Sparer M. 2012. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. 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. Select and target populations to allocate resources most effectively. 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. Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. Please be aware that although this email has restricted access, it is not encrypted. Providers of care and support. The benefit information provided is a brief summary, not a complete description of benefits. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . This role is responsible for providing leadership and direction to a large team of clinical . Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. For more information on these topics, please go to Section 3: Selecting and Targeting Populations for a Care Management Program, Section 4: Selecting Care Management Interventions, Section 6: Operating a Care Management Program, and Section 7: Measuring Value in a Care Management Program. Integrating Social Supports Into Health Plan Care Management. Created by the Balanced Budget Act of 1997, this SPA authority to mandate enrollment applies to primary care case management or MCO-model disease management programs. Existing staff who can perform certain interventions, such as nurses or care managers, might be available. 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. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. When the continuous enrollment provision ends and states resume disenrollments, Medicaid MCOs may see the overall acuity of their membership increase, with implications for per member utilization and costs, and the return of member churn (i.e., the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time). PCCM is a managed fee-for-service (FFS) based system in which beneficiaries are enrolled with a primary care provider who is paid a small monthly fee to provide case management services in addition to primary care. 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. Integrating Social Determinants of Health to Improve Outcomes and Profitability, How Risk Bearing Entities Can Extract Value from Care Management Programs, Integrated Behavioral Health: The Time is Now, Health Systems and Community-Based Networks. 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 . 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. 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. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Team Around the Person co-ordinated support for adults. Medicaid Care Management (MCM), or managed care, delivers New Hampshire Medicaid health benefits and additional services through contracts between the Department of Health and Human Services (DHHS) and managed care organizations (MCOs) or Medicaid Health Plans. Program staff should assess the type of interventions appropriate for their care management program. 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. As part of managed care plan contract requirements, state Medicaid programs have also been focused on the use of alternative payment models (APMs) to reimburse providers and incentivize quality. Garnering support from leadership and other stakeholders, developing realistic program expectations early in the process, and designing a strategic evaluation process affect program success and sustainability significantly. 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. Managed care is the dominant delivery system for Medicaid enrollees. 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. The Chronic Care Management program was created by Medicare to close those communication gaps. 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. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. 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). Under federal law, payments to Medicaid MCOs must be actuarially sound. The 2020 Medicare Physician Fee Schedule (the "Final Rule"), released on November 1, 2019, finalized two new codes in a new category of reimbursement titled "Principal Care Management" (PCM) Services. We'll help guide your family through the healthcare system. If you continue to use this site we will assume that you are happy with it. Considerations for developing a care management program. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content 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. Jada Raphael The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. Providing care for people living with chronic or complicated illnesses or conditions, is complex. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. If you have any questions, please do not hesitate to contact us today! Speaking with colleagues in other States to better understand their programs. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. The Chronic Care Model. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. Medicaid State Waiver Demonstration Projectsgeneral information. Consultation Services Payment Policy Effective October 1, 2019. States should consider relevant components from multiple States and develop a care management program best suited to that State's individual needs while building on the experiences of other State Medicaid programs. Your Care Plan is a tool for Healthy Blue care management members to help you: Stay connected with your care coordinator; Find your care coordinator . This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program. Powerful pivot table data reporting makes . 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. The program is intended to service Medicare patients with two or more chronic . 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. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. Understanding available resources and considering program design options will help State Medicaid staff decide whether to move forward with a care management program, determine the most appropriate program design for the Medicaid population, and decrease the need for program refinements. Nearly all states have some form of managed care in place comprehensive risk-based managed care and/or primary care case management (PCCM) programs.1,2 As of July 2022, 41 states (including DC) contract with comprehensive, risk-based managed care plans to provide care to at least some of their Medicaid beneficiaries (Figure 1). 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. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . 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. To estimate program costs and understand program financing, they should consider the following issues: Many programs require Federal approval from CMS in the form of a State plan amendment (SPA) or a waiver. California carved the pharmacy benefit out of managed care as of January 1, 2022. Heres how you know. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. Your care plan. 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. Opens in a new window. This group, facilitated by CHCS . Care management services Care management is a program we make available to eligible members who may need help getting the care they need. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. State Medicaid Director Letter: Guidance on how States can cover disease management. The Care Manager will be able to answer patient questions and complete requests for care. Encourage members to take advantage of the program. Assessing various risks in the patients home and environment, Improves coordination of necessary healthcare, leading to better quality care, Patients feel understood, listened to, and properly cared for. Chronic Care Management. Internet Citation: Section 1: Planning a Care Management Program. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). 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. 