DHCF Announcement on Continuity of Care and Reimbursement During MCO Transition October 6, 2020

The following is a message sent to DC physicians and providers yesterday regarding the managed care transition for the DC Medicaid program.

To: All District Medicaid Providers
Re: Continuity of Care for Beneficiaries in Managed Care and Provider Reimbursement

The Department of Health Care Finance (DHCF) contracts with Medicaid managed care organizations (MCOs) to provide health services to Medicaid and Alliance beneficiaries. On October 1, 2020, DHCF entered into new contracts with three MCOs: AmeriHealth Caritas DC; MedStar Family Choice DC; and CareFirst Community Health Plan DC (formerly known as Trusted Health Plan).

The Medicaid managed care program, DC Healthy Families, is officially in a transition period between October 1, 2020 and December 31, 2020. During this time, continuity of care (COC) is priority and there are COC requirements to ensure access to on-going care is seamless. This is particularly relevant with the new contracts as beneficiaries are either transitioning from one MCO to another or one service delivery system to another (i.e., fee-for-service to managed care).

During the transition period, MCOs will reimburse for services rendered to covered beneficiaries regardless of your contracted status with the MCO. Prior authorizations and prescriptions are also honored if issued prior to October 1, 2020. Providers are expected to maintain scheduled appointments between now and December 31, 2020, and providers can expect to be reimbursed for services provided. Additional details are provided below.

Continuity of Care Requirements

DHCF has instituted the following COC provisions:

• Health care providers should not cancel appointments with current patients. MCOs must honor any ongoing treatment that was authorized prior to the recipient’s enrollment into the MCO for up to 90 days after the transition. 

• Providers will be paid. Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the MCO’s network. MCOs must pay for previously authorized services at the rate previously received for at least 90 days after the transitions.

• Providers will be paid promptly.  During the continuity of care period, MCOs are required to follow all timely claims payment contractual requirements. DHCF will monitor complaints to ensure that any issues with delays in payment are resolved.

• Prescriptions will be honored. MCOs must allow recipients to continue to receive their prescriptions through their current provider, for up to 90 days after the transition, until their prescriptions can be transferred to a provider in the MCO’s network. 

MCO Responsibilities 

If a beneficiary was receiving a service prior to moving to a new MCO, including those services previously authorized under the fee-for-service delivery system, the enrollee’s new MCO must continue to provide that service for up to 90 days after transition. The new MCO cannot require any additional forms of authorization and cannot require that the services be provided by a participating (in network) provider. These expectations are outlined in a joint MCO letter that is available online at: https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/images/FY21%20MCO%20Provider%20Reimbursement%20.pdf.

In addition, the following services may extend beyond the 90 day COC period:

• Personal Care Aide (PCA) Services shall continue until the enrollee receives their annual comprehensive assessment or a change in condition results in a new plan of care being developed, and services are authorized and arranged as required to address the long term care needs of the enrollee.

• Prenatal and postpartum care for the entire course of pregnancy including postpartum care (six weeks after birth).

• Transplant Services for one year post-transplant.

• Oncology services including radiation and/or chemotherapy services for the duration of the current round of treatment.

• Full course of treatment of therapy for Hepatitis C treatment drugs.

If you have MCO-specific questions, the points of contact are provided in the joint MCO letter referenced above. All other questions may be addressed to Lisa Truitt at lisa.truitt@dc.gov or Melisa Byrd at melisa.byrd@dc.gov.
 
Sincerely,
Wayne Turnage
Deputy Mayor for Health and Human Services
Director Department of Health Care Finance
 
Melisa Byrd
Deputy Director/Medicaid Director