For most states, the requirements for APMs were in the 25 50% range. Monday - Friday, 8:00am - 5:00pm AK Time. The technical storage or access that is used exclusively for anonymous statistical purposes. The delayed start of Tailored Plans allows Local Management Entity/Managed Care Organizations , which will operate the Tailored Plans, more time to contract with additional providers to ensure a smooth transition for people using the plans and their care providers. Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff. 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. The relevant laws that come into play in the relationship between the State, the Managed Care Organizations (MCOs, including the HARPs), the Health Homes, the Care Management Agencies, the service providers and the recipients are as follows: The Health Insurance Portability and Accountability Act of 1996 . It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. After considering each of the issues outlined above, program staff should answer the following questions in determining whether and how to proceed with a care management program. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. 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. 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. Therefore, approval procedures are individualized, usually depending on the care management program model. 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. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Cognitive Assessment & Care Plan Services, Office-Based Opioid Use Disorder (OUD) Treatment Billing, Medicare PFS Locality Configuration and Studies, Psychological and Neuropsychological Tests, Diagnostic Services by Physical Therapists, Advance Care Planning Services Fact Sheet (PDF), Advance Care Planning Services FAQs (PDF), Behavioral Health Integration Fact Sheet (PDF), Chronic Care Management Frequently Asked Questions (PDF), Chronic Care Management and Connected Care, Billing FAQs for Transitional Care Management 2016. 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. 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. 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 . Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. Support of potential program partners, such as other State agencies and local organizations. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. 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. 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. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. Chronic pain and disease. However, they are quite different. 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. 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. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Agency for Healthcare Research and Quality, Rockville, MD. Comagine Health. States might consider implementing a care management program for a variety of reasons. If you continue to use this site we will assume that you are happy with it. a Available at: Cecil G. Sheps Center for Health Services Research. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. For general correspondence via email please use the following address. Care management refers to patient-centric, healthcare planning. 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 is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 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. The program coordinates services between health care providers, community program and supports, and family support programs. Internet Citation: Section 1: Planning a Care Management Program. These requirements apply to both capitated and fee-for-service disease management providers. 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. cost effective, non-duplicative services. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. 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. 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 . dedicated employees ~56M. This group, facilitated by CHCS . This guidance document outlines the challenges states have faced when reporting primary care case management (PCCM) programs in the OT Claims file, Eligible file and the Managed Care file and recommends guidance for states' reporting. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Official websites use .govA Communicating with hospital staffs, family doctors, specialists, etc. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Active Medicaid coverage. 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. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. Develop a measurement and evaluation strategy to demonstrate program value. 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. With 72% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs) nationally, plans have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the unwinding of the continuous enrollment requirement. Preventative care is a core tenet of care management. Aaron Mendelson et al., The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 166 no. Having a care manager provides a level of comfort to the patient with keeping track of doctor or hospital appointments, medication refills, contacting specialists, etc. 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. Tailored plans will provide specialized services and care management to meet the needs of these individuals. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. Community supports address social drivers of health and build on and scale . 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. Care Management Services for Medicaid Beneficiaries with Specific Conditions Care management services are available to Mississippi Medicaid fee-for-service beneficiaries not enrolled in MississippiCAN (MSCAN) who meet one of the five specific conditions below. Similarly, case management also involves care planning. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. The Care Manager will be able to answer patient questions and complete requests for care. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. The Chronic Care Management program was created by Medicare to close those communication gaps. 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. 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. Team Around the Person co-ordinated support for adults. We use cookies to ensure that we give you the best experience on our website. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. 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. 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. 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. Our care managers help make health care easier and less overwhelming for our members. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). Provider Analytics Tool Scheduled Maintenance. Considerations for developing a care management program. States design and administer their own Medicaid programs within federal rules. 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. Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. 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. 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). Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. Section 1115 provides the Secretary of Health and Human Services broad authority to approve projects that test policy innovations likely to further Medicaid program objectives. 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. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. Learn . While managed care is the dominant Medicaid delivery system, states decide which populations and services to include in managed care arrangements which leads to considerable variation across states. 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 services. Select and target populations to allocate resources most effectively. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. You can email in confidence to Senior Management at Care & Management Services Limited. 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. The CCM program provides help for a person to. B24 9QR. State Medicaid Director Letter: Guidance on how States can cover disease management. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. confidential@caremanserve.com. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. or Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). To help ensure participation, many states require minimum provider rates in their contracts with MCOs that may be tied to fee-for-service rates (Figure 10). Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. Increase accuracy. Sparer M. 2012. Referrals to community resources, specialists, counseling and a social worker Educational materials Follow-up calls and home visits will be scheduled, as needed How do I get more information? 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. Senior leadership might also have areas and directions that they have no interest in pursuing. Build on lessons learned from other States by attending national meetings and networking with other States. If you have any questions, please do not hesitate to contact us today! Endorse the concepts of the interventions with patients. 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 . (805) 823-0981. contact@vigilancehit.com. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. Speaking with colleagues in other States to better understand their programs. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. 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. 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. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. 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. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. Both enrollment mechanisms have advantages and disadvantages. It coordinates the care you get from different doctors. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. 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. As a result, most programs target specific populations because they are more "impactable.". lock 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). 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. 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. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Medicaid Management. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). 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. 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. 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. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. Social Determinants of Health. 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. A parent firm is a firm that owns Medicaid MCOs in two or more states. We assist you with scheduling the variety of appointments that your child may have to meet their needs. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . 7500 Security Boulevard, Baltimore, MD 21244 . Care management services Care management is a program we make available to eligible members who may need help getting the care they need. How do we help? 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. 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 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). 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. 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, . The service is intended to provide additional care to patients with a single chronic condition or allowing a provider to treat a patient with multiple chronic conditions by focusing care solely on one of those . It is more important now than ever to carefully consider the health of your patients and to know what is care management. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. 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 . When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. What Does Successful Care Management Look Like? 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. This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program. Engage stakeholders to build program support. 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. 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. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. 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. A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. 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. As described later in this section, after establishing program goals, staff must think about a measurement and evaluation strategy as a critical step early in the development process. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population.
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