Provider Central: Q&A Webinar for Vaya Network Providers Friday, June 11, 2021
Good Morning and Welcome
How the live broadcast works Attendees are seeing the broadcast on a 30 second delay. All attendees are muted throughout the broadcast. Attendees may ask questions at any time during the broadcast through the Q&A feature Questions can be seen by all attendees after they are published by the moderator. Submitted questions will be addressed at the end of the webinar.
The moderated Q&A is available in the controls bar on your screen. Look for the bubble with the question mark.
Where can I find…
Q&A Webinar Recordings and Resources: Provider Central Learning Lab Provider Webinars
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Provider Central Learning Lab Communication Bulletins
Today’s Vaya Participants Brian Ingraham, President and CEO Donald Reuss, Sr. Vice President, Provider Network Operations Carrie McCracken, Behavioral Health Network Operation Director, Provider Network Operations Tommy Duncan, Training and Special Projects Manager, Provider Network Operations Justine Tullos, Provider Network Operations (Q&A moderator) Renee Urban, Provider and Community Educator (co-producer)
Kathy Walker Staff Attorney Pisgah Legal Services Kathy@pisgahlegal.org www.pisgahlegal.org
Dylan Simosko
NC Medicaid Ombudsman Program Director Pisgah Legal Services 877-201-3750 (NC Medicaid Ombudsman general line) www.ncmedicaidombudsman.org DylanS@ncmedicaidombudsman.org
Guiding principles of our work: Stabilize the public system for members and communities we serve Ensure continuity of care and prevent or minimize disruption for members, relatives, providers and stakeholders Preserve remaining Cardinal counties Ensure Vaya’s Tailored Plan readiness and implementation is successful following contract awards
On your radar…
Updated Vaya Non-Discrimination Policy Provider Communication Bulletin, Issue 82: Our updated NonDiscrimination Policy can be found on the Vaya website. The website also includes the full text of the March 2021 resolution of the Vaya Health Board of Directors in support of the business case for diversity, equity and inclusion. For more information, please review pages 18-19 of the Vaya Health Provider Operations Manual
National Core Indicators® Staff Stability Survey N.C. DMH/DD/SAS is surveying providers that employ staff to provide habilitative and non-habilitative IDD services (through all funding sources) to gather and use data about direct support professionals (DSPs) to inform state policy and system changes for IDD services. The survey closes on June 30, 2021. Learn more: National Core Indicators® Staff Stability Survey Flyer
Learning & Participation Opportunities
Vaya Health Provider Advisory Council Monthly Meeting Wednesday, June 16, 2021 10 a.m. – 12 p.m. The PAC serves as an advisory body to Vaya on issues affecting Network Providers All network providers are invited and encouraged to attend PAC Monthly Meeting (WebEx)
Vaya Health Provider Advisory Council Agency Staffing Concerns Survey and Special Meeting Tuesday, June 22, 2021 Session 1:
For MH/SU providers (9-10:25 a.m.)
Session 2:
In advance of these meeting, the PAC Officers would appreciate your feedback on the issue through this short Agency Staffing Concerns survey. The survey takes less than 5 min to complete.
For I/DD providers (10:30-11:55 a.m.)
Agency Staffing Concerns Survey Meeting number (both sessions): 182 344 0360 Password (both sessions): UWibF7DJP76
2021 Vaya Health Provider and Learning Summit July 20 - 22, 2021 Microsoft Teams Live Event July 20
Provider Summit
July 21-22 Vaya Learning Summit (Network providers are invited to participate in sessions of interest) Currently working with MAHEC for CEUs
Provider Summit State of Vaya
Brian Ingraham, President and CEO, Vaya Health
Medicaid Transformation
Dave Richard, Deputy Secretary for NC Medicaid, NC DHHS
AMH+ / CMA
Kelly Crosbie, Director, Quality and Population Health, NC Medicaid
Integrating Care
Dr. Shannon Dowler, Chief Medicaid Officer, NC Medicaid Dr. Lorena Wade, Medical Director of Integrated Care, Vaya Health
Fraud, Waste and Abuse Trends
Patty Wilson, VP of Network Performance and Integrity, Vaya Health
Vaya’s Provider Portal & New Technologies
Robert Webb, Executive VP and Chief Information Officer, Vaya Health
Provider Prospective
Karen McLeod, President and CEO, Benchmarks Sarah Pfau, Health Policy Consultant, Cansler Collaborative Resources on behalf of NC Providers Council
COVID-19 Flexibilities Updates
Appendix K Flexibilities Appendix K flexibilities remain in place through October 20, 2021. Retainer Payments remain at a 90-day maximum until additional guidance is issued.
