It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. 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). 7500 Security Boulevard, Baltimore, MD 21244 . Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). Published: Mar 01, 2023. 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. 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. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. 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. 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. The pandemic has placed additional strain on member health, creating new challenges not only around how To provide the best experiences, we use technologies like cookies to store and/or access device information. 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. 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. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. Sparer M. 2012. Establish program goals and identify short- and long-term objectives. Case managers generally work indirectly with patients, often employed by healthcare facilities. 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. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. 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. Control costs. Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. 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. 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. lock 5600 Fishers Lane For most states, the requirements for APMs were in the 25 50% range. 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. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. 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. Engage stakeholders to build program support. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. Under federal law, payments to Medicaid MCOs must be actuarially sound. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. 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. Similarly, case management also involves care planning. Communicating with hospital staffs, family doctors, specialists, etc. 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. 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. 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. If you continue to use this site we will assume that you are happy with it. 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. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. 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. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on opt-in and opt-out care management programs. 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. Develop a measurement and evaluation strategy to demonstrate program value. A key component of the MCPD-PI was a care management workgroup. Improving Chronic Illness Care. 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. Assess financial environment to determine most appropriate program. Content last reviewed October 2014. 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. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. The program coordinates services between health care providers, community program and supports, and family support programs. a Available at: Cecil G. Sheps Center for Health Services Research. CMS launched the LAN in 2015 to encourage alignment across public and private sector payers by providing a forum for sharing best practices and developing common approaches to designing and monitoring of APMs, as well as by developing evidence on the impact of APMs. The CCM program provides help for a person to. dedicated employees ~56M. Practitioners who have identified a member who they think would benefit from disease or case management should contact the Care Management Department, to speak with a Care Manager at 1-855-757-6567 or submit a referral request using the Secure Provider . 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. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). 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. Actuarial soundnessmeans that the capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the managed care plan for the time period and the population covered under the terms of the contract. Unlike fee-for-service (FFS), capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit. Medicaid Managed Care Provider Resource Communication. 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 . State staff can learn from successes and "productive failures" of other State Medicaid care management programs. 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. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Opens in a new window. Reviewing formal evaluations of other States' programs. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Rockville, MD 20857 Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. Filling the need for trusted information on national health issues, Elizabeth Hinton and Relevant Federal and State Authorities. 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. Res. ( Availability of necessary staff and resources. 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. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. Senior leadership might also have areas and directions that they have no interest in pursuing. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. 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. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). However, there has been significant movement across states to carve these services in to MCO contracts. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. An official website of the United States government To sign up for updates or to access your subscriberpreferences, please enter your email address below. Please go to Section 5: Selecting a Care Management Program Model for more information. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. 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. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. This section provides the Secretary of Health and Human Services authority to grant waivers that allow States to implement managed care delivery systems or limit individuals' choice of provider under Medicaid. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. 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 CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. 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. A parent firm is a firm that owns Medicaid MCOs in two or more states. 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. 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. cost effective, non-duplicative services. 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. 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 . 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. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Understand motivations for establishing program. 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). Encourage members to take advantage of the program. Learn . Consultation Services Payment Policy Effective October 1, 2019. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . Note: This brief was updated on March 1, 2023 to incorporate the latest available data. 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. Residential and nursing care. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. 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. After approval of the original State plan, program staff must submit to CMS all relevant changes (required by new statutes, rules, regulations, interpretations, and court decisions) to determine whether the plan continues to meet Federal requirements and policies. 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. 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. Partnering with patients to ensure that all of their health care is effectively coordinated. 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. Jada Raphael The Chronic Care Management program was created by Medicare to close those communication gaps. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. 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. 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. Participate in reporting and data exchange included in the program. Role of care management in Medicaid program. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. While MCOs are the predominant form of Medicaid managed care, millions of other beneficiaries receive at least some Medicaid services, such as behavioral health or dental care, through limited-benefit risk-based plans, known as prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs). Sunshine Health is a managed care plan with a Florida Medicaid contract. RESTON, Va., July 8, 2020 /PRNewswire/ -- Altruista Health and North Carolina's Eastpointe Human Services today noted Eastpointe's successful launch of Altruista's care management technology, supporting whole-person care for Medicaid members in 10 counties. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Nominate a social care worker for a dignity award. 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. A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. COPD. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. B24 9QR. A geriatric care manager, usually a licensed nurse or social worker who specializes in geriatrics, is a sort of "professional relative" who can help you and your family to identify needs and find ways to meet your needs. Complex Case Management Their experiences and understanding of their own limitations might help in the early planning stage. How do we help? Increase accuracy. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. They work with our members to help them understand the types of services we offer to them and how to participate in their own care. 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. 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." 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. Medicaid members covered. 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. 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. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. Whether it's finding a community resource, making health appointments or assessing next steps for a health goal, your Care Manager will lead the way. You can decide how often to receive updates. 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. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. 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 current Administration has identified advancing health equity as an important priority for the Medicaid program. Official websites use .govA 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 often choose to implement a pilot of their care management program as a way to test the intervention on a smaller scale or if they have limited resources. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Opt-out programs generally have higher member enrollment than opt-in programs. .gov Considerations for developing a care management program. Providing care for people living with chronic or complicated illnesses or conditions, is complex. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . You and your care manager will work together to figure out the care and services you need to help you meet your health care goals. Health goes well beyond care. Similar to the Governor's office, the State legislature or individual legislators can greatly influence some of the key questions around a care management program's design, such as whether a mandatory savings requirement exists or whether the program can be operated in-house or with a vendor. Share sensitive information only on official, secure websites. Managing your child's medical issues can be hard. 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 . Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. Innovative solutions for better health outcomes. 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%. 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.)
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