2024 Session

Budget Amendments - HB30 (Conference Report)

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Ensure Oversight of Managed Care Reprocurement Implementation (language only)

Item 288 #10c

Item 288 #10c

Health and Human Resources
Department of Medical Assistance Services


Page 324, strike lines 27 through 49.

Page 325, strike lines 1 through 39, and insert:

"T.1. The Department of Medical Assistance Services is authorized to reprocure the Commonwealth's managed care service delivery system through a single managed care contract with the selected managed care organizations with an implementation date of July 1, 2024.

2. In development of a single managed care contract with the selected managed care organizations, the department shall not include the following services, which shall remain in fee-for-service: (i) dental services; (ii) developmental disability waiver services; (iii) and other services currently excluded from the managed care contracts. DMAS shall not include any new services in the contract unless explicitly authorized by the General Assembly.

3. The department shall ensure that the cost of any programmatic and/or contractual changes are fully accounted for in the Appropriation Act. Contract and program changes associated with this reprocurement shall not create any future funding commitments unless authorized by the General Assembly.

4. The department shall have its contracted actuary review the new managed care contract and report on all program changes as compared to the existing contract and estimate any fiscal impact of such changes no later than 30 days prior to the effective date of the contract.

5. The department shall provide regular updates on implementation of the new managed care contracts on a quarterly basis to the the Chairs of the House Appropriations and Senate Finance and Appropriations Committees.

6.a. As part of the reprocured Cardinal Care Managed Care Contracts, DMAS shall be authorized to include the following changes provided such modifications do not alter cost factors or add future costs to the Commonwealth.

1) Revise managed care organization staffing requirements.

2) Require DSNPs to operate with exclusively aligned enrollment starting January 1, 2025.

3) Make changes to member intelligent assignment process, however upon contract implementation no members shall be reassigned from their existing managed care plan unless the member so chooses.  Members in a managed care plan not awarded a new contract shall be assigned by DMAS to other plans that are in the best interest of the member. DMAS may suspend random assignments to a managed care organization if the MCO has 40 percent of enrolled lives within an operational region.  DMAS shall make no changes in the reassignment methodology unless specifically authorized by the General Assembly.

4) Require managed care organizations to collaborate with DMAS as part of community and programmatic initiatives, however any locality partnership initiatives must be specifically authorized by the General Assembly through a general appropriation act.

5) Add language related to readiness review requirements.

6) Add a foster care specialty plan.

7) Require managed care organizations to invite ombudsman representatives to advisory committee meetings.

8) Revise EPSDT sections to increase care coordination, reporting, member outreach and monitoring, working with community stakeholders to ensure quality of care and monitoring or providers.

9) Require managed care organizations to use the Council for Affordable Quality Healthcare (CAQH) standardized credentialing form if available for their provider type.

10) Add requirement that managed care organizations inform providers 30 priors to any policy or procedure change and must train providers on changes.

11) Increase MCO care coordination screening requirements for Health-Related Social Needs, Behavioral Health and Cancer

12) Add language requiring managed care organizations to account for specific needs and actions in the plan for identifying, assessing and engaging members on Health-Related Social Needs as part of care coordination activities.

13) Increase value-based payment models and requirements.

14) Revise quality withhold program including but not limited to increasing withhold amount from one percent to three percent as well as DMAS internal processes and reporting responsibilities, however the withhold amount shall not exceed one percent in the first and second years of the contract.  In years three and four of the contract the withhold amount shall not exceed two percent.  Beginning in year five of the contract, the withhold shall not exceed three percent.

15) Revise underwriting gain section to add that if managed care organization underwriting gain percentage exceeds three percent up to six percent the MCO must return 50 percent of the Medicaid adjusted premium revenue, if the underwriting gain percentage exceeds six percent the MCO must return 75 percent of the Medicaid adjusted premium revenue up to eight percent, and 100 percent of Medicaid adjusted premium revenue above eight percent will be returned.

16) Make changes as required by the Virginia Information Technology Agencies and Office of Attorney General high-risk reviews.

b. In addition, DMAS shall have the authority to include the following changes in the reprocured managed care contracts.

1) Add requirement for timely processing of clean claims.

2) Require managed care organizations to work with DMAS on future locality partnerships if the General Assembly has specifically authorized such work in a specific locality through a general appropriation act.

3) Implement changes to the Maternal and Child Health policies and processes, including, implementing CMS' Maternal Core Quality Measure set, increase VBP targets, require MCO outreach to members.

4) Require an annual plan on how managed care organizations are going to coordinate with the dental benefit administrator.

5) Add network adequacy/access reporting requirement."


(This amendment modifies the requirements of Medicaid managed care reprocurement.)