Hardship Payments COVID-19 Provider Hardship Funding is focused on supporting qualified providers of Medicaid services for shortfalls experienced during the COVID-19 pandemic. Vaya will discontinue hardship funding for dates of service after June 30, 2021. Providers must submit COVID-19 Provider Hardship Funding Requests for June 2021 hardship payments by Saturday July 31, 2021.
Medicaid Rate Enhancements Medicaid Rate Enhancements implemented between July 1, 2020-June 30, 2021 will continue through September 30, 2021. This includes all residential, enhanced, periodic and ICF-IID services previously increased. Please refer to the May 27, 2021 Provider Network Memo for details.
Electronic Visit Verification Updates
EVV Updates Implementation date of Electronic Visit Verification (EVV) for the Innovations waiver, Traumatic Brain Injury (TBI) waiver and (b)(3) services administered by the LME/MCOs: June 30, 2021 Effective June 30, 2021, 100% of provider claims must pass EVV validation to be reimbursed. Providers must continue to collaborate, test and operationalize the EVV process with the applicable LME/MCOs and their EVV vendor, HHAeXchange, to meet the June 30, 2021, EVV implementation date.
Please note that the HHAeXchange EVV solution is live and available for you to log in, schedule and confirm EVV compliance.
EVV Updates Vaya, in collaboration with HHAeXchange, is offering the following training session: June 15, 2021, 10 a.m. Pre-Go-Live Webinar (pre-register) This will be focused on providers using HHAeXchange Training sessions (including EDI) are posted on HHAeXchanges’ Provider Information page.
EVV Incentive Payments Vaya is offering a $10,000 EVV Incentive Payment upon verification of all required elements in the EVV Provider Readiness Attestation, and execution of a contract amendment for the incentive payment. REMINDER: Providers must attest to the submission of a test claim to Vaya and their preparation to submit EVV-compliant claims for all services that require EVV, to Vaya starting June 30, 2021
NC MEDICAID OMBUDSMAN: YOUR ADVOCATE FOR QUALITY CARE
North Carolina Department of Health and Human Services (NC
DHHS) is moving to “Medicaid Managed Care.”
NC MEDICAID MANAGED CARE
This will transfer approval of Medicaid services to health plans and
create limited networks. The NC Medicaid Ombudsman will advocate for people with
Medicaid to get the care they need and help them navigate the new environment by providing free, confidential services.
SERVICES OF THE NC MEDICAID OMBUDSMAN Provide Offer Investigate Monitor Refer
Provide information to members with Medicaid about their rights under managed care Offer members guidance on filing appeals or grievances with their health plan Investigate issues reported by members and help them try to resolve issues informally Monitor the issues Medicaid members experience with health plans and communicate with NCDHHS to address problems Refer a member to legal services if they are experiencing a legal problem or need legal advice or representation
SERVICES NOT OFFERED BY THE NC MEDICAID OMBUDSMAN The NC Medicaid Ombudsman cannot provide legal advice or represent an individual with Medicaid in a managed care appeal or grievance procedure. The Ombudsman will refer clients in need of legal services to the appropriate organization.
By phone •877-201-3750
CONTACTING THE NC MEDICAID OMBUDSMAN
By email •Coming soon!
Online •www.ncmedicaidombudsman.org
In person •Coming soon!
BACKGROUND: EXISTING NORTH CAROLINA MEDICAID PROGRAM Medicaid is a government-financed health insurance program
that covers some low- and moderate-income individuals.
In North Carolina, over 2 million people are covered by Medicaid
(out of ~10.3 million).
An additional ~100,000 children covered by NC Health Choice.
With a few exceptions, Medicaid currently operates through a
fee-for-service system, in which the state pays providers directly.
NC HEALTH CHOICE NC Health Choice is North Carolina’s Child Health
Insurance Program (CHIP). CHIP is a federal program.
