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. Managing your child's medical issues can be hard. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. The rationale behind its inception was to offer an avenue of compensation for practitioners who provided care to their patients outside of the normal confines of the average office visit. The Chronic Care Management program was created by Medicare to close those communication gaps. Considerations for developing a care management program. 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. 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. 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. https:// The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. . ) Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. To improve the coordination of care for Medicare patients between the acute care setting and community setting, the Centers for Medicare & Medicaid Services created two billing codes for Transitional Care Management (TCM). 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. What Does Successful Care Management Look Like? VigilanceHealth.com. These requirements apply to both capitated and fee-for-service disease management providers. 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. 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. Medicaid State Waiver Demonstration Projectsgeneral information. 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. 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. . 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. For example, if a State plans an external evaluation of the program, having the evaluator provide input as program measures and data collection are discussed might be useful. 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. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). 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. (805) 823-0981. contact@vigilancehit.com. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Residential and nursing care. For most states, the requirements for APMs were in the 25 50% range. Rep. 23, Robert Wood Johnson Found., Princeton, NJ, Daniel Franco Montoya, Puneet Kaur Chehal, and E. Kathleen Adams, Medicaid Managed Cares Effects on Costs, Access, and Quality: An Update, Annual Review of Public Health 41:1 (2020):537-549, Medicaid and CHIP Payment and Access Commission (MACPAC), Managed cares effect on outcomes, (Washington, DC: MACPAC, 2018), https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/. WellCare was acquired by Centene in January 2020. 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. How do we help? Innovative solutions for better health outcomes. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. The Care Manager will be able to answer patient questions and complete requests for care. Increase accuracy. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). B24 9QR. Tel: 0121 386 6605 Fax: 0121 386 6709. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." You'll get a care plan designed just for you. Build on lessons learned from other States by attending national meetings and networking with other States. However, to track progress on an ongoing basis, staff must identify short-term objectives, such as members selecting a primary care physician or decreased emergency room (ER) utilization. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. Team Around the Person co-ordinated support for adults. 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 Medicaid waivers. 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 implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . 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. States contracted with a total of 285 Medicaid MCOs as of July 2020. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. 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. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Chronic pain and disease. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. California carved the pharmacy benefit out of managed care as of January 1, 2022. http://www.nasmd.org/waivers/waivers.htmll#1915b. o Patient access to care management services 24/7. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. Medicaid managed care: costs, access, and quality of care. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. ( Building relationships with patients and caregivers, Administering assessments and developing individualized care plans, Connecting patients and caregivers to social and community support services, Establishing relationships with patients physicians and other providers, Facilitating administrative communication between healthcare providers, Monitoring care gaps and ensuring appointments are scheduled and kept, Comparing current care with proposed services. Care management teams cover a wide variety of responsibilities, all with the aim of managing patients healthcare needs, improving patient engagement and experience, and improving their overall health outcomes. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Medicaid members covered. The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. Additional information about the program change is available at Ohio Medicaid Managed Care, Ohio Medicaid Single Pharmacy Benefit Manager (SPBM), https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager. Today, Medicaid-focused startups can leverage these new behaviors to engage and educate patients in a more continuous fashion, through such tools as asynchronous telemedicine, Food and Drug Administration-approved digital therapeutics, and home testing around infection and chronic disease managementtools that can change what and where care is delivered and at a lower cost. 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. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. Care management programs often are linked with primary care case management (PCCM) programs or medical home initiatives, because Medicaid fee-for-service (FFS) might not offer the consistency of care typically provided at medical homes and necessary for successful patient interventions. 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. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. Please be aware that although this email has restricted access, it is not . For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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 . A State must decide which population to target and how to identify and stratify members for enrollment into the program. 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. 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. States might consider implementing a care management program for a variety of reasons. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. 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. 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. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. 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. States should explore funding issues during program planning to determine the most appropriate program for their State. 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. Senior leadership within the Medicaid program, its umbrella agency or department, and the Governor's office might have specific program goals that program staff must understand as they plan and develop the program. 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. This group, facilitated by CHCS . It is available for both adults and children. That is why in 2015, CMS began reimbursing providers for a program called non-complex Chronic Care Management (CCM), billed as the new code CPT 99490. Role of care management in Medicaid program. 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." 7500 Security Boulevard, Baltimore, MD 21244 . 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. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. Filling the need for trusted information on national health issues, Elizabeth Hinton and Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Care Management Triage medical needs, validate medical necessity and efficiently coordinate patient care throughout the path to recovery Navigating the healthcare system can be daunting for those with new healthcare needs or a surprise workplace injury. Speaking with colleagues in other States to better understand their programs. Complex Case Management However, there has been significant movement across states to carve these services in to MCO contracts. Preventative care is a core tenet of care management. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. If you have any questions, please do not hesitate to contact us today! Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. Assess financial environment to determine most appropriate program. Establish program goals and identify short- and long-term objectives. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. Select and target populations to allocate resources most effectively. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. Improving Chronic Illness Care. Therefore, approval procedures are individualized, usually depending on the care management program model. Meals on wheels. 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). CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization.