Virginia's July 2025 MCO Rebid: What Cardinal Care Providers Need to Know

Virginia's Medicaid managed care environment has been in motion since 2023, when DMAS consolidated the CCC Plus and Medallion 4.0 programs under the Cardinal Care brand. Two years later, the contracts themselves changed — and July 1, 2025 brought the most significant provider-facing disruption since the initial rebrand.

What Changed July 1, 2025

DMAS awarded new statewide Cardinal Care Managed Care contracts in December 2024. The five MCOs operating under the new contracts are Anthem HealthKeepers Plus, Aetna Better Health of Virginia, Optima Health, United Healthcare of the Mid-Atlantic, and one new entrant: Humana Healthy Horizons in Virginia, which replaced Molina Healthcare.

For providers, the Molina-to-Humana transition was the most operationally disruptive piece. Molina members were moved to Humana during an enrollment period running June 19 through September 30, 2025. Providers who had contracted with Molina needed to contract separately with Humana to continue serving those members without an authorization gap.

Any provider who was Molina-contracted but hadn't executed a Humana contract by July 1 was potentially serving Cardinal Care members they couldn't bill for — because federal rules prohibit MCOs from paying claims to providers who aren't in their network, regardless of prior authorization history.

The PRSS Enrollment Trap

Virginia has a specific billing risk that catches providers off guard more often than the MCO contracting issue: PRSS enrollment. DMAS's Provider Services Solution portal is the single source of truth for provider enrollment, license, and contact information. Federal rules don't just require MCO contracting — they require active enrollment in PRSS for every service location. Claims from providers with lapsed PRSS enrollment are blocked, whether submitted to DMAS FFS or to any of the five MCOs.

DMAS bulletins from 2025 have repeatedly flagged this as a payment disruption risk: providers don't always realize their enrollment has lapsed, their license information has expired, or a service location was inadvertently deactivated until they start seeing denials. The fix requires a PRSS update, which takes time to process — time during which claims that should be paying aren't.

Virginia's Unique EVV Claim Structure

Virginia's EVV model creates a compliance obligation that most other states don't have: EVV data must be embedded directly in the electronic claim form. For personal care services, the 837P record carries the EVV start and end times and location. For home health services, the 837I carries the equivalent fields.

This means EVV isn't a separate system that feeds into a side database for later auditing — it's part of the claim itself. If the EVV data elements are missing or don't match what the provider's EVV system captured, the claim fails at adjudication. Virginia is a Provider Choice state with no single mandated aggregator, which means each provider's EVV vendor integration with their billing system has to be specifically configured to populate the claim-level EVV fields correctly. Many vendors do this — but it has to be verified, not assumed.

The DD Waiver Amendment Backlog Cleared

For DD Waiver providers, 2025 also brought resolution to a nearly year-long wait. DMAS submitted waiver amendments in September 2024 that CMS paused from approval. On April 17, 2025, CMS approved those amendments, clearing the way for two changes providers had been waiting on: removal of the Associate's Degree requirement for Consumer-Directed Services Facilitators effective July 1, 2025, and the new combined $10,000 annual budget for Assistive Technology and Electronic Home-Based Services effective September 1, 2025.

Providers who had been holding authorization decisions pending CMS approval now had clarity — but the tight effective dates meant operational updates needed to happen quickly.

What Providers Should Do Now

Log into PRSS and confirm enrollment status, license expiration, and service location records are current for every location you bill from. Confirm Humana contracting is complete if you serve any members who transitioned from Molina. Verify your EVV vendor is correctly populating the 837P or 837I claim fields with EVV data — not just capturing it in a side system. And for DD Waiver providers, update your service authorization workflows to reflect the new SF qualification standards and the AT/EHBS combined budget structure.

Virginia's Cardinal Care environment is active and changing. The providers who navigate it cleanest are the ones who treat PRSS, MCO contracting, and EVV claim integration as three separate operational checkboxes — not one.