Beginning July 1, 2021, North Carolina implemented its first MCO program, enrolling more than 1.8 million Medicaid beneficiaries in MCOs as of January 2023. 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. 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. Official websites use .govA Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. Care Management | Sunshine Health A parent firm is a firm that owns Medicaid MCOs in two or more states. Engaging providers is an important component of a care management program, because interested providers will endorse the intervention concepts with patients, identify needed interventions for patients, and follow practice guidelines. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. 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. Availability of necessary staff and resources. Under federal law, payments to Medicaid MCOs must be actuarially sound. Become a shared lives carer. 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. An integral part of any care management program is a thorough understanding of the population it will affect. o Care management for chronic conditions . 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. Tailored plans will provide specialized services and care management to meet the needs of these individuals. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. 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. Principal care management services | Medicare Based on program goals, program staff should develop a measurement and evaluation strategy. Mandatory enrollment of beneficiaries into managed care programs (although States have the option, through the Balanced Budget Act of 1997, to enroll certain beneficiaries into mandatory managed care via an SPA), or. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. 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. Comprehensive Care Management The Bridge Inc. The benefit information provided is a brief summary, not a complete description of benefits. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Although 2020 data (displayed above) are the most current national data available, enrollment in Medicaid overall has grown substantially since the start of the coronavirus pandemic, resulting in growth in MCO enrollment as well. The current Administration has identified advancing health equity as an important priority for the Medicaid program. B24 9QR. info@caremanserve.com. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. 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). States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. NCDHHS Delays Implementation of the NC Medicaid Managed Care Behavioral 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. 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. States use an array of financial incentives to improve quality including linking performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. To sign up for updates or to access your subscriberpreferences, please enter your email address below. 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. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Considerations for developing a care management program. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. Internet Citation: Section 1: Planning a Care Management Program. 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. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Garnering support from leadership and other stakeholders, developing realistic program expectations early in the process, and designing a strategic evaluation process affect program success and sustainability significantly. Case managers generally work indirectly with patients, often employed by healthcare facilities. Communicating with hospital staffs, family doctors, specialists, etc. Care Management - CMCS 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/. Medicare and chronic care management: An overview - Medical News Today Care Management Entity The Medicaid Care Management Entity acts as a central accountable hub to deliver community-based intensive care coordination services for children and youth with complex behavioral health needs using an evidence-based practice called "High Fidelity Wraparound." While there is an increasing emphasis on care management for older adults who are dually eligible for Medicare and Medicaid that is focused on long-term services and supports, care managers based in healthcare organizations typically have a broader scope, including serving older adults who are not Medicaid-eligible. Medicaid Health Homes - Comprehensive Care Management 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. The technical storage or access that is used exclusively for anonymous statistical purposes. Care management refers to patient-centric, healthcare planning. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. Case Management | Provider Resources | Superior HealthPlan Providers of care and support. 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. or Self-Directed Services | Medicaid For example, if a State plans an external evaluation of the program, having the evaluator provide input as program measures and data collection are discussed might be useful. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. 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). 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). 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. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. Accessed July 26, 2007. cost effective, non-duplicative services. Care Management | CareSource These specially trained professionals can help find resources to make your daily life easier. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). Medicaid in 2022: CMS Eyes Equity, Value-Based Care Section 1: Planning a Care Management Program Your Medicare Coverage Principal care management services Principal care management services Medicare Part B (Medical Insurance) covers disease-specific services to help you manage a single, complex chronic condition that puts you at risk of hospitalization, physical or cognitive decline, or death. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. A Look at Recent Medicaid Guidance to Address Social Determinants of 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. 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. means youve safely connected to the .gov 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. website belongs to an official government organization in the United States. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. 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. Select and target populations to allocate resources most effectively. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). Help Coordinating Your Services | Texas Health and Human Services Care Management Entity - Wyoming Department of Health For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. The nature of the relationship to the patient is distinguishing factor between these terms. Tailored Care Management Updates - Aug. 29, 2022 | NC Medicaid State Medicaid Director Letter: Guidance on how States can cover disease management. Enhanced Care Management (ECM) Identify interventions needed for patients. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). We engage members in a more proactive, preventive and connected way. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. 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. Integrating Social Supports Into Health Plan Care Management. 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. If you have any questions, please do not hesitate to contact us today! The Incedo Care Management Solution is a platform that not only houses all necessary clinical information for each patient, but also supports a collaborative process of assessment, planning, care management and care coordination. Care Management Services - Access To Healthcare Network For more information, or to enroll in our Care Management program call 1-800-682-9094 x 89634, Monday through Friday, 8 a.m. to 5 p.m., Eastern Time. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. Monday - Friday, 8:00am - 5:00pm AK Time. Chronic Care Management - Care Management Medicare Reimbursement VigilanceHealth.com. We assist you with scheduling the variety of appointments that your child may have to meet their needs. 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. 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. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. Heres how you know. However, they are quite different. 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. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. Physician Leaders See Opportunity to Leverage Tech to Improve Medicaid Case Management Services - Alaska The program is intended to service Medicare patients with two or more chronic . Chronic pain and disease. PDF Care Management - Nachc 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. For most states, the requirements for APMs were in the 25 50% range. We work with youth between the ages of 5 and 21, who have a qualifying mental health diagnosis or other chronic condition that affects their daily functioning. While the vast majority of states that contract with MCOs report that the pharmacy benefit is carved in to managed care (34 of 41), six states report that pharmacy benefits are carved out of MCO contracts as of July 2022 (Figure 7). In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. 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. What Is a Geriatric Care Manager? | National Institute on Aging 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. It works by activating patients own motivation for change and adherence to their Doctor's directives. Chronic care management (CCM) made its debut in 2015 when it was rolled out by the Centers for Medicare and Medicaid Services (CMS) as a separately paid service under the Medicare fee schedule. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. This role is responsible for providing leadership and direction to a large team of clinical . ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Principal Care Management (PCM) Reimbursement under the 2020 Medicare The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. Community supports address social drivers of health and build on and scale . 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. Accelerate claims processing. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. Provider Analytics Tool Scheduled Maintenance. Incentive Payment Program. NC Medicaid Begins Tailored Care Management Dec. 1, 2022 This section provides the Secretary of Health and Human Services authority to grant waivers that allow States to implement managed care delivery systems or limit individuals' choice of provider under Medicaid. Transitional Care Management Services | Guidance Portal - HHS.gov Transitional Care Management Program Effective September 1, 2019. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. Both enrollment mechanisms have advantages and disadvantages. 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. Therefore, approval procedures are individualized, usually depending on the care management program model. 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. 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). Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. Share sensitive information only on official, secure websites. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. A State must decide which population to target and how to identify and stratify members for enrollment into the program. Medicaid Authorities and Options to Address Social Determinants of Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. Care Management: Implications for Medical Practice, Health Policy, and The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Care management | Anthem Care management services Care management is a program we make available to eligible members who may need help getting the care they need. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Under federal Medicaid managed care rules, Medicaid MCOs can be given flexibility to pay for non-medical services through "in-lieu-of" authority and/or "value-added" services. lock Timing of other State initiatives to coordinate outreach and stakeholder support. Transitional Care Management - Rural Health Info 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. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. About one-quarter of MCO states reported at least one MCO financial incentive tied to a health equity-related performance goal (e.g., reducing disparities by race/ethnicity, gender, disability status, etc.) 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. 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. 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. 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? Reviewing formal evaluations of other States' programs. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. 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.