Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. 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. 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. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . 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. However, networks can be affected by overall provider supply shortages. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. 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." 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. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. 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. Develop a measurement and evaluation strategy to demonstrate program value. Community support workers. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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." Whether youre sharing risk in a value-based, The pandemic has placed additional strain on member health, creating new challenges not only around how to safely deliver care, but also what types of, 101 West Elm Street, Suite G10, Conshohocken, PA 19428. Medicaid 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. 7500 Security Boulevard, Baltimore, MD 21244 . If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. We use cookies to ensure that we give you the best experience on our website. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Improving Chronic Illness Care. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. 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 . 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. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. Case managers generally work indirectly with patients, often employed by healthcare facilities. VigilanceHealth.com. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. Limitations, co-payments and . Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. The program is intended to service Medicare patients with two or more chronic . 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. Medicaid Managed Care Provider Resource Communication. 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. Residential and nursing care. Participate in reporting and data exchange included in the program. 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. 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 CCM services provided by a physician or other qualified health care professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management . 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. 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. 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. The program coordinates services between health care providers, community program and supports, and family support programs. Care Management Services. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Communicating with hospital staffs, family doctors, specialists, etc. Understand motivations for establishing program. 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. In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. An integral part of any care management program is a thorough understanding of the population it will affect. Complex Case Management State Medicaid Director Letter: Guidance on how States can cover disease management. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Timing of other State initiatives to coordinate outreach and stakeholder support. 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. 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. Accelerate claims processing. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. These specially trained professionals can help find resources to make your daily life easier. 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. If you have any questions, please do not hesitate to contact us today! By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. 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. 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. We engage members in a more proactive, preventive and connected way. 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 . Determine whether program will be opt-in or opt-out. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Endorse the concepts of the interventions with patients. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. 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. 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. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and 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 Reviewing formal evaluations of other States' programs. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. States contracted with a total of 285 Medicaid MCOs as of July 2020. Comagine Health. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). https:// Chronic pain and disease. Therefore, approval procedures are individualized, usually depending on the care management program model. A State must decide which population to target and how to identify and stratify members for enrollment into the program. B24 9QR. 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. 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. 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). 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. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). 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. 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. Powerful pivot table data reporting makes . 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. 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). We assist you with scheduling the variety of appointments that your child may have to meet their needs. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. 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). 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 . http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. 5600 Fishers Lane 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. 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. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. or A parent firm is a firm that owns Medicaid MCOs in two or more states. 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. It works by activating patients own motivation for change and adherence to their Doctor's directives. Become a shared lives carer. Providers of care and support. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. 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. For example, the goal of the care management program might be to increase the quality of life for program members. Synth. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). (805) 823-0981. contact@vigilancehit.com. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Medicaid waivers. Sparer M. 2012. website belongs to an official government organization in the United States. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. 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. Building relationships with patients and caregivers, Administering assessments and developing individualized care plans, Connecting patients and caregivers to social and community support services, Establishing relationships with patients physicians and other providers, Facilitating administrative communication between healthcare providers, Monitoring care gaps and ensuring appointments are scheduled and kept, Comparing current care with proposed services. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. 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. WellCare was acquired by Centene in January 2020. 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. Published: Mar 01, 2023. How do we help? Under federal law, payments to Medicaid MCOs must be actuarially sound. 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 . 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. Provider Analytics Tool Scheduled Maintenance. As a result, most programs target specific populations because they are more "impactable.". 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. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. The CCM program provides help for a person to. Select program model based on available staff and resources. 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. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. 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. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. 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. 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. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . Consider pilot testing to test intervention on a smaller scale. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. Tailored plans will provide specialized services and care management to meet the needs of these individuals. Birmingham. States might consider implementing a care management program for a variety of reasons. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content 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. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Share sensitive information only on official, secure websites. 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. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. 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? 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. 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).
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