NC Health Choice provides coverage to some low-
and moderate-income children with family incomes higher than Medicaid eligibility limit but below statespecified limit.
CURRENT MEDICAID MANAGED CARE IN NORTH CAROLINA
While most of Medicaid operates on under a fee-forservice system, services for significant behavioral health needs or intellectual/developmental disabilities are provided through managed care. Services are provided by Local Management Entities/Managed Care Organizations (LME/MCOs) which contract with the NCDHHS to manage these services.
REGIONAL LME/MCOS
MEDICAID TRANSFORMATION
Most Medicaid and NC Health Choice beneficiaries must enroll in one of six managed care Prepaid Health Plans (PHPs or health plans).
Some populations cannot enroll. Others have a choice whether to enroll.
Health plans are responsible for reviewing and evaluating requests for services.
MEDICAID MANAGED CARE ENROLLMENT GROUPS Who must enroll?
Who may enroll?
MANDATORY
PERMITTED
EXCLUDED
EXCLUDED
All Medicaid and NC Health Choice participants unless exempt or excluded
• Eastern Band of Cherokee Indians
• Refugee Medical Assistance • Medically needy • Presumptive eligibility • Emergency Medicaid • HIPP program • Family planning • Individuals in prison • MSP (MQB, QI-1) • PACE
• • • • •
• Beneficiaries with significant behavioral health needs or intellectual/developmental disabilities
Who is excluded from enrollment?
Who is excluded from enrollment but only delayed? CAP/C* CAP/DA* Innovations Waiver* TBI Waiver* Nursing facility residents (90 days or more)* • Dual eligible (Medicare)* • Children in foster care*
NORTH CAROLINA’S TRANSITION TO MANAGED CARE
Changes The new system is Individuals with significant Health plans will have a intended to focus on behavioral health needs or health outcomes and care network of providers, and Most people with Medicaid intellectual/developmental management – moving to services generally must be will enroll in “Standard disabilities will have a “integrated care” to obtained from providers in Plans” and coverage will choice whether to enroll in address both medical and a person’s health plan begin July 1, 2021. a health plan until July non-medical drivers of network. 2022. health.
NORTH CAROLINA’S TRANSITION TO MANAGED CARE
What Is Not Changing Eligibility rules How services and are authorized Covered the application and/or services. Some process for delivered for new services Medicaid and those not added. NC Health enrolled in a Choice. health plan.
Waiver waitlists.
Clinical coverage policies.
NC MEDICAID TRANSFORMATION TIMELINE TRIBAL OPTION & MANAGED CARE LAUNCH OPEN ENROLLMENT BEGINS
3/15/21
5/21/21 OPEN ENROLLMENT
Begin statewide Open Enrollment
END OF CHOICE PERIOD
AUTO ENROLLMENT
7/1/21
5/22/21 Starting 5/17/21 Conclude statewide Open Mail Member Enrollment Welcome Packets & ID Cards
9/30/21
90 DAY CHANGE PERIOD
METHODS FOR HEALTH PLAN ENROLLMENT
Mobile App
• NC Medicaid Managed Care app available on iOS or Android
Call Center
• 833-870-5500, TTY 833-870-5588 • Open Enrollment Monday - Sunday 7 a.m. – 8 p.m. • All other times Monday - Saturday 7 a.m. – 5 p.m.
By Mail In-person By Fax
• NC Medicaid, PO Box 613, Morrisville NC 27560
• DSS offices and outreach sites (COVID-dependent)
• 833-898-9655
MEDICAID MANAGED CARE REGIONS
AmeriHealth Caritas
• Statewide
Healthy Blue
• Statewide
United Health Care
• Statewide
WellCare
• Statewide
Carolina Complete Health Inc. – Regions 3, 4, and 5
• Partnership between Centene Corporation and North Carolina Medical Society [NCMS, working with the North Carolina Community Health Center Association (NCCHCA)]
Eastern Band of Cherokee Indians (EBCI) Tribal Option
• Available to federally recognized tribal members or others eligible for services through Indian Health Service (IHS) who live in Cherokee, Graham, Haywood, Jackson, or Swain County. • Eligible members in the following counties may opt in: Buncombe, Clay, Henderson, Macon, Madison, and Transylvania
WHAT IS HAPPENING TO LME/MCOS? Now until July 2022…LME/MCO
After July 2022…Tailored Plans
LMEs continue managing care for those only
Tailored Plans will manage both services and
with significant behavioral health needs or intellectual/developmental disabilities (next slide). Physical health care for this population
continues to be Fee-for-Service (also known as NC Medicaid Direct).
physical health care only for those with significant behavioral health needs or intellectual/developmental disabilities. One Tailored Plan per Region.
