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. Content last reviewed October 2014. 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. 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. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. 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. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. 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. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. Team Around the Person co-ordinated support for adults. COPD. 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. Role of care management in Medicaid program. Residential and nursing care. When the continuous enrollment provision ends and states resume disenrollments, Medicaid MCOs may see the overall acuity of their membership increase, with implications for per member utilization and costs, and the return of member churn (i.e., the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time). States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. 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. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. Providing care for people living with chronic or complicated illnesses or conditions, is complex. States may request Section 1915(b) waiver authority to operate programs that impact the delivery system of some or all of the individuals eligible for Medicaid in a State by: Section 1915(b) waiver programs need not be operated statewide. 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). Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. Control costs. info@caremanserve.com. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . Whether it's finding a community resource, making health appointments or assessing next steps for a health goal, your Care Manager will lead the way. 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. In planning a care management program, States have found the following strategies helpful: Each of these strategies can be useful to learn about other States' experiences and to understand a care management program's impact on outcomes. The technical storage or access that is used exclusively for anonymous statistical purposes. Medicaid waivers. 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. 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. 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. Heres how you know. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. 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). means youve safely connected to the .gov website. 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. It coordinates the care you get from different doctors. Tel: 0121 386 6605 Fax: 0121 386 6709. 5600 Fishers Lane 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). Our Care Management program is free and voluntary. An official website of the United States government If they operate a Medicaid managed care program, states can require Medicaid managed care organizations (MCOs) to connect beneficiaries to social supports as part of their care management obligations. Increase accuracy. Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. 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. 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. 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. o Care management for chronic conditions . As well as having ideas to share on clinical aspects of the care management program, large provider groups, hospitals, provider associations, and individual providers can serve as ambassadors to patients for the program. 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. 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. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. 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. 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. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. It is more important now than ever to carefully consider the health of your patients and to know what is care management. The CCM program provides help for a person to. Please be aware that although this email has restricted access, it is not . http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. What Does Successful Care Management Look Like? Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. States incorporate quality metrics into the ongoing monitoring of their programs, including linking financial incentives like performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. Agency for Healthcare Research and Quality, Rockville, MD. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Your patients may already be working with one of our care managers. 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. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. If you have any questions, please do not hesitate to contact us today! Support of potential program partners, such as other State agencies and local organizations. 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). 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. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Rockville, MD 20857 However, networks can be affected by overall provider supply shortages. 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. 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. 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. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. You can email in confidence to Senior Management at Care & Management Services Limited. 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. States might consider implementing a care management program for a variety of reasons. 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 State Waiver Demonstration Projectsgeneral information. 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. Copyright 2020 - 2021 Care & Management Services. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). 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." A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. Managed care is the dominant delivery system for Medicaid enrollees. 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. Health goes well beyond care. 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 Support of providers and patients. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. 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. 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). Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . Determine whether program will be opt-in or opt-out. Please go to Section 5: Selecting a Care Management Program Model for more information. Please be aware that although this email has restricted access, it is not encrypted. https:// 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. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. As an integral component of the Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans, Tailored Care Management (TCM) is a new care management model that reflects the goal of whole-person care management in NC Medicaid Managed Care. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. Enrollment growth has been primarily attributed to the Families First Coronavirus Response Act (FFCRA) provision that required states to ensure continuous enrollment for Medicaid enrollees in exchange for a temporary increase in the Medicaid match rate. 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. Incentive Payment Program. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. 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). 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. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. Powerful pivot table data reporting makes . 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. Rep. 23, Robert Wood Johnson Found., Princeton, NJ, Daniel Franco Montoya, Puneet Kaur Chehal, and E. Kathleen Adams, Medicaid Managed Cares Effects on Costs, Access, and Quality: An Update, Annual Review of Public Health 41:1 (2020):537-549, Medicaid and CHIP Payment and Access Commission (MACPAC), Managed cares effect on outcomes, (Washington, DC: MACPAC, 2018), https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). You can email in confidence to Senior Management at Care & Management Services Limited. o Continuity of care with a designated provider or care team member. 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. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. 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. dedicated employees ~56M. 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. Mandatory enrollment of beneficiaries into managed care programs (although States have the option, through the Balanced Budget Act of 1997, to enroll certain beneficiaries into mandatory managed care via an SPA), or. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Become a shared lives carer. 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 . Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. Care Management Services. Innovative solutions for better health outcomes. Your Medicare Coverage Principal care management services Principal care management services Medicare Part B (Medical Insurance) covers disease-specific services to help you manage a single, complex chronic condition that puts you at risk of hospitalization, physical or cognitive decline, or death. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Although this group is still less likely to be enrolled in MCOs than children and adults, over time, states have been moving to include adults ages 65+ and people eligible through disability in MCOs. 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 The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. 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. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. 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. For general correspondence via email please use the following address. Build on lessons learned from other States by attending national meetings and networking with other States. These specially trained professionals can help find resources to make your daily life easier. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. Official websites use .govA 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. Program staff should assess the type of interventions appropriate for their care management program. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. The Chronic Care Management program was created by Medicare to close those communication gaps. States use an array of financial incentives to improve quality including linking performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. 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. 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. Integrating Social Supports Into Health Plan Care Management. How do we help? We'll help guide your family through the healthcare system. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. 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. 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. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. cost effective, non-duplicative services. Managing your child's medical issues can be hard. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. 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. 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. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. As a result, staff would want to track incremental progress in performance measures related to this goal or conduct a formal program evaluation.