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How do we help? It is more important now than ever to carefully consider the health of your patients and to know what is care management. Complex Case Management Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. 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. 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. 5600 Fishers Lane This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program. States reported setting different percentage requirements depending on the services and population served under the managed care contract.10 Thirteen states11 reported that their APM targets were linked to the Health Care Payment Learning & Action Networks (LANs) APM Framework that categorizes APMs in tiers.12, While there is some evidence of positive impacts from state use of financial incentives to engage managed care plans around quality and outcomes, the results are more mixed and limited at the provider level.13,14,15. Become a shared lives carer. Care management programs often are linked with primary care case management (PCCM) programs or medical home initiatives, because Medicaid fee-for-service (FFS) might not offer the consistency of care typically provided at medical homes and necessary for successful patient interventions. Synth. . 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. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Sparer M. 2012. Powerful pivot table data reporting makes . This does not apply to Carolina Access providers participating in the EBCI Tribal Option. means youve safely connected to the .gov website. Accessed July 26, 2007. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. Centers for Medicare and Medicaid Services (CMS) recognizes care management as a critical tool to achieve the Quadruple Aim (better care, better patient and provider experiences, . 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 States should explore funding issues during program planning to determine the most appropriate program for their State. 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. 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. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. Program staff should assess the type of interventions appropriate for their care management program. For general correspondence via email please use the following address. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. 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). Residential and nursing care. For general correspondence via email please use the following address. 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. 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. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. Please go to Section 4: Selecting Care Management Interventions for a comprehensive discussion of types of interventions and a comparison of the relative costs of various interventions. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Birmingham. 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 . 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. Please be aware that although this email has restricted access, it is not encrypted. Heres how you know. Identify interventions needed for patients. To improve the coordination of care for Medicare patients between the acute care setting and community setting, the Centers for Medicare & Medicaid Services created two billing codes for Transitional Care Management (TCM). Encourage members to take advantage of the program. Team Around the Person co-ordinated support for adults. Rockville, MD 20857 Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. o Continuity of care with a designated provider or care team member. Build on lessons learned from other States by attending national meetings and networking with other States. Support of providers and patients. It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. Internet Citation: Section 1: Planning a Care Management Program. 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 . A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. However, they are quite different. Speaking with colleagues in other States to better understand their programs. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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. 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. Referrals to community resources, specialists, counseling and a social worker Educational materials Follow-up calls and home visits will be scheduled, as needed How do I get more information? 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. http://www.nasmd.org/waivers/waivers.htmll#1915b. A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. Your care plan. WellCare was acquired by Centene in January 2020. A parent firm is a firm that owns Medicaid MCOs in two or more states. Transitional Care Management Program Effective September 1, 2019. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). Care management programs are designed to assist patients and their support systems in managing multiple health conditions more effectively, to improve health outcomes for the patient. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. 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. Assessing various risks in the patients home and environment, Improves coordination of necessary healthcare, leading to better quality care, Patients feel understood, listened to, and properly cared for. 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. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. Every care management program should have an overarching aim, which might be as simple as "to maximize the quality of life and promote a regular source of care for patients with chronic conditions." A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. 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. Nominate a social care worker for a dignity award. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. 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. 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. . States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. 1 Care Management Framework The following framework (see other side) outlines . You can decide how often to receive updates. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. 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 . info@caremanserve.com. 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. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . The benefit information provided is a brief summary, not a complete description of benefits. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. Select and target populations to allocate resources most effectively. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. 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. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. 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). Some States are using DRA-related SPAs to provide targeted disease management for conditions such as chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, pediatric obesity, and pediatric asthma. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. 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. 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. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. 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. Medicaid MCOs provide comprehensive acute care and, in some cases, long-term services and supports to Medicaid beneficiaries and are paid a set per member per month payment for these services. States contracted with a total of 285 Medicaid MCOs as of July 2020. Similarly, case management also involves care planning. Care management operates within healthcare systems. 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. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. Please go to Section 5: Selecting a Care Management Program Model for more information. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. 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. website belongs to an official government organization in the United States. Using the Incedo Care Management Solution, it is infinitely simpler to develop the programs needed to serve their patients, manage the quality of care, and improve health outcomes. It is available for both adults and children. 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. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. 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 . VCCI works with members referred for complex case management by healthcare and human services providers, state colleagues and partners, as well as through our care management predictive modeling methodology. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. 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. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. It works by activating patients own motivation for change and adherence to their Doctor's directives. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. 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. Payments made to MCOs accounted for about 52% of total Medicaid spending (Figure 4), an increase of three percentage points from the previous fiscal year. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . 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. 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. 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. 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. 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. . Considerations for developing a care management program. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Preventative care is a core tenet of care management. The program coordinates services between health care providers, community program and supports, and family support programs. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. Senior leadership might also have areas and directions that they have no interest in pursuing. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. Determine program interventions that will be most effective for selected populations. Monday - Friday, 8:00am - 5:00pm AK Time. Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. Consultation Services Payment Policy Effective October 1, 2019. 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. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. California carved the pharmacy benefit out of managed care as of January 1, 2022. Meals on wheels. 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. Likewise, Virginia sets a lower percentage (10%) for its MLTSS program, Commonwealth Coordinated Care Plus, than for its Medallion 4.0 Medicaid physical and behavioral health managed care program that serves the states low-income children and families and the APM target is set at 25%. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). Providers of care and support. The Chronic Care Management program was created by Medicare to close those communication gaps. Comagine Health. Accelerate claims processing. 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. Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and Medicaid waivers. ( In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. 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. o Care management for chronic conditions . The provider's role in Superior's Care Management program is extremely important. 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 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. Medicaid members covered. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Increase accuracy. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Health goes well beyond care. 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. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. 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.