Provider Central: Q&A Webinar for Vaya Network Providers - Friday, June 11, 2021 - Vaya Health
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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 Provider Provider
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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 Non- Discrimination 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 In advance of these meeting, the PAC
Officers would appreciate your
Session 1: feedback on the issue through this
For MH/SU providers (9-10:25 a.m.) short Agency Staffing Concerns
survey. The survey takes less than 5
Session 2: 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): UWibF7DJP762021 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
Kelly Crosbie, Director, Quality and Population Health,
AMH+ / CMA
NC Medicaid
Dr. Shannon Dowler, Chief Medicaid Officer, NC Medicaid
Integrating Care Dr. Lorena Wade, Medical Director of Integrated Care,
Vaya Health
Patty Wilson, VP of Network Performance and Integrity,
Fraud, Waste and Abuse Trends
Vaya Health
Vaya’s Provider Portal & New Robert Webb, Executive VP and Chief Information Officer,
Technologies Vaya Health
Karen McLeod, President and CEO, Benchmarks
Provider Prospective Sarah Pfau, Health Policy Consultant, Cansler Collaborative
Resources on behalf of NC Providers CouncilCOVID-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, 2021NC 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 This will transfer approval of Medicaid services to health plans and
create limited networks.
MANAGED CARE
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 information to members with Medicaid about their rights under managed
Provide care
Offer Offer members guidance on filing appeals or grievances with their health plan
Investigate issues reported by members and help them try to resolve issues
Investigate informally
Monitor the issues Medicaid members experience with health plans and
Monitor communicate with NCDHHS to address problems
Refer a member to legal services if they are experiencing a legal problem or need
Refer legal advice or representationSERVICES 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
By email
CONTACTING THE •Coming soon!
NC MEDICAID
OMBUDSMAN 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 state- specified limit.
CURRENT MEDICAID MANAGED CARE IN NORTH CAROLINA While most of Medicaid operates on under a fee-for- service 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 Most Medicaid Some populations Health plans are
TRANSFORMATION and NC Health cannot enroll. responsible for
Choice Others have a reviewing and
beneficiaries choice whether to evaluating
must enroll in one enroll. requests for
of six managed services.
care Prepaid
Health Plans
(PHPs or health
plans).MEDICAID MANAGED CARE
ENROLLMENT GROUPS
Who must enroll? Who may enroll? Who is excluded from Who is excluded from
enrollment? enrollment but only delayed?
MANDATORY PERMITTED EXCLUDED EXCLUDED
All Medicaid and • Eastern Band of Cherokee • Refugee Medical • CAP/C*
NC Health Choice Indians Assistance • CAP/DA*
participants • Medically needy • Innovations Waiver*
unless exempt or • Beneficiaries with • Presumptive • TBI Waiver*
excluded significant behavioral eligibility • Nursing facility residents
health needs or • Emergency Medicaid (90 days or more)*
intellectual/developmental • HIPP program • Dual eligible (Medicare)*
disabilities • Family planning • Children in foster care*
• Individuals in prison
• MSP (MQB, QI-1)
• PACENORTH 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
network of providers, and Most people with Medicaid health outcomes and care
intellectual/developmental
services generally must be will enroll in “Standard management – moving to
disabilities will have a
obtained from providers in Plans” and coverage will “integrated care” to
choice whether to enroll in
a person’s health plan begin July 1, 2021. address both medical and
a health plan until July
network. non-medical drivers of
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 Clinical
services. Some Waiver
process for delivered for coverage
new services waitlists.
Medicaid and those not policies.
added.
