Title of Regulation: 12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-880).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: December 12, 2019.

Effective Date: December 27, 2019.

Agency Contact: Emily McClellan, Regulatory Supervisor, Policy Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804) 786-1680, or email emily.mcclellan@dmas.virginia.gov.

Basis: Section 32.1-325 of the Code of Virginia grants the Board of Medical Assistance Services the authority to administer and amend the State Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the State Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by § 1902(a) of the Social Security Act (42 USC § 1396a), provides governing authority for payments for services.

Purpose: The purpose of this action is to bring Virginia regulations into alignment with current Family Access to Medical Insurance Security (FAMIS) MOMS contracts and current Medicaid Managed Care practice. DMAS intends to remove an exclusion for individuals in the third trimester of pregnancy. These changes will stipulate that members in their third trimester of pregnancy will no longer be allowed to request exclusion from Managed Care Organization (MCO) enrollment. In the last year, only 10 women requested exemption. With the implementation of Medallion 4.0 and the upcoming Medicaid expansion, this exemption is no longer necessary to ensure access to care. The Medicaid Managed Care health plans all have 100% network adequacy for prenatal and obstetric care, including obstetricians and gynecologists, nurse practitioners, family physicians, and certified nurse midwives in all regions of the Commonwealth. Women will still have the option of changing health plans if their provider is not contracted with a specific MCO. The regulations are essential to protect the health, safety, and welfare of citizens in that the regulatory changes ensure access to care for women in their third trimester of pregnancy.

Rationale for Using Fast-Track Rulemaking Process: This regulatory action is being promulgated as a fast-track rulemaking action because it is not expected to be controversial. The changes in the regulatory text do not reflect changes in Medicaid programs, but rather the updated text reflects changes that have already been made in FAMIS MOMS contracts and practice.

Substance: The removal of the third trimester managed care exclusion from 12VAC30-141-880 within the FAMIS MOMS regulations is also being removed from the Medallion 4.0 regulations in a separate fast-track rulemaking action. The Medallion 4.0 plans provide a number of innovations to improve outcomes for pregnant women and their infants. These plans also ensure that pregnant women receive high quality care and care coordination, which is not available to fee-for-service members. As a result, pregnant women will receive a greater benefit from enrolling in Medicaid Managed Care and receive high quality care and care coordination as early as possible in their pregnancies.

These benefits are designed to improve health outcomes for women and their infants and are not available for the fee-for-service population. By ending this third trimester exclusion, DMAS is committed to ensuring that all pregnant women and infants can receive the comprehensive array of high quality services and care coordination offered by the Medicaid Managed Care health plans.

Issues: The primary advantages of this action to both the public and the agency are (i) the removal of regulations that could negatively impact health outcomes and (ii) improved access to care for qualified Medicaid members. These changes create no disadvantages to the public, the agency, the Commonwealth, or the regulated community.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The Board of Medical Assistance Services (Board) proposes to remove the language allowing exclusion from managed care enrollment for individuals in the third trimester of pregnancy to reflect changes in practice and contracts as they apply to the Family Access to Medical Insurance Security (FAMIS) plan.²

Result of Analysis. There is insufficient data to accurately compare the magnitude of the benefits versus the costs. Detailed analysis of the benefits and costs can be found in the next section.

Estimated Economic Impact. The purpose of this action is to bring this regulation into alignment with the current FAMIS MOMS contracts and current Medicaid managed care practices.

Current language in this regulation provides an exemption for individuals in the third trimester of pregnancy to opt out of the requirement to enroll in a managed care plan. Prior to 2012, managed care coverage was not available in all parts of Virginia, especially in rural areas as the managed care delivery system in Virginia had been gaining ground but was not fully mature yet. To address this issue, this regulation has allowed pregnant individuals to receive services from fee-for-service providers who were not enrolled in a managed care provider network (e.g., certified professional midwives). In 2012, managed care coverage had become available statewide, and currently all six managed care organizations include the 13 major health systems in their network and all provide statewide coverage. As a result of the managed care network expansions, there were only 10 exemption requests last year.

In addition to the changes in practice reducing the number of exemption requests significantly, the Department of Medical Assistance Services (DMAS) plans to add specific contract language effective July 1, 2019, that will address how these pregnant individuals could access the services they need. These changes will stipulate that members in their third trimester of pregnancy will no longer be allowed to request exclusion from managed care enrollment but will still provide the option of changing health plans if their provider is not contracted with a specific managed care organization but is a part of another plan's network. In other words, affected individuals will be allowed to switch their managed care network that does not include the provider sought and enroll in the one that has a contract with the desired provider. If the desired provider is not in the network of any of the six managed care organizations, affected individuals will not have access to that specific provider under the contract language.

However, DMAS plans to revise the existing "Good Cause Exemption" under 12VAC30-141-880 to allow qualified pregnant women to temporarily remain in fee-for-service while under the care of a Medicaid-enrolled certified professional or licensed midwife.  This process will require that pregnant members obtain an attestation from a physician or nurse practitioner (including certified nurse midwives and other nurse practitioners), within the third trimester, that no diagnoses are present that could increase the risk of adverse outcomes for mother or baby. To define these risks, DMAS will work with the Board of Medicine, the Board of Nursing, the American College of Obstetricians and Gynecologists, the American College of Nurse Midwives and other stakeholders, as deemed appropriate.

