Consultation Services Payment Policy Effective October 1, 2019. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. States contracted with a total of 285 Medicaid MCOs as of July 2020. 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. . 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. Secure Federal support and approval. 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. ) Tel: 0121 386 6605 Fax: 0121 386 6709. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. 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). Develop a measurement and evaluation strategy to demonstrate program value. 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. 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. 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. Comagine Health. This revised product comprises Subregulatory Guidance for the Transitional Care Management Services and its content is based on publicly available content from the 2021 Medicare Physician Fee Schedule Final Rule https://www.federalregister.gov/d/2012-26900 & 2015 Medicare Physician Fee Schedule Final Rule These requirements apply to both capitated and fee-for-service disease management providers. Team Around the Person co-ordinated support for adults. Identify interventions needed for patients. Similarly, case management also involves care planning. 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, . More than half of MCO states reported requiring MCOs to screen enrollees for social needs, screen enrollees for behavioral health needs, provide referrals to social services, and partner with community-based organizations (CBOs). Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. 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. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . 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. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Mandatory enrollment of beneficiaries into managed care programs (although States have the option, through the Balanced Budget Act of 1997, to enroll certain beneficiaries into mandatory managed care via an SPA), or. 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. Determine whether program will be opt-in or opt-out. Build on lessons learned from other States by attending national meetings and networking with other States. Attending national health policy meetings, such as meetings sponsored by the National Association of State Medicaid Directors, National Academy for State Health Policy, National Conference of State Legislatures, National Governors Association, or the Disease Management Association of America. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. 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. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. Heres how you know. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. 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. Support of providers and patients. 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. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. However, they are quite different. 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. Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . 5 (March 2017): 341-353, doi:10.7326/M16-1881, California Health Care Foundation, Making Quality Matter in Medi-Cal Managed Care: How Other States Hold Health Plans Financially Accountable for Performance, (Sacramento, CA: California Health Care Foundation, February 2019), https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf, New York State Department of Health, 2017 Quality Incentive for Medicaid Managed Care Plans, Albany, NY: New York State Department of Health, 2017, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf, The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 States should explore funding issues during program planning to determine the most appropriate program for their State. Limitations, co-payments and . 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. 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. Short term help at home. 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. ECM is a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of high-cost and/or highneed - Medi-Cal managed care health plan (MCP) Members through systematic coordination of services and comprehensive, community-based care . Provider Analytics Tool Scheduled Maintenance. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. Your patients may already be working with one of our care managers. website belongs to an official government organization in the United States. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. Most MCO states reported leveraging Medicaid MCO contracts to promote at least one strategy to address social determinants of health in FY 2022 (Figure 12). 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. Planning these components early will allow staff to design an appropriate care management program for their members. Accelerate claims processing. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. It is more important now than ever to carefully consider the health of your patients and to know what is care management. 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. 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. 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 plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Sparer M. 2012. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 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. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. Powerful pivot table data reporting makes . Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. Please be aware that although this email has restricted access, it is not . At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. 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). 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 . Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. It coordinates the care you get from different doctors. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. Medicaid waivers. Care Management for At-Risk Children (CMARC) The Medicaid program currently offers a set of care management services for at-risk children ages zero-to-five. 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. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. Opt-out programs generally have higher member enrollment than opt-in programs. 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. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. 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." 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. confidential@caremanserve.com. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. If you continue to use this site we will assume that you are happy with it. 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. The benefit information provided is a brief summary, not a complete description of benefits. Incentive Payment Program. A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. 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." Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Under federal law, payments to Medicaid MCOs must be actuarially sound. dedicated employees ~56M. 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. Our care managers help make health care easier and less overwhelming for our members. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. An integral part of any care management program is a thorough understanding of the population it will affect. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content 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. 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 Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. 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. Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework, (McLean, VA: The MITRE Corporation, 2017), https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Copyright 2020 - 2021 Care & Management Services. 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. 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. Innovative solutions for better health outcomes. 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. 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). The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. https:// For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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. Meals on wheels. A key challenge that States must address is targeting resources most effectively for members who are presently high risk and impactable versus members who might be low risk or medium risk currently but who can be prevented from migrating to high risk. Telephone: (301) 427-1364, https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html, 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, http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp, U.S. Department of Health & Human Services. 4.3 (18) FAMCare is powerful, cloud-based case management software for human services agencies who are looking to manage cases faster and make data reviews and reporting simpler to allow you to help more clients. 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. A key component of the MCPD-PI was a care management workgroup. Determine program interventions that will be most effective for selected populations. A State must decide which population to target and how to identify and stratify members for enrollment into the program. 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 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. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. 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. Sign up to get the latest information about your choice of CMS topics. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. Speaking with colleagues in other States to better understand their programs. Please be aware that although this email has restricted access, it is not encrypted. The Chronic Care Model. 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. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. In FY 2022, states reported a range of state-mandated PIP focus areas with an emphasis on reducing disparities and improving health equity including related to maternal and child health; diabetes education and management; substance use disorder (SUD); and access to culturally and linguistically appropriate services. Res. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. Thirty-five MCO states reported covering 75% or more of low-income adults in pre-ACA expansion groups (e.g., parents, pregnant women) through MCOs. Nominate a social care worker for a dignity award. 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. 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. 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). States determine how they will deliver and pay for care for Medicaid beneficiaries. 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%.

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