TWO ROUTES TO STAY IN MEDICAID DIRECT/LME BASED ON SIGNIFICANT BEHAVIORAL HEALTH NEEDS Diagnosis Includes individuals: with serious emotional disturbance, or
diagnosis of severe substance use disorder, or traumatic brain injury (TBI); or
with developmental disabilities, as
defined in GS 122C-3(12a); or
with serious mental illness (based on
certain definition).
OR Use of Services Includes individuals: with 2 or more psychiatric
hospitalizations or readmissions within prior 18 months; or
with 2 or more visits to the Emergency
Department (ED) for psychiatric problems in the past 18 months; or
who have been involuntarily treated
within prior 18 months.
Details at: https://files.nc.gov/ncdhhs/BH-IDD-TP-EligibilityUpdate-AppendixB-0020221-Updates.pdf
Individuals with Medicaid who were incorrectly identified
REQUESTING REQUEST TO STAY IN NC MEDICAID DIRECT
as being required to enroll in a health plan, or whose circumstances change, can request in writing that they be disenrolled from managed care (and transferred to Medicaid Direct or LME/MCO plus Medicaid Direct).
LME/MCO care coordinators or providers may assist
individuals in completing the beneficiary disenrollment request form. Providers can also request disenrollment/transfer on a
different form. NCDHHS will mail the individual a decision on their
request, and that decision can be appealed to the NC Office of Administrative Hearings (OAH) within 30 days.
Once coverage under managed care begins on
CHANGING HEALTH PLANS
July 1, 2021, individuals in Standard Plans can switch to a different health plan for any reason until September 30, 2021.
After that, they can switch health plans for “good
cause” throughout the year, until next open enrollment period. To request to change your health plan, contact
the Enrollment Broker at 1-833-870-5500 (TTY: 1833-870-5588).
PLAN SELECTION 60 days to select a health plan and primary care physician (PCP) or Advanced Medical Home (AMH). Those who do not are automatically assigned to a health plan.
Members have 90 days after health plan coverage begins to change their health plan for any reason.
Exempt people can disenroll at any time.
Members may change health plans for ‘good cause’ after the 90-day period until the next open enrollment. Appeal rights if denied.
Members who do not select a PCP are assigned to one by their health plan. Members can change PCPs twice a year.
NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) Individuals receive the same service from health plans as they
received under NC Medicaid Direct. No change to the amount, duration and scope of NEMT. Individuals contact their health plan to schedule NEMT. Each PHP has NEMT contact information.
Individuals who frequently use NEMT will be identified (through
PHP working with local DSSs) and health plans are supposed to reach out to them.
NON-EMERGENCY MEDICAL TRANSPORTATION Plans must: Provide NEMT appropriate for the member to the nearest enrolled medical provider. Provide NEMT to a Medicaid-covered service provider, including services not covered
through NC Medicaid Managed Care, provided by a qualified Medicaid provider.
Provide travel-related expenses including: Lodging, food, parking fees/tolls, transportation vouchers
Develop a network of NEMT providers.
NC Medicaid Managed Care members can contact their health plan starting
June 1, 2021 for trips taking place on or after July 1, 2021.
BENEFICIARY PROTECTIONS Department approves all marketing materials and plans cannot engage in direct
solicitations.
Health plans must provide language assistance services, including interpretation and
translation.
Written and oral member materials must include taglines in top 15 most common non-English languages in North Carolina.
Grievance, appeal and state fair hearing procedures, including timeliness standards. Appeals are for denials of benefit determinations or denials of payment or of
disenrollment.
Grievances include all other complaints against the health plan or providers. Health plans must have member advisory committees, including for Long-Term
Services and Supports (LTSS), and must facilitate transfers to different health plans or different providers, when appropriate.
