The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. Together with your Care team, he or she can oversee your needs and coordinate your care. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Today, Medicaid-focused startups can leverage these new behaviors to engage and educate patients in a more continuous fashion, through such tools as asynchronous telemedicine, Food and Drug Administration-approved digital therapeutics, and home testing around infection and chronic disease managementtools that can change what and where care is delivered and at a lower cost. Participate in reporting and data exchange included in the program. Determine whether program will be opt-in or opt-out. Senior leadership might also have areas and directions that they have no interest in pursuing. Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. 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. Res. 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. Rockville, MD 20857 States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. For example, the Department of Education might be interested if the care management program focuses on children's health, such as environmental management for asthma. Mandatory requirements include an increase of the look-back period for long-term care beneficiaries to 5 years and proof of citizenship for all new Medicaid applicants and current Medicaid beneficiaries. 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. 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). Most MCO states reported leveraging Medicaid MCO contracts to promote at least one strategy to address social determinants of health in FY 2022 (Figure 12). confidential@caremanserve.com. 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. Active Medicaid coverage. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. Support of potential program partners, such as other State agencies and local organizations. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. website belongs to an official government organization in the United States. Partnering with patients to ensure that all of their health care is effectively coordinated. Speaking with colleagues in other States to better understand their programs. Increase accuracy. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. While managed care is the dominant Medicaid delivery system, states decide which populations and services to include in managed care arrangements which leads to considerable variation across states. 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. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Chronic Care Management. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. 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. 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. Please go to Section 5: Selecting a Care Management Program Model for more information. With 72% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs) nationally, plans have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the unwinding of the continuous enrollment requirement. 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. An integral part of any care management program is a thorough understanding of the population it will affect. Assess financial environment to determine most appropriate program. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. . The nature of the relationship to the patient is distinguishing factor between these terms. 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. in place in FY 2022. Similar to the Governor's office, the State legislature or individual legislators can greatly influence some of the key questions around a care management program's design, such as whether a mandatory savings requirement exists or whether the program can be operated in-house or with a vendor. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. 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. Limitations, co-payments and . The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. 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). http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. 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. 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. 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. 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. Support of providers and patients. 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. A key component of the MCPD-PI was a care management workgroup. 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. Case managers generally work indirectly with patients, often employed by healthcare facilities. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . 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. (805) 823-0981. contact@vigilancehit.com. Comagine Health. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. 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. Senior leadership within the Medicaid program, its umbrella agency or department, and the Governor's office might have specific program goals that program staff must understand as they plan and develop the program. o Continuity of care with a designated provider or care team member. 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. o Patient access to care management services 24/7. It is more important now than ever to carefully consider the health of your patients and to know what is care management. Communicating with hospital staffs, family doctors, specialists, etc. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. If appropriate or adequate staff are unavailable, States can contract with a vendor, share staff with other State agencies, or partner with local organizations to perform needed services. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. The Chronic Care Model. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. 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. Consultation Services Payment Policy Effective October 1, 2019. A State must decide which population to target and how to identify and stratify members for enrollment into the program. Reviewing formal evaluations of other States' programs. For more information on these topics, please go to Section 3: Selecting and Targeting Populations for a Care Management Program, Section 4: Selecting Care Management Interventions, Section 6: Operating a Care Management Program, and Section 7: Measuring Value in a Care Management Program. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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). Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Monday - Friday, 8:00am - 5:00pm AK Time. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. Medicaid members covered. 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. 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. 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. States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. Content last reviewed October 2014. Select program model based on available staff and resources. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). As a result, most programs target specific populations because they are more "impactable.". 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. 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. States might consider implementing a care management program for a variety of reasons. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. 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. Understand motivations for establishing program. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. These specially trained professionals can help find resources to make your daily life easier. 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. 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. Not consenting or withdrawing consent, may adversely affect certain features and functions. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. 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. Considerations for developing a care management program. 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. 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. Share sensitive information only on official, secure websites. Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. The benefit information provided is a brief summary, not a complete description of benefits. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. 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. 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 Engage stakeholders to build program support. Team Around the Person co-ordinated support for adults. a Available at: Cecil G. Sheps Center for Health Services Research. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . The provider's role in Superior's Care Management program is extremely important. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. 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 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 Please be aware that although this email has restricted access, it is not encrypted. States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. 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. VigilanceHealth.com. 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. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 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. Accessed July 26, 2007. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. In FY 2022, similar numbers of states (about one quarter) reported requiring MCOs to have a health equity plan in place, meet health equity reporting requirements, and train staff on health equity and/or implicit bias. 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. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . Identify interventions needed for patients. Care management refers to patient-centric, healthcare planning. Sunshine Health is a managed care plan with a Florida Medicaid contract. Medicaid State Waiver Demonstration Projectsgeneral information. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. However, there has been significant movement across states to carve these services in to MCO contracts. info@caremanserve.com. It is available for both adults and children. Medicaid managed care: costs, access, and quality of care. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. 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. 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 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. 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/. Endorse the concepts of the interventions with patients. The Care Manager will be able to answer patient questions and complete requests for care. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). Consider pilot testing to test intervention on a smaller scale. The relevant laws that come into play in the relationship between the State, the Managed Care Organizations (MCOs, including the HARPs), the Health Homes, the Care Management Agencies, the service providers and the recipients are as follows: The Health Insurance Portability and Accountability Act of 1996 .