Partnering with patients to ensure that all of their health care is effectively coordinated. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. Innovative solutions for better health outcomes. Considerations for developing a care management program. 10 Things to Know About Medicaid Managed Care, has grown substantially since the start of the coronavirus pandemic, National Association of Insurance Commissioners (NAIC) data, report that the pharmacy benefit is carved in, 2020 CMS Medicaid managed care final rule, to direct/bolster payments to Medicaid providers, reported using at least one financial incentive, reported at least one MCO financial incentive, state-mandated PIP focus areas with an emphasis on reducing disparities, https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/, https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager, https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf, https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf, Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Consider pilot testing to test intervention on a smaller scale. Sparer M. 2012. Understand motivations for establishing program. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Linking the medical home and care management can provide additional benefits to both Medicaid and the care management program, including the following: Implementation of another State initiative might enhance or hinder implementation of a care management program. Receiving personalized attention from a Care Manager helps patients to better understand their health and subsequently be more engaged in their healthcare and feel more in control. Care management programs are designed to assist patients and their support systems in managing multiple health conditions more effectively, to improve health outcomes for the patient. State-to-state variation reflects many factors, including the proportion of the state Medicaid population enrolled in MCOs, the health profile of the Medicaid population, whether high-risk/high-cost beneficiaries (e.g., persons with disabilities, dual eligible beneficiaries) are included in or excluded from MCO enrollment, and whether or not long-term services and supports are included in MCO contracts. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Based on program goals, program staff should develop a measurement and evaluation strategy. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . If you continue to use this site we will assume that you are happy with it. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. Transitional Care Management Program Effective September 1, 2019. It is more important now than ever to carefully consider the health of your patients and to know what is care management. Every care management program should have an overarching aim, which might be as simple as "to maximize the quality of life and promote a regular source of care for patients with chronic conditions." Your care plan. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. In response to the COVID-19 pandemic, states had options and flexibilities under existing managed care rules to direct/bolster payments to Medicaid providers and to preserve access to care for enrollees. . Plans can use a variety of strategies to address provider network issues, including direct outreach to providers, financial incentives, automatic assignment of members to PCPs, and prompt payment policies. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . ECM is a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of high-cost and/or highneed - Medi-Cal managed care health plan (MCP) Members through systematic coordination of services and comprehensive, community-based care . States may request Section 1915(b) waiver authority to operate programs that impact the delivery system of some or all of the individuals eligible for Medicaid in a State by: Section 1915(b) waiver programs need not be operated statewide. The nature of the relationship to the patient is distinguishing factor between these terms. Please go to Section 5: Selecting a Care Management Program Model for more information. Tailored plans will provide specialized services and care management to meet the needs of these individuals. Medicaid MCOs provide comprehensive acute care and, in some cases, long-term services and supports to Medicaid beneficiaries and are paid a set per member per month payment for these services. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). For example, North Carolina experienced improved outcomes in asthma management more quickly than in diabetes management.a In addition, the evidence base suggests that programs might see improvements in process measures such as screening rates more quickly than desired changes in utilization rates, financial outcomes, and health outcomes. States determine how they will deliver and pay for care for Medicaid beneficiaries. Their experiences and understanding of their own limitations might help in the early planning stage. Despite activity in this area, detailed performance information at the plan-level is not frequently made publicly available by state Medicaid agencies, limiting transparency and the ability of Medicaid beneficiaries (and other stakeholders) to assess how plans are performing on key indicators related to access, quality, etc. Medicaid Management. Communicating with hospital staffs, family doctors, specialists, etc. Of the 39 states that had implemented the ACA Medicaid expansion as of July 2022, 32 states were using MCOs to cover newly eligible adults and most covered more than 75% of beneficiaries in this group through MCOs. State Medicaid Director Letter: Guidance on how States can cover disease management. Interventions may target the patient or the provider and generally range from "low-touch" interventions, such as mailings, to "high-touch" interventions, such as home visits by nurse care managers. This section of the Guide, Planning a Care Management Program, incorporates information from the 13 State Medicaid care management programs in the initial AHRQ Learning Network and additional literature to provide information to State Medicaid staff and policymakers about: Although each State faces a unique environment, all States share several considerations in developing a Medicaid care management program. