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Adrienne T. FegansSr. Program Administrator
MEDALLION 4.0
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Will cover approximately 740,000 Medicaid and FAMIS members effective August 1, 2018
MEDALLION 4.0 PROGRAM DESIGN Medallion 4.0 will cover the basic Medallion 3.0 and
FAMIS populations
New carved in populations and services:
• Third Party Liability (TPL)
• Early Intervention (EI) Services
• Community Mental Health and Rehabilitation Services (CMHRS)
Focus will be on each covered population
One Medallion /FAMIS contract
Members will have a choice of six (6) managed care organizations (MCOs) with statewide coverage
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MEDALLION 4.0 HEALTH PLANS
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Same as CCC Plus
MEDALLION 4.0 MEMBERS
The first and foremost goal and expectation of Medallion 4.0 is to improve the quality of life and health
outcomes for enrolled individuals
IT’S ALL ABOUT THE MEMBER
MEMBER CHOICE
MEMBER FOCUS
MEMBER ENGAGEMENT
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LAUNCH BY REGIONAnticipated Launch
DateRegion of Virginia Regional Launch
Population
August 1, 2018 Tidewater 161,421
September 1, 2018 Central 189,438
October 1, 2018 Northern/Winchester 178,416
November 1, 2018 Charlottesville/Western 88,486
December 1, 2018 Roanoke/Alleghany 72,827
December 1, 2018 Southwest 46,558
Total 737,146
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MEDALLION 4.0 REGIONS
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MEDALLION 4.0 PROGRAM DESIGN
Expands
• Care Coordination Programs
• Telehealth and Telemedicine
• Stakeholder Engagement
Social Determinants of Health
Use of Social Media and Apps
Trauma Informed Care and Transition Planning
Increase Focus on Network
Adequacy
Additional Quality and HEDIS
Requirements
Collaboration and Joint Projects
Across Sister Agencies
• Dept. of Behavioral Health and
Developmental Services
(DBHDS)
• VA Dept. of Health (VDH)
• VA Dept. of Social Services
(VDSS)
• VA Dept. of Education (DOE)
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MANAGED CARE ALIGNMENT
Six Managed Care Organizations with statewide service
Six Regions {Medallion 3.0 is currently 7}
Services (where possible)
Provider and member engagement
Quality, data and outcomes
Strong compliance and reporting
Streamlined processes and shared services
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Medallion 4.0 and CCC Plus Managed Care Programs
Are Aligned In Many Ways
MEDALLION 4.0 ADVANTAGES
Managed Care Organizations (MCOs):
Focus on quality of care for individuals
Offer a network of high quality providers
Offer enhanced benefits
Provide comprehensive health coverage and will focus on prevention
Focus on innovation and social determinants of health
Designate foster care liaison within each MCOs
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POPULATION FOCUS
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Pregnant Women
Infants
Children/Teens
Foster Care & Adoption Assistance
Adults
PREGNANT WOMEN
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Expanded Case Management
Increase Prenatal and Postpartum Utilization
Lower C-Section Rate
Increase Family Planning and Long Acting Reversible Contraception (LARC) Utilization
Opioid Treatment Through the Addiction and Recovery Treatment Services (ARTS) Program
Targeted Maternal Child Health (MCH) Special Projects
INFANTS
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Newborn Enrollment
Promote Safe Sleep Initiatives
Decrease Neonatal Abstinence Syndrome (NAS) Babies and Substance-Exposed Infants (SEI)
Early Intervention (EI)
Increase immunizations
Increase well visits
CHILDREN
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Increase
Oral Health Utilization
Vision Screenings
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
Children and Youth with Special Health Care Needs
Community Mental Health and Rehabilitation Services (CMHRS)
Prevent and/or reduce obesity, asthma, and other chronic conditions
TEENS
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Increase Well Visits
Expanded Vision Care and Access
Focus on Messaging to Adolescents
EPSDT Focus
FOSTER CARE & ADOPTION ASSISTANCE
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Trauma Informed Care and Resilience
Enrolling Eligible Members in Fostering Futures and Former Foster Care
Focus on Transition to Adulthood
Collaboration with VDSS, LDSS and LCPA
Foster Care and Adoptive Parents
ADULTS
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Wellness and Prevention
Expanded Chronic Case Management and Disease Management
Enhanced Services
Behavioral Health
Family Planning/LARC
Social Determinants of Health
Decrease Emergency Department Use
POPULATIONS EXCLUDED
CCC Plus enrollees, including Aged, Blind, Disabled and Home and Community-Based Waiver Services
Plan First
Inpatient mental health in state psychiatric hospital
Hospice enrollees
Nursing facility members
Newly eligible pregnant members in third trimester who request exemption
Hospitalized at the time of scheduled enrollment
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CONTINUITY OF CARE
During the continuity of care period of up to 30
days, MCOs will allow members to use their
existing providers while new providers are located
MCOs have the ability to go out of network to provide a service if they do not have a provider in their network that can provide a service
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KEYS TO CONTINUITY
Start with contacting the MCO
Work with them to coordinate care for the member
Let them know the member’s current providers and use the MCO as a resource to
locate providers
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CARE MANAGEMENT
It is our goal to provide the best services for our foster care and
adoptive youth!
