Page 389

_ 389 Item Details($) Appropriations($) ITEM 288. First Year Second Year First Year Second Year FY2025 FY2026 FY2025 FY2026 implementation under a reprocurement no members shall be reassigned from their existing managed care plan unless the member so chooses. Members in a managed care plan not awarded a new contract shall be assigned by DMAS to other plans that are in the best interest of the member. DMAS may suspend random assignments to a managed care organization if the MCO has 40 percent of enrolled lives within an operational region. DMAS shall make no changes in the reassignment methodology unless specifically authorized by the General Assembly. 4) Require managed care organizations to collaborate with DMAS as part of community and programmatic initiatives, however any locality partnership initiatives must be specifically authorized by the General Assembly through a general appropriation act. 5) Add language related to readiness review requirements. 6) Add a foster care specialty plan via a competitive procurement process among the current contractors. 7) Require managed care organizations to invite ombudsman representatives to advisory committee meetings. 8) Revise EPSDT sections to increase care coordination, reporting, member outreach and monitoring, working with community stakeholders to ensure quality of care and monitoring or providers. 9) Require managed care organizations to use the Council for Affordable Quality Healthcare (CAQH) standardized credentialing form if available for their provider type. 10) Add requirement that managed care organizations inform providers 30 priors to any policy or procedure change and must train providers on changes. 11) Increase MCO care coordination screening requirements for Health-Related Social Needs, Behavioral Health and Cancer. 12) Add language requiring managed care organizations to account for specific needs and actions in the plan for identifying, assessing and engaging members on Health-Related Social Needs as part of care coordination activities. 13) Increase value-based payment models and requirements. 14) Revise quality withhold program including but not limited to increasing withhold amount from one percent to three percent as well as DMAS internal processes and reporting responsibilities, however the withhold amount shall not exceed one percent in the first and second years of the contract. In years three and four of the contract the withhold amount shall not exceed two percent. Beginning in year five of the contract, the withhold shall not exceed three percent. 15) Revise underwriting gain section to add that if managed care organization underwriting gain percentage exceeds three percent up to six percent the MCO must return 50 percent of the Medicaid adjusted premium revenue, if the underwriting gain percentage exceeds six percent the MCO must return 75 percent of the Medicaid adjusted premium revenue up to eight percent, and 100 percent of Medicaid adjusted premium revenue above eight percent will be returned. 16) Make changes as required by the Virginia Information Technology Agencies and Office of Attorney General high-risk reviews. 17) Make technical changes necessary to implement behavioral health policies and processes that are authorized and appropriated in this Act. b. In addition, DMAS shall have the authority to include the following changes in the reprocured or amended managed care contracts. 1) Add requirement for timely processing of clean claims. 2) Require managed care organizations to work with DMAS on future locality partnerships if the General Assembly has specifically authorized such work in a specific