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. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. 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. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. 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. 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. The program coordinates services between health care providers, community program and supports, and family support programs. 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. 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. We use cookies to ensure that we give you the best experience on our website. For general correspondence via email please use the following address. 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. Partnering with patients to ensure that all of their health care is effectively coordinated. lock Team Around the Person co-ordinated support for adults. You can email in confidence to Senior Management at Care & Management Services Limited. Together with your Care team, he or she can oversee your needs and coordinate your care. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. 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/. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. 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. a Available at: Cecil G. Sheps Center for Health Services Research. Medical Care Management Services | Aetna Care management when it counts Aetna One care management is transforming the health care experience using predictive analytics, personal outreach and local access through CVS Health . Specifically, among other requirements, the DRA allows States to impose cost-sharing requirements on services such as prescriptions, increase copayments on emergency services, and alter existing Medicaid benefits packages to mirror certain commercial insurance packages through use of "benchmark" plans. 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. For example, the goal of the care management program might be to increase the quality of life for program members. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. 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. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Determine whether program will be opt-in or opt-out. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Preventative care is a core tenet of care management. 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). States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. Medicaid waivers. 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. 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. Providing care for people living with chronic or complicated illnesses or conditions, is complex. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. CMS has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements, including guidance outlining how managed care plans can support states in promoting continuity of coverage. confidential@caremanserve.com. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Learn . AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Medicaid managed care: costs, access, and quality of care. Therefore, approval procedures are individualized, usually depending on the care management program model. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. Sunshine Health is a managed care plan with a Florida Medicaid contract. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. 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. Ohio is unbundling many components of pharmacy benefit administration from MCO responsibilities and contracting with a single PBM instead. 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. States may use a variety of mechanisms to adjust plan risk, incentivize plan performance, and ensure payments are not too high or too low, including risk sharing arrangements, risk and acuity adjustments, medical loss ratios (MLRs, which reflect the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement), or incentive and withhold arrangements. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Develop a measurement and evaluation strategy to demonstrate program value. This guidance document outlines the challenges states have faced when reporting primary care case management (PCCM) programs in the OT Claims file, Eligible file and the Managed Care file and recommends guidance for states' reporting. It works by activating patients own motivation for change and adherence to their Doctor's directives. We assist you with scheduling the variety of appointments that your child may have to meet their needs. Your patients may already be working with one of our care managers. Meals on wheels. Incentive Payment Program. Monday - Friday, 8:00am - 5:00pm AK Time. http://www.nasmd.org/waivers/waivers.htmll#1915b. Residential and nursing 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. Whether youre sharing risk in a value-based, The pandemic has placed additional strain on member health, creating new challenges not only around how to safely deliver care, but also what types of, 101 West Elm Street, Suite G10, Conshohocken, PA 19428. 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. 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 . o Patient access to care management services 24/7. Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. Social Determinants of Health. 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. 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. Determine program interventions that will be most effective for selected populations. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. Share sensitive information only on official, secure websites. A key challenge that States must address is targeting resources most effectively for members who are presently high risk and impactable versus members who might be low risk or medium risk currently but who can be prevented from migrating to high risk. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). 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. Case managers generally work indirectly with patients, often employed by healthcare facilities. 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. 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 explore funding issues during program planning to determine the most appropriate program for their State. .gov If you have questions about getting service coordination or service management through your health plan, call the help line phone number listed on the back of your health plan ID card. It coordinates the care you get from different doctors. Engage stakeholders to build program support. Powerful pivot table data reporting makes . Innovative solutions for better health outcomes. . Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . 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. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. 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. ( Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Transitional Care Management Program Effective September 1, 2019. 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. 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. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. Accelerate claims processing. 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. 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 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. Understand motivations for establishing program. Care management operates within healthcare systems. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and Opens in a new window. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. 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. 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. Managing your child's medical issues can be hard. 7500 Security Boulevard, Baltimore, MD 21244 . Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. 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." It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. 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). 4.3 (18) FAMCare is powerful, cloud-based case management software for human services agencies who are looking to manage cases faster and make data reviews and reporting simpler to allow you to help more clients. 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. 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). 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. 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. Secure Federal support and approval. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. What Does Successful Care Management Look Like? cost effective, non-duplicative services. Please go to Section 5: Selecting a Care Management Program Model for more information.