For several months now, DMAS, representatives of the CCC Plus managed care organizations (MCOs), VHCA-VCAL staff, and other industry stakeholders have been discussing the best and least burdensome approach to reconciling the initial $20 per day Medicaid add-on payments made via separate nursing facility invoice (for dates of service from March 12, 2020 through June 30, 2020). As a reminder, effective for dates of service beginning July 1, 2020, the invoice process ceased, and the add-on was including in the rate paid via the normal claims process.

DMAS and the MCOs initially examined their own respective invoice payment information against enrollment and claims data. This examination produced varying results between DMAS’s encounter data warehouse system and the internal MCO data, which therefore was inconclusive for reconciliation purposes. Industry representatives suggested that DMAS request accounts receivable/payable related to the $20 add-on directly from the nursing facilities. DMAS agreed, and the facilities were requested to submit this information by fee-for-service (FFS) and by MCO. DMAS requested information on pass-through amounts received/expected from both PACE and hospice organizations as well.

Proposed Reconciliation

This data collection indicated that only 85 facilities reported a difference in what was expected to what was received.  The result, while mixed in terms of under and over payments to facilities, netted at $406,220 owed to nursing facilities. In discussion with DMAS and the MCOs, the following reconciliation was agreed upon:

DMAS (FFS):  All FFS amounts owed will be processed on April 16 (with the exception of one facility they have contacted for additional information); payment should be received by 4/27

• DMAS intended to “write off” amounts owed by the facilities but is currently making sure they are statutorily allowed to do so. 

DMAS (Hospice & PACE):  Amounts owed will be processed to most hospices and PACE organizations on April 16 (there are several from which they are seeking additional information which would delay this process by one or more weeks for those). the hospices and PACE organizations would be instructed on the amounts owed to each facility (matching the amounts they received from DMAS) and will pass that through to the facilities (expected to be received by the facilities in the first/second week of May). 

Aetna:  Indicates that it will pay all amounts owed (no date given) and is writing off all amounts owed by the facilities. 

Anthem:  It has processed all amounts owed that were less than $2,000 variance from what was expected (should have hit accounts by April 8); there were six facilities with amounts over $2,000 variance from what was expected which it has contacted and will be paid by April 30, assuming the facilities respond timely. It also indicates it is willing to write off all amounts owed by the facilities. 

Magellan:  No information yet. 

Optima:  Indicates that it will pay all amounts owed; processed April 5 (so payment is imminent), and is writing off all amounts owed by the facilities. 

United:  It has reached out to a handful of facilities with significant discrepancies (with an expected response by April 16). Notwithstanding the results of that outreach for those facilities, it intends to make the payments to the facilities by April 30 (payments out the door in early May). It also indicated it is writing off all amounts owed by the facilities.

VA Premier:  Indicates it has processed payments for all amounts owed and is writing off all amounts owed by the facilities.

If you have questions regarding this approach and what to expect, please contact Steve Ford.