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. However, they are quite different. Monday - Friday, 8:00am - 5:00pm AK Time. An integral part of any care management program is a thorough understanding of the population it will affect. 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 . Published: Mar 01, 2023. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." 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. Please go to Section 5: Selecting a Care Management Program Model for more information. Accelerate claims processing. ) Complex Case Management 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. You can decide how often to receive updates. The NC Medicaid Ombudsman can help Medicaid beneficiaries get access to health care and connect beneficiaries to resources like legal aid, social services and other programs. 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. Transitional Care Management Program Effective September 1, 2019. The new codes will be effective as of January 1, 2020, and provide reimbursement for managing a patient's care for a single high-risk disease or complex chronic condition. 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). 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 . States contracted with a total of 285 Medicaid MCOs as of July 2020. Rockville, MD 20857 Your patients may already be working with one of our care managers. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . lock Support of providers and patients. Beginning July 1, 2021, North Carolina implemented its first MCO program, enrolling more than 1.8 million Medicaid beneficiaries in MCOs as of January 2023. Our care managers help make health care easier and less overwhelming for our members. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . 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 . CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. Comagine Health. If you have questions about getting service coordination or service management through your health plan, call the help line phone number listed on the back of your health plan ID card. Availability of necessary staff and resources. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Care Management Services. It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. An official website of the United States government 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. 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. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. 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. A parent firm is a firm that owns Medicaid MCOs in two or more states. A State must decide which population to target and how to identify and stratify members for enrollment into the program. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). Medicaid managed care operates within a complex legal framework that includes contracts spelling out a state's performance expectations regarding coverage, care, access, payment, quality improvement, and other matters. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. If you're enrolled in a care management program, you can get personalized help from: Outreach workers Registered nurses Social workers Your care management team will help coordinate your healthcare. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. 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. Determine whether program will be opt-in or opt-out. Specifically, among other requirements, the DRA allows States to impose cost-sharing requirements on services such as prescriptions, increase copayments on emergency services, and alter existing Medicaid benefits packages to mirror certain commercial insurance packages through use of "benchmark" plans. Content last reviewed October 2014. cost effective, non-duplicative services. 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. Medicaid managed care: costs, access, and quality of care. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. MCOs represent a mix of private for-profit, private non-profit, and government plans. 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. Community supports address social drivers of health and build on and scale . What Does Successful Care Management Look Like? 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. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. As well as having ideas to share on clinical aspects of the care management program, large provider groups, hospitals, provider associations, and individual providers can serve as ambassadors to patients for the program. Sunshine Health is a managed care plan with a Florida Medicaid contract. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. 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. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. For most states, the requirements for APMs were in the 25 50% range. 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. means youve safely connected to the .gov website. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. in place in FY 2022. States should explore funding issues during program planning to determine the most appropriate program for their State. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. 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. ( After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. 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. 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, . An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. 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. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. Medicaid waivers. Whether youre sharing risk in a value-based, The pandemic has placed additional strain on member health, creating new challenges not only around how to safely deliver care, but also what types of, 101 West Elm Street, Suite G10, Conshohocken, PA 19428. Assess financial environment to determine most appropriate program. Establish program goals and identify short- and long-term objectives. 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. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . It works by activating patients own motivation for change and adherence to their Doctor's directives. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Understand motivations for establishing program. 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. However, there has been significant movement across states to carve these services in to MCO contracts. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. 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. The technical storage or access that is used exclusively for anonymous statistical purposes. A key component of the MCPD-PI was a care management workgroup. As of July 2020, a total of 14 firms operated Medicaid MCOs in two or more states (called parent firms),8 and these firms accounted for 62% of enrollment in 2020 (Figure 9). Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . . Dental Care Early and Periodic Screening, Diagnostic, and Treatment Hospice Benefits Mandatory & Optional Medicaid Benefits Prevention Telehealth Assurance of Transportation Prescription Drugs Branded Prescription Drug Fee Program Drug Utilization Review Federal Upper Limit Medicaid Drug Policy Medicaid Drug Rebate Program Pharmacy Pricing The nature of the relationship to the patient is distinguishing factor between these terms. Learn . Incentive Payment Program. Their experiences and understanding of their own limitations might help in the early planning stage. Share sensitive information only on official, secure websites. As a result, most programs target specific populations because they are more "impactable.". 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. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. Secure Federal support and approval. Both enrollment mechanisms have advantages and disadvantages. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards.