It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. 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. You'll get a care plan designed just for you. 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. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. An integral part of any care management program is a thorough understanding of the population it will affect. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. The Bridge offers comprehensive care management services for individuals covered by Medicaid and living with: a) two or more chronic medical conditions; b) HIV/AIDS; or c) a diagnosis of serious mental illness. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. Both enrollment mechanisms have advantages and disadvantages. Managing your child's medical issues can be hard. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. An official website of the United States government An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. 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. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. After considering each of the issues outlined above, program staff should answer the following questions in determining whether and how to proceed with a care management program. Build on lessons learned from other States by attending national meetings and networking with other States. Care Management Complaints, Grievances and Plan Appeals Disease Management Emergency Situations EPSDT Program Fraud, Waste and Abuse Get the Most from Your Coverage Interoperability and Patient Access Key Contacts Member Handbook LTC Newsletters Member Rights and Responsibilities Non-Discrimination Notice Prior Authorization means youve safely connected to the .gov website. 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. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. 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. Your Medicare Coverage Principal care management services Principal care management services Medicare Part B (Medical Insurance) covers disease-specific services to help you manage a single, complex chronic condition that puts you at risk of hospitalization, physical or cognitive decline, or death. Similarly, case management also involves care planning. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. ECM helps coordinate primary care, acute care, behavioral health, developmental, oral health, community-based long-term services and supports (LTSS), and referrals to available community . Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. Health goes well beyond care. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Improving Chronic Illness Care. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. 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. You can decide how often to receive updates. Community supports address social drivers of health and build on and scale . B24 9QR. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. For example, the goal of the care management program might be to increase the quality of life for program members. The benefit information provided is a brief summary, not a complete description of benefits. Some States are using DRA-related SPAs to provide targeted disease management for conditions such as chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, pediatric obesity, and pediatric asthma. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). 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. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. Accelerate claims processing. The 2020 CMS Medicaid managed care final rule removed the requirement that states use time and distance standards to ensure provider network adequacy and instead lets states choose any quantitative standard. For general correspondence via email please use the following address. Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, | Email Alerts: | | Under federal Medicaid managed care rules, Medicaid MCOs can be given flexibility to pay for non-medical services through "in-lieu-of" authority and/or "value-added" services. The CalAIM Incentive Payment Program is intended to support the implementation and expansion of ECM and Community Supports by incentivizing managed care plans (MCPs), in accordance with 42 CFR Section 438.6(b), to drive MCP delivery system investment in provider capacity and delivery system infrastructure; bridge current silos across physical and behavioral health . It is more important now than ever to carefully consider the health of your patients and to know what is care management. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. Care Management is a free and voluntary service for Medicaid recipients who may need additional support navigating the health care system to meet a child's medical and behavioral health needs. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. Five firms UnitedHealth Group, Centene, Anthem (renamed Elevance in 2022), Molina, and Aetna/CVS each have MCOs in 12 or more states (Figure 8) and accounted for 50% of all Medicaid MCO enrollment (Figure 9). Access Care Management services deliver innovative programs individualized and customized to Maximize value-based reimbursement Positively affect quality metrics Improved patient compliance Enhance health outcomes Increase patient satisfaction With experience in self-pay, Medicaid and underinsured populations, our outcomes are notable. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. Managed care is the dominant delivery system for Medicaid enrollees. Through the hard work and attention of care managers and an effective technology solution, the integration of healthcare systems and services can revolutionize the experience for patients. 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 . Determine whether program will be opt-in or opt-out. Role of care management in Medicaid program. Copyright 2020 - 2021 Care & Management Services. Using the Incedo Care Management Solution, it is infinitely simpler to develop the programs needed to serve their patients, manage the quality of care, and improve health outcomes. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. Likewise, Virginia sets a lower percentage (10%) for its MLTSS program, Commonwealth Coordinated Care Plus, than for its Medallion 4.0 Medicaid physical and behavioral health managed care program that serves the states low-income children and families and the APM target is set at 25%. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. In FY 2022, similar numbers of states (about one quarter) reported requiring MCOs to have a health equity plan in place, meet health equity reporting requirements, and train staff on health equity and/or implicit bias. Care Management Services. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. Opens in a new window. 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. Note: This brief was updated on March 1, 2023 to incorporate the latest available data. The program coordinates services between health care providers, community program and supports, and family support programs. Speaking with colleagues in other States to better understand their programs. These specially trained professionals can help find resources to make your daily life easier. With 72% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs) nationally, plans have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the unwinding of the continuous enrollment requirement. Partnering with patients to ensure that all of their health care is effectively coordinated. Based on program goals, program staff should develop a measurement and evaluation strategy. A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. dedicated employees ~56M. Preventative care is a core tenet of care management. The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. 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. website belongs to an official government organization in the United States. Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. Chronic care management (CCM) made its debut in 2015 when it was rolled out by the Centers for Medicare and Medicaid Services (CMS) as a separately paid service under the Medicare fee schedule. 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. Section 1115 provides the Secretary of Health and Human Services broad authority to approve projects that test policy innovations likely to further Medicaid program objectives. Monday - Friday, 8:00am - 5:00pm AK Time. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on opt-in and opt-out care management programs. Care management integrates all of a patients healthcare needs into a single individualized care plan that is maintained by the Care Management in a system, such as the Incedo Care Management Solution. It coordinates the care you get from different doctors. If they operate a Medicaid managed care program, states can require Medicaid managed care organizations (MCOs) to connect beneficiaries to social supports as part of their care management obligations. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. 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. or States determine how they will deliver and pay for care for Medicaid beneficiaries. 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. The program is intended to service Medicare patients with two or more chronic . This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. Social Determinants of Health. Integrating Social Supports Into Health Plan Care Management. Share sensitive information only on official, secure websites. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Published: Mar 01, 2023. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and 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. Active Medicaid coverage. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. As of July 2021, about half of MCO states identified a specific target in their MCO contracts for the percentage of provider payments or plan members that MCOs must cover via APMs. Opt-out programs generally have higher member enrollment than opt-in programs. Sparer M. 2012. Participate in reporting and data exchange included in the program. Case managers generally work indirectly with patients, often employed by healthcare facilities. Care Management Services for Medicaid Beneficiaries with Specific Conditions Care management services are available to Mississippi Medicaid fee-for-service beneficiaries not enrolled in MississippiCAN (MSCAN) who meet one of the five specific conditions below. Care management refers to patient-centric, healthcare planning. .gov It is available for both adults and children. 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, . Telephone: (301) 427-1364,, AHRQ Publishing and Communications Guidelines, Evidence-based Practice Center (EPC) Reports, Healthcare Cost and Utilization Project (HCUP), AHRQ Quality Indicator Tools for Data Analytics, United States Health Information Knowledgebase (USHIK), AHRQ Informed Consent & Authorization Toolkit for Minimal Risk Research, Grant Application, Review & Award Process, Study Sections for Scientific Peer Review, Getting Recognition for Your AHRQ-Funded Study, AHRQ Research Summit on Diagnostic Safety, AHRQ Research Summit on Learning Health Systems, About AHRQ's Quality & Patient Safety Work, Designing and Implementing Medicaid Disease and Care Management Programs, Section 1: Planning a Care Management Program, Section 2: Engaging Stakeholders in a Care Management Program, Section 3: Selecting and Targeting Populations for a Care Management Program, Section 4: Selecting Care Management Interventions, Section 5: Selecting a Care Management Program Model, Section 6: Operating a Care Management Program, Section 7: Measuring Value in a Care Management Program, Section 8: The Care Management Evidence Base, Section 5: Selecting a Care Management Program Model for more information,, U.S. Department of Health & Human Services. 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. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . We assist you with scheduling the variety of appointments that your child may have to meet their needs. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care and costs is both limited and mixed.3,4,5. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. While there is an increasing emphasis on care management for older adults who are dually eligible for Medicare and Medicaid that is focused on long-term services and supports, care managers based in healthcare organizations typically have a broader scope, including serving older adults who are not Medicaid-eligible. Control costs. Medicaid waivers. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. This group, facilitated by CHCS . The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. 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. 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. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. The CCM program provides help for a person to. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. Engage stakeholders to build program support. Availability of necessary staff and resources. Considerations for developing a care management program. Alternative payment models (APMs) replace FFS/volume-driven provider payments and lie along a continuum, ranging from arrangements that involve limited or no provider financial risk (e.g., pay-for-performance (P4P) models) to arrangements that place providers at more financial risk (e.g., shared savings/risk arrangements or global capitation payments). Additionally, while we can track state requirements for Medicaid managed care plans, plans have flexibility in certain areas including in setting provider payment rates and plans may choose to offer additional benefits beyond those required by the state. o Patient access to care management services 24/7. A State must decide which population to target and how to identify and stratify members for enrollment into the program. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Addressing their health concerns from a holistic point of view, integrating physical, behavioral, and social health improves overall well-being. Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework, (McLean, VA: The MITRE Corporation, 2017), Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. Provider Analytics Tool Scheduled Maintenance. Sunshine Health is a managed care plan with a Florida Medicaid contract. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . Existing staff who can perform certain interventions, such as nurses or care managers, might be available. The service is intended to provide additional care to patients with a single chronic condition or allowing a provider to treat a patient with multiple chronic conditions by focusing care solely on one of those . Share on Facebook. For most states, the requirements for APMs were in the 25 50% range. States reported setting different percentage requirements depending on the services and population served under the managed care contract.10 Thirteen states11 reported that their APM targets were linked to the Health Care Payment Learning & Action Networks (LANs) APM Framework that categorizes APMs in tiers.12, While there is some evidence of positive impacts from state use of financial incentives to engage managed care plans around quality and outcomes, the results are more mixed and limited at the provider level.13,14,15. The share of Medicaid spending on MCOs varies by state, but over three-quarters of MCO states directed at least 40% of total Medicaid dollars to payments to MCOs (Figure 5). Medicaid State Waiver Demonstration Projectsgeneral information. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. Increase accuracy. Medicaid members covered. If you have any questions, please do not hesitate to contact us today! States should coordinate and communicate routinely with these stakeholders. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. Agency for Healthcare Research and Quality, Rockville, MD. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. 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. However, there has been significant movement across states to carve these services in to MCO contracts. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. (805) 823-0981. Your care plan. Encourage members to take advantage of the program. 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. We work with youth between the ages of 5 and 21, who have a qualifying mental health diagnosis or other chronic condition that affects their daily functioning. 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." States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. In planning a care management program, States have found the following strategies helpful: Each of these strategies can be useful to learn about other States' experiences and to understand a care management program's impact on outcomes. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. Jada Raphael For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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. Medicaid managed care: costs, access, and quality of care. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. 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. Team Around the Person co-ordinated support for adults. 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. Senior leadership might also have areas and directions that they have no interest in pursuing. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. capite provinciis rome,