Collaboration with MCO foster care contacts to handle of variety of:
Prescription issues
Billing issues
Denied services and claims
Resolving transportation issues
Locating a provider
Scheduling appointments
Offering alternate placements
Completion of Health Risk Assessments
FOSTER CARE CONTACTS
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Aetna Better Health
Melissa Fraase Parent, MSW, LCSW
Clinical Health Services Manager, 959-299-6323 [email protected]
Monique Brown
Foster Care Outreach Team, [email protected]
Anthem Health Keepers Plus Jamie Nye, LPC
Behavioral Health Case Manager II, 1-844-533-1994 x 48320 [email protected]
InTotal Health (note that email addresses may
change when plan formally
switches to United)
Kristen Smith
Health and Social Service Manager, [email protected]
Rhonda Richardson
Foster Care Coordinator, [email protected]
Julie Garcia, MSW, LNHA, ACM (if unable to reach Kristen and Rhonda)
Health Service Director, 703-286-3972, [email protected]
Kaiser Permanente
Traci Templer, LCSW
Pediatric Social Worker/Case Manager, 202-308-2171 [email protected]
Veronica Tillar, RN, BSN (If Traci is unavailable)
Manager, Outpatient Continuing Care, 301-625-6154 [email protected]
Magellan Complete Care(starting August 1, 2018)
Cheryl Ricciardi
VP, Health Services, 804-762-6094 [email protected]
Optima Family Care Optima Family Care Line
1-866-503-5828 (this line goes directly to the Case Management team)
Virginia Premier Health Plan
Sheena Holmes
Medallion Senior Patient Care Coordinator, 804-819-5151 x78297
Cassandra Johnson
Case Management Manager, 804-819-5151 x55031 [email protected]
May7th
May 7th
May11th
DSS enters eligibility in system
May18th
System generates nightly letter confirming eligibility and indicates potential eligibility for managed care
Individual receives letter and contacts enrollment broker before May 18th and is enrolled in managed care effective June 1st
No call by May 18th, system enrolls individual in MCO effective June 1st
ENROLLMENT TIMELINE EXAMPLE
May 21st
Letter mailed to individual indicating the assigned MCO and effective date of June 1st
May 31st
Individual has until last working day of month to change MCOs for June 1st effective date
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MCO SELECTION PROCESS Family Services Specialist or LCPA Worker (party holding
custody) can call helpline to request or make a change to MCO
The 18th of the month is the cut-off date
Call before the 18th of month; assignment occurs on 1st
day of the next month
Call after the 18th of the month; assignment occurs on the 1st day of the following month
Foster Care children can change their MCO at any time - they do not have to wait for open enrollment
Foster Care parents may call the helpline to inquire about enrollment or general information but they cannot make changes to the child’s MCO
MCO SELECTION PROCESS Work with the foster care parents to determine the
child’s providers
Call the Managed Care Helpline to determine provider’s participation and select the MCO
Inform provider of the child’s selected MCO
If out of network, work with the MCO to find a provider during the continuity of care period
Foster care parents should not be receiving bills for Medicaid covered services – prior to taking child to provider while under FFS make sure provider accepts VA Medicaid
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ENROLLMENT
In a limited number of cases, for a short time an individual may need to obtain prescription medications, however they may not have their new MCO ID card
Pharmacists should verify plan enrollment via MediCall or ARS and then contact the assigned health plan for instructions to complete the transaction
All health plans have established processes to handle any issues related to ID cards
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MANAGED CARE HELPLINE
