Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. Increase accuracy. How States Are Using Comprehensive Medicaid Managed Care to Strengthen 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 . 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. Chronic Care Management | Top Rated CCM for Healthcare Organizations If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . 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. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. o Continuity of care with a designated provider or care team member. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. This group, facilitated by CHCS . State-to-state variation reflects many factors, including the proportion of the state Medicaid population enrolled in MCOs, the health profile of the Medicaid population, whether high-risk/high-cost beneficiaries (e.g., persons with disabilities, dual eligible beneficiaries) are included in or excluded from MCO enrollment, and whether or not long-term services and supports are included in MCO contracts. Rockville, MD 20857 For general correspondence via email please use the following address. You'll get a care plan designed just for you. 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. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. Chronic Care Management and Connected Care | CMS Care management refers to patient-centric, healthcare planning. Accessed July 26, 2007. Care Management Providers | NC Medicaid 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. 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. Although MCOs provide comprehensive services to beneficiaries, states may carve specific services out of MCO contracts to fee-for-service systems or limited benefit plans. Transitional Care Management Services | Guidance Portal - HHS.gov State staff can learn from successes and "productive failures" of other State Medicaid care management programs. Planning these components early will allow staff to design an appropriate care management program for their members. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. Senior leadership might also have areas and directions that they have no interest in pursuing. Chronic pain and disease. 10 Things to Know About Medicaid Managed Care, has grown substantially since the start of the coronavirus pandemic, National Association of Insurance Commissioners (NAIC) data, report that the pharmacy benefit is carved in, 2020 CMS Medicaid managed care final rule, to direct/bolster payments to Medicaid providers, reported using at least one financial incentive, reported at least one MCO financial incentive, state-mandated PIP focus areas with an emphasis on reducing disparities, https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/, https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager, https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf, https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf, Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. 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. 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. Care Management | Healthy Blue of North Carolina Opt-out programs generally have higher member enrollment than opt-in programs. 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 . 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 The current Administration has identified advancing health equity as an important priority for the Medicaid program. Transitional Care Management - Rural Health Info How Medicare's Chronic Care Management Works - Verywell Health It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. An integral part of any care management program is a thorough understanding of the population it will affect. MCOs represent a mix of private for-profit, private non-profit, and government plans. 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. This review discusses the application of the chronic care model in the care of complex diabetes and its translation in the current reimbursement structure designed by Centers for Medicare and Medicaid Services (CMS). BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Community support workers. However, networks can be affected by overall provider supply shortages. 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. A parent firm is a firm that owns Medicaid MCOs in two or more states. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. Partnering with patients to ensure that all of their health care is effectively coordinated. 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. 10 Things to Know About Medicaid Managed Care | KFF Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. Case managers generally work indirectly with patients, often employed by healthcare facilities. Linking the medical home and care management can provide additional benefits to both Medicaid and the care management program, including the following: Implementation of another State initiative might enhance or hinder implementation of a care management program. Select and target populations to allocate resources most effectively. Care Management - CMCS When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Medicaid Health Homes - Comprehensive Care Management What Is Principal Care Management? Elements and Benefits of Medicare's Care Management | CareSource Health goes well beyond care. Sparer M. 2012. 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. Providing care for people living with chronic or complicated illnesses or conditions, is complex. This includes post-acute and long-term rehabilitation programs such as physical therapy, occupational or recreational therapies, speech-language pathology services, cognitive training, or neurorehabilitation. 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. 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. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. Case/Care Management Services - Virginia Premier Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and Managing your child's medical issues can be hard. State Medicaid Director Letter: Guidance on how States can cover disease management. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. 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/. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Developing relationships with senior Medicaid and agency leadership, the Governor's office, the provider community, the patient and advocacy community, the State legislature and staff, and CMS is critical for the success of a care management program. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. Both enrollment mechanisms have advantages and disadvantages. Filling the need for trusted information on national health issues, Elizabeth Hinton and Become a shared lives carer. Enhanced Care Management (ECM) For most states, the requirements for APMs were in the 25 50% range. 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. Monday - Friday, 8:00am - 5:00pm AK Time. Share on Facebook. 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. 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). website belongs to an official government organization in the United States. There's a change in your health status. o Care management for chronic conditions . Support of potential program partners, such as other State agencies and local organizations. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. 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. Enhanced Care Management and Community Supports (ILOS) - California The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . . If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. 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 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. Your care plan. Care Management - NH Healthy Families An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. Guidance to Managed Care Organizations, Health Homes, Care Management Program staff should assess the type of interventions appropriate for their care management program. 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. For example, the goal of the care management program might be to increase the quality of life for program members. Medicaid State Waiver Demonstration Projectsgeneral information. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. You can email in confidence to Senior Management at Care & Management Services Limited. Care Management | Sunshine Health As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. Self-Directed Services | Medicaid 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. 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. 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. 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. Develop a measurement and evaluation strategy to demonstrate program value. 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 Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). 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. Medicaid Managed Care Provider Resource Communication. Demonstrations must be "budget neutral" over the life of the project, meaning they cannot be expected to cost the Federal Government more than it would cost without the waiver. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Through the hard work and attention of care managers and an effective technology solution, the integration of healthcare systems and services can revolutionize the experience for patients. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Role of care management in Medicaid program. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. The program coordinates services between health care providers, community program and supports, and family support programs. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. Nominate a social care worker for a dignity award. The nature of the relationship to the patient is distinguishing factor between these terms. Care management services Care management is a program we make available to eligible members who may need help getting the care they need. Understand motivations for establishing program. Incentive Payment Program. Social care | Sheffield City Council 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. We use cookies to ensure that we give you the best experience on our website. As states expand Medicaid managed care to include higher-need, higher-cost beneficiaries, expensive long-term services and supports, and adults newly eligible for Medicaid under the ACA, the share of Medicaid dollars going to MCOs could continue to increase. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). ( However, they are quite different. 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.