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 Created by the Balanced Budget Act of 1997, this SPA authority to mandate enrollment applies to primary care case management or MCO-model disease management programs. An official website of the United States government 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. By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. A State must decide which population to target and how to identify and stratify members for enrollment into the program. For most states, the requirements for APMs were in the 25 50% range. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. 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. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. 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 Agency for Healthcare Research and Quality, Rockville, MD. Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. 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. 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.) 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. 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. The current Administration has identified advancing health equity as an important priority for the Medicaid program. 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). Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. Learn . Care management teams cover a wide variety of responsibilities, all with the aim of managing patients healthcare needs, improving patient engagement and experience, and improving their overall health outcomes. Copyright 2020 - 2021 Care & Management Services. Role of care management in Medicaid program. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . 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). Monday - Friday, 8:00am - 5:00pm AK Time. 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. These specially trained professionals can help find resources to make your daily life easier. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). Develop a measurement and evaluation strategy to demonstrate program value. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . You can decide how often to receive updates. Provider Analytics Tool Scheduled Maintenance. Meals on wheels. While the vast majority of states that contract with MCOs report that the pharmacy benefit is carved in to managed care (34 of 41), six states report that pharmacy benefits are carved out of MCO contracts as of July 2022 (Figure 7). 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 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. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. Control costs. 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. If you're enrolled in a care management program, you can get personalized help from: Outreach workers Registered nurses Social workers Your care management team will help coordinate your healthcare. Considerations for developing a care management program. Accelerate claims processing. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. The benefit information provided is a brief summary, not a complete description of benefits. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. 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. 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. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Social Determinants of Health. 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." 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. Care management integrates all of a patients healthcare needs into a single individualized care plan that is maintained by the Care Management in a system, such as the Incedo Care Management Solution. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. 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 technical storage or access that is used exclusively for anonymous statistical purposes. 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. . Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Medicaid waivers. Synth. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. Relevant Federal and State Authorities. 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. What Does Successful Care Management Look Like? Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. 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. 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. 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. Together with your Care team, he or she can oversee your needs and coordinate your care. An SPA authorized under section 1932(a) of the Social Security Act provides much of the same flexibility available under waivers and also does not require the periodic renewals associated with programs operating under waiver authority. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. States contracted with a total of 285 Medicaid MCOs as of July 2020. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content 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. Heres how you know. Community supports address social drivers of health and build on and scale . Res. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). The Care Manager will be able to answer patient questions and complete requests for care. Additional information about the program change is available at Ohio Medicaid Managed Care, Ohio Medicaid Single Pharmacy Benefit Manager (SPBM), https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager. website belongs to an official government organization in the United States. If you have any questions, please do not hesitate to contact us today! o Patient access to care management services 24/7. Share on Facebook. Improving Chronic Illness Care. Medicaid State Waiver Demonstration Projectsgeneral information. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Sunshine Health is a managed care plan with a Florida Medicaid contract. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. 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 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. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? 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. Availability of necessary staff and resources. Accessed July 26, 2007. A key component of the MCPD-PI was a care management workgroup. The CalAIM Incentive Payment Program is intended to support the implementation and expansion of ECM and Community Supports by incentivizing managed care plans (MCPs), in accordance with 42 CFR Section 438.6(b), to drive MCP delivery system investment in provider capacity and delivery system infrastructure; bridge current silos across physical and behavioral health . 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. Care Management Complaints, Grievances and Plan Appeals Disease Management Emergency Situations EPSDT Program Fraud, Waste and Abuse Get the Most from Your Coverage Interoperability and Patient Access Key Contacts Member Handbook LTC Newsletters Member Rights and Responsibilities Non-Discrimination Notice Prior Authorization Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. Sign up to get the latest information about your choice of CMS topics. 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. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. 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. o Care management for chronic conditions . If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. ( To sign up for updates or to access your subscriberpreferences, please enter your email address below. The pandemic has placed additional strain on member health, creating new challenges not only around how To provide the best experiences, we use technologies like cookies to store and/or access device information. For example, the goal of the care management program might be to increase the quality of life for program members. Select program model based on available staff and resources. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. 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 . Care management refers to patient-centric, healthcare planning. Despite activity in this area, detailed performance information at the plan-level is not frequently made publicly available by state Medicaid agencies, limiting transparency and the ability of Medicaid beneficiaries (and other stakeholders) to assess how plans are performing on key indicators related to access, quality, etc. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. We'll help guide your family through the healthcare system. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. lock 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. 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 . Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. States might consider implementing a care management program for a variety of reasons. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. It is available for both adults and children. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. Chronic Care Management. Nearly all states have some form of managed care in place comprehensive risk-based managed care and/or primary care case management (PCCM) programs.1,2 As of July 2022, 41 states (including DC) contract with comprehensive, risk-based managed care plans to provide care to at least some of their Medicaid beneficiaries (Figure 1). 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. 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. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. 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. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. Most States implement a program based on some combination of the following three reasons: States usually establish care management programs to meet multiple needs. As part of managed care plan contract requirements, state Medicaid programs have also been focused on the use of alternative payment models (APMs) to reimburse providers and incentivize quality. Transitional Care Management Program Effective September 1, 2019. 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. For example, if a State plans an external evaluation of the program, having the evaluator provide input as program measures and data collection are discussed might be useful. However, to track progress on an ongoing basis, staff must identify short-term objectives, such as members selecting a primary care physician or decreased emergency room (ER) utilization. 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 . 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. 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. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. For more information on strategies to engage the Governor's office, State legislators, and senior Medicaid and agency leadership, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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. 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. Timing of other State initiatives to coordinate outreach and stakeholder support. States should coordinate and communicate routinely with these stakeholders. CMS launched the LAN in 2015 to encourage alignment across public and private sector payers by providing a forum for sharing best practices and developing common approaches to designing and monitoring of APMs, as well as by developing evidence on the impact of APMs. 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). 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. Limitations, co-payments and . AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. 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). Actuarial soundnessmeans that the capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the managed care plan for the time period and the population covered under the terms of the contract. Unlike fee-for-service (FFS), capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit. Establish program goals and identify short- and long-term objectives. Their experiences and understanding of their own limitations might help in the early planning stage. 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. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Endorse the concepts of the interventions with patients. info@caremanserve.com. This role is responsible for providing leadership and direction to a large team of clinical . Rockville, MD 20857 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. 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. Your patients may already be working with one of our care managers. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS.