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. Both enrollment mechanisms have advantages and disadvantages. 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. 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. Relevant Federal and State Authorities. Consider pilot testing to test intervention on a smaller scale. 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. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. Meals on wheels. Build on lessons learned from other States by attending national meetings and networking with other States. 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. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. 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. 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. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. Therefore, approval procedures are individualized, usually depending on the care management program model. Determine whether program will be opt-in or opt-out. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. 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. Speaking with colleagues in other States to better understand their programs. For general correspondence via email please use the following address. Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. What Does Successful Care Management Look Like? Control costs. http://www.nasmd.org/waivers/waivers.htmll#1915b. 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. However, there has been significant movement across states to carve these services in to MCO contracts. Community support workers. Select and target populations to allocate resources most effectively. In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. 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. 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. Managing your child's medical issues can be hard. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. 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. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. 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. Sunshine Health is a managed care plan with a Florida Medicaid contract. WellCare was acquired by Centene in January 2020. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. 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. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. Sign up to get the latest information about your choice of CMS topics. Medicaid Managed Care Provider Resource Communication. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Care management refers to patient-centric, healthcare planning. Access Care Management services deliver innovative programs individualized and customized to Maximize value-based reimbursement Positively affect quality metrics Improved patient compliance Enhance health outcomes Increase patient satisfaction With experience in self-pay, Medicaid and underinsured populations, our outcomes are notable. The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Preventative care is a core tenet of care management. 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. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. ( A parent firm is a firm that owns Medicaid MCOs in two or more states. In response to the COVID-19 pandemic, states had options and flexibilities under existing managed care rules to direct/bolster payments to Medicaid providers and to preserve access to care for enrollees. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. We engage members in a more proactive, preventive and connected way. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . To learn more, call the NC Medicaid Ombudsman toll free at 1-877-201-3750 , 8 a.m. to 5 p.m., Monday through Friday, except state holidays. 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. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. 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. 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. o Care management for chronic conditions . Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. For general correspondence via email please use the following address. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. o Continuity of care with a designated provider or care team member. 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. 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. 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. 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. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. 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. Support of potential program partners, such as other State agencies and local organizations. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. There's a change in your health status. 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. 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 . The nature of the relationship to the patient is distinguishing factor between these terms. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. 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. Together with your Care team, he or she can oversee your needs and coordinate your care. 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. Powerful pivot table data reporting makes . Care management services Care management is a program we make available to eligible members who may need help getting the care they need. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. Our care managers help make health care easier and less overwhelming for our members. 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. 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. Tailored plans will provide specialized services and care management to meet the needs of these individuals. Chronic pain and disease. 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. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. https:// Establish program goals and identify short- and long-term objectives. Partnering with patients to ensure that all of their health care is effectively coordinated. 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. Res. 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. Twenty-Four-Hour Coverage for Tailored Care Management Providers AMH+ practices and CMAs must arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis, 24 hours per day, seven days per week. 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. Care Management Triage medical needs, validate medical necessity and efficiently coordinate patient care throughout the path to recovery Navigating the healthcare system can be daunting for those with new healthcare needs or a surprise workplace injury. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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). Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. Considerations for developing a care management program. 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. Analysis of National Association of Insurance Commissioners (NAIC) data for the Medicaid managed care market show that average loss ratios in 2021 (in aggregate across plans) remained lower by three percentage points from 2019 (implying increased profitability) (Figure 6). Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). 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. Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. 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. 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. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. 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). Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. 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). Please be aware that although this email has restricted access, it is not . 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. Alternative payment models (APMs) replace FFS/volume-driven provider payments and lie along a continuum, ranging from arrangements that involve limited or no provider financial risk (e.g., pay-for-performance (P4P) models) to arrangements that place providers at more financial risk (e.g., shared savings/risk arrangements or global capitation payments). Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. 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. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. 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. Integrating Social Supports Into Health Plan Care Management. For most states, the requirements for APMs were in the 25 50% range. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Transitional Care Management Program Effective September 1, 2019. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. 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. 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 . A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. 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. Note: This brief was updated on March 1, 2023 to incorporate the latest available data. Senior leadership might also have areas and directions that they have no interest in pursuing. 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. Chronic Care Management. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. If you have any questions, please do not hesitate to contact us today! Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. Jada Raphael Case managers generally work indirectly with patients, often employed by healthcare facilities.