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Medical Care Management Services | Aetna Care management when it counts Aetna One care management is transforming the health care experience using predictive analytics, personal outreach and local access through CVS Health . The Chronic Care Management program was created by Medicare to close those communication gaps. All five are publicly traded companies ranked in the Fortune 500.9 Earnings reports from 2022 for these five for-profit parent firms (Centene, Molina, Elevance, UnitedHealth Group, and Aetna/CVS) showed growth in Medicaid membership (2022 over 2021) ranging from 6 to 17% and for the three firms that provided Medicaid-specific revenue information (Centene, Molina, and UnitedHealth Group) growth in Medicaid revenues ranging from 11 to 21% (2022 over 2021). Establish program goals and identify short- and long-term objectives. Most States implement a program based on some combination of the following three reasons: States usually establish care management programs to meet multiple needs. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. Agency for Healthcare Research and Quality, Rockville, MD. Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. For most states, the requirements for APMs were in the 25 50% range. While MCOs are the predominant form of Medicaid managed care, millions of other beneficiaries receive at least some Medicaid services, such as behavioral health or dental care, through limited-benefit risk-based plans, known as prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs). You and your care manager will work together to figure out the care and services you need to help you meet your health care goals. Developing relationships with senior Medicaid and agency leadership, the Governor's office, the provider community, the patient and advocacy community, the State legislature and staff, and CMS is critical for the success of a care management program. Active Medicaid coverage. Medicaid waivers. Endorse the concepts of the interventions with patients. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. Heres how you know. Incentive Payment Program. Care management services Care management is a program we make available to eligible members who may need help getting the care they need. States contracted with a total of 285 Medicaid MCOs as of July 2020. Encourage members to take advantage of the program. A parent firm is a firm that owns Medicaid MCOs in two or more states. Consultation Services Payment Policy Effective October 1, 2019. This guidance document outlines the challenges states have faced when reporting primary care case management (PCCM) programs in the OT Claims file, Eligible file and the Managed Care file and recommends guidance for states' reporting. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. Care management refers to patient-centric, healthcare planning. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. The Incedo Care Management Solution is a platform that not only houses all necessary clinical information for each patient, but also supports a collaborative process of assessment, planning, care management and care coordination. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. Comagine Health. Preventative care is a core tenet of care management. The relevant laws that come into play in the relationship between the State, the Managed Care Organizations (MCOs, including the HARPs), the Health Homes, the Care Management Agencies, the service providers and the recipients are as follows: The Health Insurance Portability and Accountability Act of 1996 . Secure Federal support and approval. Learn . Care managers are responsible to collaborate with the care team and coordinate all necessary healthcare services and supports, including preventative care measures and community-based services If appropriate or adequate staff are unavailable, States can contract with a vendor, share staff with other State agencies, or partner with local organizations to perform needed services. The provider's role in Superior's Care Management program is extremely important. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. VCCI works with members referred for complex case management by healthcare and human services providers, state colleagues and partners, as well as through our care management predictive modeling methodology. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Four types of authorities exist under Section 1915(b) that States may request: The State Medicaid plan is a document that defines how the State will operate its Medicaid program. Your patients may already be working with one of our care managers. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Speaking with colleagues in other States to better understand their programs. Care management is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." 3 It also encompasses those care coordination activities needed to help manage chronic illness. As a result, most programs target specific populations because they are more "impactable.". How do we help? It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. Content last reviewed October 2014. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. in place in FY 2022. Medicaid MCOs provide comprehensive acute care and, in some cases, long-term services and supports to Medicaid beneficiaries and are paid a set per member per month payment for these. Support of potential program partners, such as other State agencies and local organizations. 5 (March 2017): 341-353, doi:10.7326/M16-1881, California Health Care Foundation, Making Quality Matter in Medi-Cal Managed Care: How Other States Hold Health Plans Financially Accountable for Performance, (Sacramento, CA: California Health Care Foundation, February 2019), https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf, New York State Department of Health, 2017 Quality Incentive for Medicaid Managed Care Plans, Albany, NY: New York State Department of Health, 2017, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf, The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 An SPA authorized under section 1932(a) of the Social Security Act provides much of the same flexibility available under waivers and also does not require the periodic renewals associated with programs operating under waiver authority. Short term help at home. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. Develop a measurement and evaluation strategy to demonstrate program value. The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. Enrollment growth has been primarily attributed to the Families First Coronavirus Response Act (FFCRA) provision that required states to ensure continuous enrollment for Medicaid enrollees in exchange for a temporary increase in the Medicaid match rate. As described later in this section, after establishing program goals, staff must think about a measurement and evaluation strategy as a critical step early in the development process. Opens in a new window. By involving consumers during the planning, implementation, and evaluation stages, program staff will be better able to gauge the possible impact of certain interventions and will be able to design a better, more effective program overall. This section provides the Secretary of Health and Human Services authority to grant waivers that allow States to implement managed care delivery systems or limit individuals' choice of provider under Medicaid. Please be aware that although this email has restricted access, it is not encrypted. Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and Residential and nursing care. You can decide how often to receive updates. States incorporate quality metrics into the ongoing monitoring of their programs, including linking financial incentives like performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. 7500 Security Boulevard, Baltimore, MD 21244 . Secure .gov websites use HTTPSA While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, it is estimated that millions will lose coverage. For more information on strategies to engage the Governor's office, State legislators, and senior Medicaid and agency leadership, please go to Section 2: Engaging Stakeholders in a Care Management Program. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework, (McLean, VA: The MITRE Corporation, 2017), https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf. The delayed start of Tailored Plans allows Local Management Entity/Managed Care Organizations , which will operate the Tailored Plans, more time to contract with additional providers to ensure a smooth transition for people using the plans and their care providers. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Cognitive Assessment & Care Plan Services, Office-Based Opioid Use Disorder (OUD) Treatment Billing, Medicare PFS Locality Configuration and Studies, Psychological and Neuropsychological Tests, Diagnostic Services by Physical Therapists, Advance Care Planning Services Fact Sheet (PDF), Advance Care Planning Services FAQs (PDF), Behavioral Health Integration Fact Sheet (PDF), Chronic Care Management Frequently Asked Questions (PDF), Chronic Care Management and Connected Care, Billing FAQs for Transitional Care Management 2016. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. Please go to Section 4: Selecting Care Management Interventions for a comprehensive discussion of types of interventions and a comparison of the relative costs of various interventions. A key challenge that States must address is targeting resources most effectively for members who are presently high risk and impactable versus members who might be low risk or medium risk currently but who can be prevented from migrating to high risk. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Centers for Medicare and Medicaid Services (CMS) recognizes care management as a critical tool to achieve the Quadruple Aim (better care, better patient and provider experiences, . Together with your Care team, he or she can oversee your needs and coordinate your care. Share sensitive information only on official, secure websites. Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. States often choose to implement a pilot of their care management program as a way to test the intervention on a smaller scale or if they have limited resources. As a result, staff would want to track incremental progress in performance measures related to this goal or conduct a formal program evaluation. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. Self-directed Medicaid services means that participants, or their representatives if applicable, have decision-making authority over certain services and take direct responsibility to manage their services with the assistance of a system of available supports. Demonstrations must be "budget neutral" over the life of the project, meaning they cannot be expected to cost the Federal Government more than it would cost without the waiver. States may use a variety of mechanisms to adjust plan risk, incentivize plan performance, and ensure payments are not too high or too low, including risk sharing arrangements, risk and acuity adjustments, medical loss ratios (MLRs, which reflect the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement), or incentive and withhold arrangements. Sign up to get the latest information about your choice of CMS topics. For example, a State might want to improve the quality of care provided to beneficiaries with chronic conditions while containing costs in response to a legislative mandate. Mandatory requirements include an increase of the look-back period for long-term care beneficiaries to 5 years and proof of citizenship for all new Medicaid applicants and current Medicaid beneficiaries. VigilanceHealth.com. Similar to waivers, a section 1932(a) SPA authority provides flexibility with respect to limiting providers, eligible populations, and geographic areas that normally is unavailable under traditional SPAs. Select and target populations to allocate resources most effectively. Managing your child's medical issues can be hard. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. The Care Manager will be able to answer patient questions and complete requests for care. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. Meals on wheels. There's a change in your health status. A geriatric care manager, usually a licensed nurse or social worker who specializes in geriatrics, is a sort of "professional relative" who can help you and your family to identify needs and find ways to meet your needs. This group, facilitated by CHCS . Actuarial soundnessmeans that the capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the managed care plan for the time period and the population covered under the terms of the contract. Unlike fee-for-service (FFS), capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Integrating Social Supports Into Health Plan Care Management. Thirty-five MCO states reported covering 75% or more of low-income adults in pre-ACA expansion groups (e.g., parents, pregnant women) through MCOs. Chronic pain and disease. Although MCOs provide comprehensive services to beneficiaries, states may carve specific services out of MCO contracts to fee-for-service systems or limited benefit plans. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. Provider Analytics Tool Scheduled Maintenance. ) For more information, or to enroll in our Care Management program call 1-800-682-9094 x 89634, Monday through Friday, 8 a.m. to 5 p.m., Eastern Time. It coordinates the care you get from different doctors. Payments made to MCOs accounted for about 52% of total Medicaid spending (Figure 4), an increase of three percentage points from the previous fiscal year. However, they are quite different. To learn more, call the NC Medicaid Ombudsman toll free at 1-877-201-3750 , 8 a.m. to 5 p.m., Monday through Friday, except state holidays. CMS has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements, including guidance outlining how managed care plans can support states in promoting continuity of coverage. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). States use an array of financial incentives to improve quality including linking performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. Rockville, MD 20857 Improving Chronic Illness Care. Medicaid officials and State policymakers should take time to consider each of these issues and evaluate their State's support, resources, and readiness to design and implement a care management program. lock https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. Mandatory enrollment of beneficiaries into managed care programs (although States have the option, through the Balanced Budget Act of 1997, to enroll certain beneficiaries into mandatory managed care via an SPA), or. a Available at: Cecil G. Sheps Center for Health Services Research. Texas worked closely with its regional and central offices to communicate its care management program design and to identify a model that it could use to seek CMS approval for its program. Engage stakeholders to build program support. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. As an integral component of the Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans, Tailored Care Management (TCM) is a new care management model that reflects the goal of whole-person care management in NC Medicaid Managed Care. WellCare was acquired by Centene in January 2020. that have received an approval letter from the New York State Department of Health identifying them as a "Designated Provider-lead Health Home") and any converting care management agencies such as OMH TCM, and COBRA providers that are billing directly for health home services. Support of providers and patients. It is available for both adults and children. Relevant Federal and State Authorities. For example, in Pennsylvania, the APM target for the HealthChoices physical health MCO program and the behavioral health managed care program is 50% and 20%, respectively, for calendar year 2021. Aaron Mendelson et al., The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 166 no. Chronic Care Management. Accelerate claims processing. To help ensure participation, many states require minimum provider rates in their contracts with MCOs that may be tied to fee-for-service rates (Figure 10). While managed care is the dominant Medicaid delivery system, states decide which populations and services to include in managed care arrangements which leads to considerable variation across states. Res. Birmingham. Increase accuracy. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement.

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