Health plans must operate member services line, behavioral health crisis lines and a
nurse line.
KEY TAKEAWAYS Choose health plan and doctor, unless exempt. • Otherwise, members are assigned to a health plan and doctor. • Health plan changes for any reason are available for 90 days. After that health plan changes are available for good cause.
Eligibility for Medicaid does not change.
Medicaid continues to cover the same services.
Health plan decides whether to approve services that doctor requests.
Generally, members must see providers in their health plan’s network.
No enhanced Mental Health, Developmental Disability, or Substance Abuse services in Standard Plan.
Toll-free
CONTACTING THE NC MEDICAID OMBUDSMAN BY PHONE
877-201-3750
Hours as Monday - Friday 8 a.m. – 5 p.m. of April 15th Closed on State Holidays The Queue
Calls are routed to the next available staffperson assigned to answer calls that day
trained staff will provide overflow Back-up Additional support during busy time periods
The Ombudsman's primary responsibilities are
PROVIDING INFORMATION AND EDUCATION
to educate, inform and assist Medicaid beneficiaries about: the transformation to Medicaid Managed Care how to navigate the managed care system beneficiary's rights and responsibilities under
managed care
But the Ombudsman's role does not end there...
INVESTIGATION, FOLLOW-UP, RESOLUTION
Ombudsman staff will be true advocates for
beneficiaries, seeking the best and most efficient outcome for the beneficiary.
Ombudsman staff will regularly communicate
with the beneficiary concerning these efforts.
NO WRONG DOOR APPROACH Ombudsmen will also provide general information
and referrals for many other issues. For example: Medicaid and NC Health Choice eligibility Private health insurance (including ACA coverage) Referrals for other benefits such as food stamps,
Social Security Disability and Supplemental Security Income, and veterans' benefits
LEGAL REFERRALS Partners: Legal Aid of North Carolina, Charlotte Center for Legal Advocacy, and Pisgah Legal Services. These agencies will accept referrals from the Ombudsman for members who need or request legal advice or representation to assist with appeals or other issues.
QUESTIONS? Contact us: phone number: 877-201-3750 Follow us on Facebook and Twitter: NC Medicaid Ombudsman Visit our website: www.ncmedicaidombudsman.org
MEDICAID TRANSFORMATION: BEHAVIORAL HEALTH AND I/DD POPULATIONS
TOP THINGS TO KNOW NC Medicaid Beneficiaries who were auto-assigned to a Prepaid Health Plan should call the Enrollment Broker at 1-833-870-5500 (TTY: 1-833-8705588) or visit ncmedicaidplans.gov to make sure the providers they need to see are in that Plan’s network. If their doctors are not in that network, they should request to change plans. They can change plans for any reason until September 30.
TOP THINGS TO KNOW If Medicaid beneficiaries need enhanced behavioral health services for mental illness, substance abuse, or intellectual disability, they or their provider need to fill out a Request to Stay in NC Medicaid Direct form, found here. ncmedicaidplans.gov/submit-forms-online
TOP THINGS TO KNOW Beginning July 1, Health Plans will provide Non-Emergency Medical Transportation (NEMT) for those enrolled in that plan. The county department of social services will continue to provide transportation for those not enrolled in a Health Plan. Beneficiaries can begin calling their Plan now to schedule transportation.
TOP THINGS TO KNOW Transition of Care Protections mean that that patients can continue seeing their current care providers for up to 90 days even if those providers are not in the health plan’s network. More information on these protections can be found here. Medicaid.ncdhhs.gov/transformation/care-management/transition-care
TOP THINGS TO KNOW
If you or someone you know needs help with any issues related to Medicaid Managed Care, the NC Medicaid Ombudsman is available at 877-201-3750 or ncmedicaidombudsman.org. The NC Medicaid Ombudsman provides free information, education, referrals, and advocates for beneficiaries to get the care they need.
CONTACTING PISGAH LEGAL SERVICES
Benefits Screening Line: 828-407-4464
Questions Thoughts Ideas
Our Next Q&A Webinar
Friday, June 25, 2021 11:00 a.m. – 12:00 p.m.
We are always available to support you:
provider.info @vayahealth.com