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The purpose of this memo is to provide an update about specific changes for long-term services and supports (LTSS) and hospice services under the Virginia Medicaid Cardinal Care Managed Care program. Refer to the DMAS Medicaid Memo dated 10/17/23 for general information related to the Cardinal Care implementation. 

CARDINAL CARE MANAGED CARE (CCMC)

Cardinal Care Managed Care (CCMC) is the new name for Virginia’s consolidated managed care program, effective October 1, 2023. CCMC operates with the same five managed care organizations (MCOs) that administered both the CCC Plus and Medallion 4.0 programs. The full transition to CCMC will take place over the next 60 days and is expected to be seamless for members and providers, other than for a few continuity of care improvements, including for LTSS and hospice services as explained below.

Continuity of Care Improvements (Effective November 1, 2023)

CCMC improves continuity of the managed care benefit so that populations will no longer need to enroll in fee for service briefly before transitioning between managed care programs. To ensure adequate advance notice is provided to the impacted Medicaid providers, DMAS will implement the improved continuity of care benefit starting November 1, 2023. Medicaid members that had transitioned from Medallion 4.0 to CCC Plus, i.e., entered hospice or long-term care, will no longer be disenrolled from managed care before being re-enrolled. See below for changes to LTSS authorization processes and revised procedures for hospice care.

Service Authorization and Claims

The fee-for-service service authorization and claims processing rules will not change because of CCMC. Providers should continue to use the same service authorization and billing processes for fee-for-service unless notified of a specific change.

For members previously in Medallion 4.0 who need long-term services and supports (LTSS), providers must continue to request service authorization through Acentra (formerly known as Kepro) for dates of service prior to November 1, 2023. Beginning with dates of service on and after November 1, 2023, CCMC health plans will coordinate and authorize LTSS services for their members. 

Changes To Procedures for Hospice Care Under Cardinal Care Managed Care

Beginning November 1, 2023, under CCMC, all members will have access to hospice services, and members who elect to enter hospice care will remain enrolled in managed care with their CCMC MCO. (A member also may be in a waiver and receive hospice services.) The CCMC MCO must cover all services associated with the provision of hospice services for its enrolled members and must ensure that children under age twenty-one (21) are permitted to continue to receive curative medical services even if they also elect to receive hospice services. The CCMC MCO is responsible for providing information to members about the availability and function of hospice services. 

To receive inpatient hospice services, members must be enrolled in the hospice Level of Care. The admitting facility’s information is submitted by the hospice agency to the CCMC MCO via the 421a Hospice Admission Form. The MCO is contractually required to enter hospice admissions and discharges into the DMAS Medicaid Enterprise System (MES) no later than two (2) business days of notification of admission/discharge. This procedure is currently in place for CCC Plus members and will become effective for all CCMC members, including those formerly in Medallion 4.0, November 1, 2023. 

Billing For Hospice Services Under Cardinal Care Managed Care

Under CCMC, hospice providers will bill the member’s MCO directly for services. Former Medallion 4.0 members who entered hospice care and transitioned to FFS prior to November 1, 2023, will not be re-enrolled in managed care under the CCMC program or with their former MCO after November 1, 2023.  Hospice providers serving these and other members in fee-for-service should continue to bill DMAS directly for those services. 

Individuals who elect the hospice benefit with a begin date when they have only FFS Medicaid will be excluded from enrollment in CCMC. 

The FFS claims processing rules for hospice will not change because of Cardinal Care; providers should continue to use the same admission and billing processes for FFS members, unless otherwise notified. Providers must continue to enter hospice admissions with a start date prior to November 1, 2023, directly into the DMAS portal for Medallion 4.0 members. 

Due to the impact on CCMC enrollment, it is critical that hospice providers enter new hospice admissions into the DMAS portal for FFS members as expeditiously as possible. Delayed entry of the hospice benefit will impact member enrollment and could have significant downstream effects on members and other providers.

MEMBER ELIGIBILITY AND MCO ENROLLMENT VERIFICATION

Providers should continue to use the DMAS web-based automated response system (ARS) and the Medicall telephonic system, and 270/271 eligibility transactions to verify member eligibility and managed care enrollment. As of January 1, 2023, DMAS’s eligibility verification systems reflect the member’s fee-for-service or MCO enrollment. ARS and Medicall will continue to differentiate between Medicaid and FAMIS coverage. 

MCOs have transitioned to a no wrong door submission process for service authorizations and claims, however, if providers have a business need to identify the CCC Plus and Medallion 4.0 program they can do so from the MCO provider ID reflected in ARS and Medicall. For MCO-enrolled members, eligibility verification systems will include the member’s MCO name, MCO ID, MCO phone number, and the member’s MCO enrollment dates. Sample automated response system (ARS) eligibility verification screen-prints are available in  the Cardinal Care provider information presentation available on the DMAS Cardinal Care Provider Transition web page. 

CARDINAL CARE MCO CONTACTS

MCOs will issue separate guidance to providers regarding any Cardinal Care-related changes to MCO contracting, claims and service authorization processes. Providers may also contact the MCOs directly using the MCO Provider Services Contact Information shown in the Provider Contact Information and Resources table below.