July 1st Medicaid Changes- What Providers Need To Know

As you may already know, some important changes began on July 1, 2025.

Here’s what behavior analysts in Virginia should know about the Cardinal Care changes effective July 1, 2025:

1. Humana Healthy Horizons joins as a new MCO

• Humana becomes one of the five Cardinal Care MCOs (joining Aetna, Anthem, Sentara, and UnitedHealthcare)
• Molina exits the program as of June 30, 2025. Molina-enrolled members will automatically transition to Humana on July 1
• If you provided ABA or other behavior-analytic services under Molina, it’s critical to contract with Humana promptly to maintain service continuity.

2. Special enrollment period: June 19 – September 30, 2025

• Members may choose or switch MCOs during this period.
  • Selected plan by the 18th → effective on the 1st of next month
  • After the 18th → effective the 1st of the following month

3. Provider enrollment & PRSS

• Regardless of your MCO, all providers must be enrolled and periodically revalidated via DMAS PRSS per federal rules
• Failure to maintain active PRSS enrollment could result in denied claims from both Humana and DMAS

4. Prior authorizations & service continuity

• Existing service authorizations  will be honored for at least 30 days after July 1, or as otherwise specified in your contract
• This grace period helps ensure uninterrupted care while transitioning to Humana’s model.

5. Model of care: integrated & member‑centered

• The new Cardinal Care emphasizes a holistic, responsive care management approach with integrated behavioral health
• Expect data-driven, risk-based care coordination, including three levels of care management intensity tailored to member needs—this could affect ABA programs
• As ABA providers, you may see enhanced collaboration opportunities with care management teams (especially around functional assessments, treatment planning, and progress monitoring).

Action Steps for ABA Providers

1. Contract with Humana Healthy Horizons
   • Contact Humana’s BH provider line (email: VA_BH_Medicaid@humana.com) to initiate credentialing.
2. Verify & update PRSS enrollment
   • Log into the DMAS Provider Services Solution portal and confirm your demographic and licensure details are current.
3. Ensure prior auth coverage continuity
   • Track upcoming expiring authorizations and follow Humana’s authorization protocols during and after the 30-day grace period.
4. Understand Humana’s care management model
   • Familiarize yourself with Humana’s care coordination processes—what they expect from providers, steps for referrals, data sharing, etc.
5. Stay informed & engaged

Review updated FAQs, Q&A recordings, provider toolkits, and Cardinal Care materials on the DMAS site https://www.dmas.virginia.gov/for-providers/cardinal-care-providers/