NC Health enrolled in a
Choice. health plan.NC MEDICAID TRANSFORMATION TIMELINE
TRIBAL OPTION &
MANAGED CARE
LAUNCH
OPEN ENROLLMENT AUTO END OF
BEGINS ENROLLMENT CHOICE PERIOD
3/15/21 5/21/21 7/1/21 9/30/21
OPEN ENROLLMENT 5/22/21 Starting 90 DAY
5/17/21
Begin Conclude CHANGE PERIOD
statewide statewide
Open Open
Enrollment Enrollment Mail Member
Welcome
Packets
& ID CardsMETHODS 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 • NC Medicaid, PO Box 613, Morrisville NC 27560
In-person • DSS offices and outreach sites (COVID-dependent)
By Fax • 833-898-9655MEDICAID MANAGED CARE REGIONS
AmeriHealth Caritas • Statewide
Healthy Blue • Statewide
United Health Care • Statewide
WellCare • Statewide
Carolina Complete • Partnership between Centene Corporation and North
Health Inc. – Carolina Medical Society [NCMS, working with the North
Regions 3, 4, and 5 Carolina Community Health Center Association (NCCHCA)]
• Available to federally recognized tribal members or
others eligible for services through Indian Health Service
Eastern Band of (IHS) who live in Cherokee, Graham, Haywood, Jackson, or
Cherokee Indians Swain County.
(EBCI) Tribal Option • Eligible members in the following counties may opt in:
Buncombe, Clay, Henderson, Macon, Madison, and
TransylvaniaWHAT 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 physical health care only for those intellectual/developmental disabilities (next with significant behavioral health needs or slide). intellectual/developmental disabilities. Physical health care for this population One Tailored Plan per Region. continues to be Fee-for-Service (also known as NC Medicaid Direct).
TWO ROUTES TO STAY IN MEDICAID DIRECT/LME
BASED ON SIGNIFICANT BEHAVIORAL HEALTH NEEDS
Diagnosis OR Use of Services
Includes individuals: Includes individuals:
with serious emotional disturbance, or with 2 or more psychiatric
diagnosis of severe substance use hospitalizations or readmissions within
disorder, or traumatic brain injury (TBI); prior 18 months; or
or
with 2 or more visits to the Emergency
with developmental disabilities, as Department (ED) for psychiatric
defined in GS 122C-3(12a); or problems in the past 18 months; or
with serious mental illness (based on who have been involuntarily treated
certain definition). 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
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).
REQUESTING
REQUEST TO STAY LME/MCO care coordinators or providers may assist
individuals in completing the beneficiary disenrollment
IN NC MEDICAID
request form.
DIRECT
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
July 1, 2021, individuals in Standard Plans can
switch to a different health plan for any reason
until September 30, 2021.
CHANGING After that, they can switch health plans for “good
HEALTH PLANS 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: 1-
833-870-5588).PLAN SELECTION
60 days to select a
Members may
health plan and
change health Members who do
primary care Members have 90 Exempt plans for ‘good not select a PCP
physician (PCP) or days after health people cause’ after the are assigned to
Advanced Medical plan coverage can 90-day period until one by their health
Home (AMH). begins to change disenroll the next open plan. Members
Those who do not their health plan at any enrollment. can change PCPs
are automatically for any reason. time.
Appeal rights if twice a year.
assigned to a
denied.
health plan.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 Health Generally, No enhanced
assigned to a plan members Mental Health,
health plan and Eligibility Medicaid
decides must see Developmental
doctor. for continues to
whether to providers Disability, or
• Health plan Medicaid cover the
approve in their Substance
changes for any does not same
services health Abuse services
reason are change. services.
that doctor plan’s in Standard
available for 90 requests. network. Plan.
days. After that
health plan
changes are
available for good
cause.Toll-free 877-201-3750
CONTACTING THE Hours as Monday - Friday 8 a.m. – 5 p.m.
of
NC MEDICAID April 15th Closed on State Holidays
OMBUDSMAN BY
PHONE The Calls are routed to the next available staff-
Queue person assigned to answer calls that day
Back-up Additional trained staff will provide overflow
support during busy time periods The Ombudsman's primary responsibilities are
to educate, inform and assist Medicaid
PROVIDING beneficiaries about:
INFORMATION the transformation to Medicaid Managed Care
AND EDUCATION 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' benefitsLEGAL 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 POPULATIONSTOP 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: 1-833-870- 5588) 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 Friday, June 25, 2021 Webinar 11:00 a.m. – 12:00 p.m.
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