A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. Please go to Section 5: Selecting a Care Management Program Model for more information. 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. You can decide how often to receive updates. 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. info@caremanserve.com. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. 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. Jada Raphael 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. 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. Similarly, case management also involves care planning. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. 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/. Most States implement a program based on some combination of the following three reasons: States usually establish care management programs to meet multiple needs. Consider pilot testing to test intervention on a smaller scale. Res. California carved the pharmacy benefit out of managed care as of January 1, 2022. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. 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. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. Engaging providers is an important component of a care management program, because interested providers will endorse the intervention concepts with patients, identify needed interventions for patients, and follow practice guidelines. Control costs. However, they are quite different. 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. 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. Addressing their health concerns from a holistic point of view, integrating physical, behavioral, and social health improves overall well-being. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. What Does Successful Care Management Look Like? 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). 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. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. 7500 Security Boulevard, Baltimore, MD 21244 . For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. It is available for both adults and children. 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. 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). 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. Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. 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. 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. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. Payments made to MCOs accounted for about 52% of total Medicaid spending (Figure 4), an increase of three percentage points from the previous fiscal year. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. 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. 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. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Short term help at home. 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. 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). Official websites use .govA 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. 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. Transitional Care Management Program Effective September 1, 2019. This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program. 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. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. 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. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. Together with your Care team, he or she can oversee your needs and coordinate your care. 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. Determine whether program will be opt-in or opt-out. 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. 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. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. website belongs to an official government organization in the United States. Tel: 0121 386 6605 Fax: 0121 386 6709. 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. If you have questions about getting service coordination or service management through your health plan, call the help line phone number listed on the back of your health plan ID card. 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. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. 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 . If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. 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. Communicating with hospital staffs, family doctors, specialists, etc. An integral part of any care management program is a thorough understanding of the population it will affect. Garnering support from leadership and other stakeholders, developing realistic program expectations early in the process, and designing a strategic evaluation process affect program success and sustainability significantly. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. 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 . 907-770-7525 or 888-578-2547. Case managers generally work indirectly with patients, often employed by healthcare facilities. Medicaid waivers. Select program model based on available staff and resources. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. 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. Secure Federal support and approval. . Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. a Available at: Cecil G. Sheps Center for Health Services Research. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. Managing your child's medical issues can be hard. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . 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. Participate in reporting and data exchange included in the program. 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. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. 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. For most states, the requirements for APMs were in the 25 50% range. The share of Medicaid spending on MCOs varies by state, but over three-quarters of MCO states directed at least 40% of total Medicaid dollars to payments to MCOs (Figure 5). As a result, most programs target specific populations because they are more "impactable.". Medicaid Managed Care Provider Resource Communication. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. 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.) Planning these components early will allow staff to design an appropriate care management program for their members. 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. 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). Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. 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. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. Although this group is still less likely to be enrolled in MCOs than children and adults, over time, states have been moving to include adults ages 65+ and people eligible through disability in MCOs. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). 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. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. 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. The current Administration has identified advancing health equity as an important priority for the Medicaid program. 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. Limitations, co-payments and . Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). Preventative care is a core tenet of care management. There's a change in your health status. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. These specially trained professionals can help find resources to make your daily life easier. We engage members in a more proactive, preventive and connected way. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. 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. States determine how they will deliver and pay for care for Medicaid beneficiaries. Care management services Care management is a program we make available to eligible members who may need help getting the care they need. Published: Mar 01, 2023. 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. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. 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. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. Encourage members to take advantage of the program. 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. It is more important now than ever to carefully consider the health of your patients and to know what is care management. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. You can email in confidence to Senior Management at Care & Management Services Limited. ) For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. For example, North Carolina experienced improved outcomes in asthma management more quickly than in diabetes management.a In addition, the evidence base suggests that programs might see improvements in process measures such as screening rates more quickly than desired changes in utilization rates, financial outcomes, and health outcomes. 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). Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. Role of care management in Medicaid program. Senior leadership might also have areas and directions that they have no interest in pursuing. Care Management Services. Medicaid managed care: costs, access, and quality of care. As states expand Medicaid managed care to include higher-need, higher-cost beneficiaries, expensive long-term services and supports, and adults newly eligible for Medicaid under the ACA, the share of Medicaid dollars going to MCOs could continue to increase. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . CMS announced a Request for Information (in early 2022) to inform development of a comprehensive access strategy across Medicaid fee-for-service and managed care delivery systems. By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. 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. CMS has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements, including guidance outlining how managed care plans can support states in promoting continuity of coverage. 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. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Your patients may already be working with one of our care managers. Speaking with colleagues in other States to better understand their programs. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. The benefit information provided is a brief summary, not a complete description of benefits. The CCM program provides help for a person to. MCOs represent a mix of private for-profit, private non-profit, and government plans. It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. 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 Developing relationships with senior Medicaid and agency leadership, the Governor's office, the provider community, the patient and advocacy community, the State legislature and staff, and CMS is critical for the success of a care management program. 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. Sunshine Health is a managed care plan with a Florida Medicaid contract. Chronic Care Management. 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. While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, it is estimated that millions will lose coverage. Sign up to get the latest information about your choice of CMS topics. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. 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 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. 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.

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