According to DMAS, the managed care health plans all have 100% network adequacy for prenatal and obstetric care, including obstetricians/gynecologists, nurse practitioners, family physicians, and certified nurse midwives in all regions of the Commonwealth. DMAS also notes that managed care plans provide a number of innovations to improve outcomes for pregnant women and their infants and ensure that pregnant women receive high quality care and care coordination, which is not available to fee-for-service members. Therefore, DMAS believes the proposed amendments will be beneficial for the affected individuals by assuring quality care. If an affected individual desires to receive services from a fee-for-service-only provider, DMAS is working to provide the option to request it under the "Good Cause Exemption." The "Good Cause Exemption" determination process will be revised to ensure that only the low-risk pregnancies are allowed an exemption. Thus, the proposed amendments will encourage affected individuals to stay in the managed care network but will allow exemptions as appropriate.

Provided that DMAS achieves its goal of tailoring the "Good Cause Exemption" to accommodate the affected individuals by the time the proposed amendments become effective, this action should provide a net benefit as it will reflect the changes in contracts and practice without taking away what may be a valued option for some. Otherwise, the net effect would depend on the level of quality achieved by forcing affected individuals to receive services only from a managed care network and the value attached by the pregnant members to receiving services from the fee-for-service-only provider they prefer.

Businesses and Entities Affected. Last year, there were 10 requests to opt out of managed care network to receive services from fee-for-service-only pregnancy care providers.

Localities Particularly Affected. The third trimester pregnancy exclusion has been more common in rural areas such as in Southwest Virginia.

Projected Impact on Employment. The proposed amendments are unlikely to significantly affect total employment.

Effects on the Use and Value of Private Property. The proposed amendments are unlikely to significantly affect the use and value of private property.

Real Estate Development Costs. The proposed amendments would not affect real estate development costs.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. Although a few fee-for-service-only providers may lose a few pregnant Medicaid members as customers due to added encouragement to stay in the managed care network during pregnancy, the costs and other effects are unlikely to be significant.

Alternative Method that Minimizes Adverse Impact. The proposed amendments are unlikely to have a significant adverse impact on small businesses.

Adverse Impacts:

Businesses. The proposed amendments are unlikely to have a significant adverse impact on businesses.

Localities. The proposed amendments would not adversely affect localities.

Other Entities. The proposed amendments would not adversely affect other entities.

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²This exclusion is also proposed to be removed from Medallion 4.0 regulations in a separate regulatory action. See http://townhall.virginia.gov/l/viewstage.cfm?stageid=8178

Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget and concurs with this analysis.

Summary:

The amendments remove an exclusion from using Medicaid Managed Care through a managed care organization for individuals in the third trimester of pregnancy.

12VAC30-141-880. Assignment to managed care.

A. All eligible enrollees shall be assigned in managed care through the department or the central processing unit (CPU) under contract to DMAS. FAMIS MOMS individuals, during the preassignment period to an MCHIP, shall receive Medicaid-like benefits via fee-for-service utilizing a FAMIS MOMS card issued by DMAS. After assignment to an MCHIP, benefits and the delivery of benefits shall be administered specific to the managed care program in which the individual is enrolled.

1. MCHIPs shall be offered to enrollees in all areas.

2. All enrollees shall be assigned to that contracted MCHIP.

3. Enrollees shall be assigned through a random system algorithm.

4. Enrolled individuals will receive a letter indicating that they may select one of the contracted MCHIPs that serve such area. Enrollees who do not select an MCHIP as described above, shall be assigned to an MCHIP as described in subdivision 3 of this subsection.

5. Individuals assigned to an MCHIP who lose and then regain eligibility for FAMIS MOMS within 60 calendar days will be reassigned to their previous MCHIP.

B. Following their initial assignment to an MCHIP, those enrollees shall be restricted to that MCHIP until their next annual eligibility redetermination, unless appropriately disenrolled by the department.

1. During the first 90 calendar days of managed care assignment, an enrollee may request reassignment for any reason from that MCHIP to another MCHIP serving that geographic area. Such reassignment shall be effective no later than the first day of the second month after the month in which the enrollee requests reassignment.

2. After the first 90 calendar days of the assignment period, the enrollee may only be reassigned from one MCHIP to another MCHIP upon determination by DMAS that good cause exists pursuant to subsection C of this section.

C. Disenrollment for good cause may be requested at any time.

1. After the first 90 calendar days of assignment in managed care, enrollees may request disenrollment from DMAS based on good cause. The request must be made in writing to DMAS and cite the reasons why the enrollee wishes to be reassigned. DMAS shall establish procedures for good cause reassignment through written policy directives.

2. DMAS shall determine whether good cause exists for reassignment.

D. Exclusion for assignment to a MCHIP. The following individuals shall be excluded from assignment to a MCHIP. Newly eligible individuals who are in the third trimester of pregnancy and who request exclusion within a department-specified timeframe of the effective date of their MCHIP enrollment. Exclusion may be granted only if the member's obstetrical provider (physician or hospital) does not participate with the enrollee's assigned MCHIP. Exclusion requests made during the third trimester may be made by the enrollee, MCHIP, or provider. DMAS shall determine if the request meets the criteria for exclusion.