Care management services Care management is a program we make available to eligible members who may need help getting the care they need. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. Increase accuracy. 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. WellCare was acquired by Centene in January 2020. (805) 823-0981. contact@vigilancehit.com. 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. 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. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. 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. Determine program interventions that will be most effective for selected populations. 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. Not consenting or withdrawing consent, may adversely affect certain features and functions. 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. Support of potential program partners, such as other State agencies and local organizations. Control costs. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. 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, . 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. Relevant Federal and State Authorities. 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 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. o Care management for chronic conditions . Sign up to get the latest information about your choice of CMS topics. 1 Care Management Framework The following framework (see other side) outlines . 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. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. Opens in a new window. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." A parent firm is a firm that owns Medicaid MCOs in two or more states. While the vast majority of states that contract with MCOs report that the pharmacy benefit is carved in to managed care (34 of 41), six states report that pharmacy benefits are carved out of MCO contracts as of July 2022 (Figure 7). 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 . In January 2023, CMS released guidance on the use of in lieu of services (ILOS) in Medicaid managed care to reduce health disparities and address unmet health-related social needs (HRSN). Role of care management in Medicaid 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). As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. 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). 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. This group, facilitated by CHCS . 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 . 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. If you have any questions, please do not hesitate to contact us today! 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. . Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. 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 Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. State Medicaid Director Letter: Guidance on how States can cover disease management. 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. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 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. We engage members in a more proactive, preventive and connected way. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and 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. 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. Please go to Section 5: Selecting a Care Management Program Model for more information. 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. 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. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. 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. Sparer M. 2012. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. cost effective, non-duplicative services. If goals have not been set already by the State legislature or Governor's office, Medicaid program staff should determine program goals based on the motivations for establishing a care management program. 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. Res. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. 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. Coordinating and managing health care for complex patients is a complicated task, but organizations like InfoMC have innovated to provide solutions for care teams to serve those in need more efficiently. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . 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. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. 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. 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. 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. By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. Care management refers to patient-centric, healthcare planning. This includes post-acute and long-term rehabilitation programs such as physical therapy, occupational or recreational therapies, speech-language pathology services, cognitive training, or neurorehabilitation. A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. Communicating with hospital staffs, family doctors, specialists, etc. About one-quarter of MCO states reported at least one MCO financial incentive tied to a health equity-related performance goal (e.g., reducing disparities by race/ethnicity, gender, disability status, etc.) Endorse the concepts of the interventions with patients. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. 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. Community supports address social drivers of health and build on and scale . 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. Understand motivations for establishing program. Secure Federal support and approval. Improving Chronic Illness Care. Incentive Payment Program. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. 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. Your care plan. California carved the pharmacy benefit out of managed care as of January 1, 2022. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. . Program staff should assess the type of interventions appropriate for their care management program. 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. Note: This brief was updated on March 1, 2023 to incorporate the latest available data. Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. 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. Medicaid waivers. States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. To sign up for updates or to access your subscriberpreferences, please enter your email address below. 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). B24 9QR. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. 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. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. However, they are quite different. 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. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. It is also contracting with a Pharmacy Pricing and Audit Consultant (PPAC) who provides operational and consulting support in the areas of pharmacy reimbursement, benefit design, oversight, and auditing. 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. Birmingham. 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. 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). Reviewing formal evaluations of other States' programs. States should coordinate and communicate routinely with these stakeholders. Chronic Care Management. 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). Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. Support of providers and patients. It is available for both adults and children. 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. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). As a result, during the planning stage, program staff should work with CMS staff, both at the regional and national levels, to solicit feedback and understand the type of authority that must be used to implement certain care management program components versus others. Innovative solutions for better health outcomes. 907-770-7525 or 888-578-2547. Care Management Entity The Medicaid Care Management Entity acts as a central accountable hub to deliver community-based intensive care coordination services for children and youth with complex behavioral health needs using an evidence-based practice called "High Fidelity Wraparound." Managing your child's medical issues can be hard. lock A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. COPD. Therefore, approval procedures are individualized, usually depending on the care management program model. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . 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. Consultation Services Payment Policy Effective October 1, 2019. Although 2020 data (displayed above) are the most current national data available, enrollment in Medicaid overall has grown substantially since the start of the coronavirus pandemic, resulting in growth in MCO enrollment as well. Medicaid Managed Care Provider Resource Communication. Rockville, MD 20857 Establish program goals and identify short- and long-term objectives. Official websites use .govA Develop a measurement and evaluation strategy to demonstrate program value. However, there has been significant movement across states to carve these services in to MCO contracts. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Select program model based on available staff and resources. Based on program goals, program staff should develop a measurement and evaluation strategy. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. 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." These specially trained professionals can help find resources to make your daily life easier. 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. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. Meals on wheels. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Plan efforts to recruit and maintain their provider networks can affect enrollees access to care through factors such as travel times, wait times, or choice of provider. Partnering with patients to ensure that all of their health care is effectively coordinated. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. 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. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. However, networks can be affected by overall provider supply shortages. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. 7500 Security Boulevard, Baltimore, MD 21244 . 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.
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