Exciting Changes in Managed Care Industry

October 2023

Managed Care Consultants of America is proud to announce the release of our October newsletter, which highlights the latest changes in the managed care industry. Our team of experts have worked tirelessly to provide you with the most up-to-date information, ensuring that you stay ahead of the curve. From new regulations to emerging technologies, our newsletter covers it all. Be sure to read it and stay informed.

Positive Healthcare Plan, a Medicare Advantage Part D Special Needs Health Plan, is not renewing its contract with CMS for 2024.This means that PHP will cease providing insurance coverage to Medicare beneficiaries in Broward, Duval, and Miami-Dade Counties on December 31, 2023. PHP will continue to process all claims with dates of service up to and including December 31, 2023, pursuant to the plan’s claims submission timeliness policy.

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SNF Consolidated Billing and Managed Care

What is SNF Consolidated billing and how does it impact managed care claims?  Congress passed the Balanced Budget Act of 1997 which mandated that the majority of services provided to a Medicare beneficiary while under a Part A SNF stay be bundled and billed back to the SNF. It did not, in general, have implication for Managed Care claims, however that is beginning to change. Several insurance plans have inserted language into their contracts to include the ability to apply consolidated billing per CMS guidelines.  While this language has been in a few contracts, these same insurance plans were not applying the rule to their clams but that is beginning to change. Managed Care Consultants of America has been notified by several clients that they are now receiving bills for services that are occurring outside of their building – in essence, applying consolidated billing. Note that not all contracts or insurance plans are applying consolidated billing; it is important to be educated on the subject for every contract. 

The old standard for managed care, that if a service is outside of our facility, it is not our cost is starting to change. Protect yourself by reviewing your contracts to look for such language, speak with your Managed Care Liaison for better understanding and be more vigilant about Part A patients receiving care outside of the SNF. 

Resources on Consolidated Billing & the updated 2023 Exclusions List:  SNF Consolidated Billing | MM13192 - HCPCS Codes SNF Consolidated Billing

Statewide Medicaid Managed Care Open Enrollment Begins Oct. 1

The Statewide Medicaid Managed Care annual open enrollment (OE) season begins October 1, 2023. During open enrollment, enrollees may choose a different managed care plan or remain with their current plan. Open enrollment will occur in phases based on the region in which the person lives.

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Medicare and the Affordable Care Act both have open enrollments opening soon.

Medicare Open Enrollment is from October 15th - December 7th. Beneficiaries are able to move to new Medicare Advantage plans, Part D or Supplements. There is a 2nd enrollment period exclusively for Medicare Advantage plan members to change plans or go back to traditional Medicare with a Part D plan from January 1st – March 31st.   

Medicare Open Enrollment | CMS

The Affordable Care Act Open Enrollment is from November 1st – January 15th.   This is the window to enroll in or change ACA Commercial / Marketplace plans.  

Open Enrollment is Nov 1 - Jan 15. Are you ready? | HealthCare.gov

To help eliminate resident benefit confusion come 2024, there are a few things a facility can do. 

Engage with your residents and family members regarding potential changes and encourage them to bring the new information to the business office as soon as they receive it. Sending out letters or placing a sign in the lobby are both tactics that can assist with this effort. Regardless, it is still very important to be regularly re-validate benefits through April and every time payable services are rendered. 

Educational Webinars Hosted by MCCA


  • Direct Admits hosted by: Kristin Cull 
  • Medicaid Move-In Best Practice ALF hosted by: Regina Wild


  • LTC vs. MMA hosted by: Alana Hanson-Williams
  • Triple Check hosted by: Mary Hirsch


  • End of Year to Do's hosted by: Destiny Quinones

Please reach out to your liaison for invitations to join.

Housekeeping Items

  • Verify benefits every 1st and 15th of the month as a best practice
  • New employees, please let our liaisons know so we can setup training
  • Discharge Summaries should be sent to the health plans and patient's PCP upon discharge
  • Have you registered for our new portal? Register here!

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