Managed Care Helpline 1-800-643-2273
Hours:
• Monday through Friday (8:30 am to 6:00 pm)
Medallion 4.0 Enrollment Website:
• www.virginiamanagedcare.com
Call Managed Care Helpline to
• request information
• find out if providers participate in an MCO
• enroll in a health plan
• change a health plan
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COMMUNITY MENTAL HEALTH AND REHABILITATION SERVICES (CMHRS)
The CMHRS transition to Medallion 4.0 will occur inaccordance with the regional implementation of theprogram, beginning August 1, 2018
On the effective dates, Magellan of Virginia, DMAS’Behavioral Health Services Administrator (BHSA), will nolonger administer CMHRS for Medallion 4.0/FAMIS enrolledmembers
Instead, CMHRS will transition into the Medallion 4.0 MCOcontract, utilizing DMAS’ current CMHRS coverage criteriaand program requirements
Medallion 4.0 CMHRS will mirror CCC Plus CMHRS
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MEDALLION 4.0/ FAMIS MOMS CMHRS
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CMHRS will be part of the Medallion 4.0 program beginning August 1, 2018
Se
rvic
es Intensive In Home (IIH)
Therapeutic Day Treatment (TDT)
MH Case Management
MH Family Support PartnersMH Peer Support Services
EPSDT Behavioral Therapy
Day Treatment/Partial Hosp.
Psychosocial Rehabilitation
Intensive Community Treatment
Mental Health Skill Building
Crisis Intervention
Crisis Stabilization
No changes made to program regulations, medical necessity, criteria, procedure codes, unit values, etc.
Core Service Authorization processes will be standardized across health plans.
MEDALLION 4.0 FAMIS CMHRS
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CMHRS will be part of the Medallion 4.0 program beginning August 1, 2018
Se
rvic
es
Intensive In Home (IIH)
Therapeutic Day Treatment (TDT)
MH Case Management
Crisis Intervention
No changes made to program regulations, medical necessity, criteria, procedure codes, unit values, etc.
Core Service Authorization processes will be standardized across health plans.
RESIDENTIAL TREATMENT CENTER (RTC)
Effective April 1, 2019 each MCO will cover Residential Treatment Services consisting of Psychiatric Residential Treatment Facility (PRTF) and Therapeutic Group Home Services (TGH) for Medallion 4.0 and CCC Plus individuals
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TREATMENT FOSTER CARE – CASE MANAGEMENT (TFC-CM) SERVICES
TFC-CM services will continue to be administered through Magellan of Virginia
until it is carved into Medallion 4.0 on April 1, 2019
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Medallion 4.0
Public Notices - VA Regulatory Town Hall | Notice of Privacy Practices | FOIA Requests | Web Policy | WAI Level A Compliant | Contact Us
SEND COMMENTS & QUESTIONS [email protected]
Medallion 4.0 Focus:
Evolving from the Medallion 3.0 foundation
Serving over 700,000 healthy connected Medicaid & FAMIS members & their communities
Engaging Health Systems & Stakeholders
Providing holistic & integrated care
Adding new services & populations
Flexible delivery systems & payment models
Growing stronger through improved quality, data & reporting
Medallion 4.0 Medicaid Managed Care Program
Milestones Proposed Dates*
Post Request for Proposals (RFP) July 17, 2017
Announce Awards Late Fall 2017
Regions Proposed Effective Dates*
Tidewater Region Effective Date August 1, 2018
Central Region Effective Date September 1, 2018
Northern/Winchester Region Effective Date October 1, 2018
Charlottesville/Western Region Effective Date November 1, 2018
Roanoke/Alleghany Region Effective Date December 1, 2018
Southwest Region Effective Date December 1, 2018
Important Medallion 4.0 Managed Care Timeline Dates:
Medallion 4.0 Managed Care Regional Effective Dates:
Home | Regional Map | Meetings | Presentations | Reports
QUESTIONS?
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Growing Strong
