginia Medicaid Web Portal, please contact the ACS Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996.  Both options are available at  no cost to the provider. Providers may also access service authorization information including status via KePRO’s Provider Portal, effective October 31, 2011 at



DMAS has contracts with the following eligibility verification vendors offering  internet  real-time,  batch  and/or integrated platforms. Eligibility details such  as eligibility status, third party liability, and service limits for many service types and procedures are available. Contact information for each of the vendors is listed  below.


Passport Health

SIEMENS Medical Solutions –


Communications, Inc.

Health Services

Foundation Enterprise



1 (877) 363-3666



1 (888) 661-5657




1 (610) 219-2322




The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m.  to  5:00  p.m., except on holidays. The “HELPLINE” numbers are:


1-804-786-6273            Richmond area and out-of-state long distance

1-800-552-8627            All other areas (in-state, toll-free long distance)


Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Identification Number available when you call.