Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on opt-in and opt-out care management programs. 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 Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. California carved the pharmacy benefit out of managed care as of January 1, 2022. This review discusses the application of the chronic care model in the care of complex diabetes and its translation in the current reimbursement structure designed by Centers for Medicare and Medicaid Services (CMS). Medicaid officials and State policymakers should take time to consider each of these issues and evaluate their State's support, resources, and readiness to design and implement a care management program. Improving Chronic Illness Care. You can email in confidence to Senior Management at Care & Management Services Limited. The benefit information provided is a brief summary, not a complete description of benefits. 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. 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. States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. Their experiences and understanding of their own limitations might help in the early planning stage. 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. 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 Care Manager will be able to answer patient questions and complete requests for care. Provider Analytics Tool Scheduled Maintenance. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Meals on wheels. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). 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? Jada Raphael 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. The program is intended to service Medicare patients with two or more chronic . 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. Role of care management in Medicaid program. 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 addition to more empowered patients, there are numerous other benefits of care management and a care management solution. Thirty-five MCO states reported covering 75% or more of low-income adults in pre-ACA expansion groups (e.g., parents, pregnant women) through MCOs. 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. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. 5 (March 2017): 341-353, doi:10.7326/M16-1881, California Health Care Foundation, Making Quality Matter in Medi-Cal Managed Care: How Other States Hold Health Plans Financially Accountable for Performance, (Sacramento, CA: California Health Care Foundation, February 2019), https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf, New York State Department of Health, 2017 Quality Incentive for Medicaid Managed Care Plans, Albany, NY: New York State Department of Health, 2017, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf, The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. States should explore funding issues during program planning to determine the most appropriate program for their State. Incentive Payment Program. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Providers of care and support. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. States should coordinate and communicate routinely with these stakeholders. Encourage members to take advantage of the program. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . Both enrollment mechanisms have advantages and disadvantages. Community supports address social drivers of health and build on and scale . Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. 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. 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. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. Sparer M. 2012. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content Share on Facebook. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. A geriatric care manager, usually a licensed nurse or social worker who specializes in geriatrics, is a sort of "professional relative" who can help you and your family to identify needs and find ways to meet your needs. 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. Select program model based on available staff and resources. Similar to waivers, a section 1932(a) SPA authority provides flexibility with respect to limiting providers, eligible populations, and geographic areas that normally is unavailable under traditional SPAs. Become a shared lives carer. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. 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. For example, North Carolina experienced improved outcomes in asthma management more quickly than in diabetes management.a In addition, the evidence base suggests that programs might see improvements in process measures such as screening rates more quickly than desired changes in utilization rates, financial outcomes, and health outcomes. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). Support of providers and patients. Based on program goals, program staff should develop a measurement and evaluation strategy. o Continuity of care with a designated provider or care team member. Content last reviewed October 2014. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Medicaid Management. However, networks can be affected by overall provider supply shortages. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. It works by activating patients own motivation for change and adherence to their Doctor's directives. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. VigilanceHealth.com. States might consider implementing a care management program for a variety of reasons. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. 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. 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. Medicaid Managed Care Provider Resource Communication. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. Consider pilot testing to test intervention on a smaller scale. Building relationships with patients and caregivers, Administering assessments and developing individualized care plans, Connecting patients and caregivers to social and community support services, Establishing relationships with patients physicians and other providers, Facilitating administrative communication between healthcare providers, Monitoring care gaps and ensuring appointments are scheduled and kept, Comparing current care with proposed services. Of the 39 states that had implemented the ACA Medicaid expansion as of July 2022, 32 states were using MCOs to cover newly eligible adults and most covered more than 75% of beneficiaries in this group through MCOs. Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . 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. 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. cost effective, non-duplicative services. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. 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. As a result, staff would want to track incremental progress in performance measures related to this goal or conduct a formal program evaluation. 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. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. 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 Medicaid waivers. 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. 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. 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. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Chronic pain and disease. Speaking with colleagues in other States to better understand their programs. A parent firm is a firm that owns Medicaid MCOs in two or more states. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. For most states, the requirements for APMs were in the 25 50% range. Not consenting or withdrawing consent, may adversely affect certain features and functions. dedicated employees ~56M. It is more important now than ever to carefully consider the health of your patients and to know what is care management. Your patients may already be working with one of our care managers. Community support workers. Complex Case Management Identify interventions needed for patients. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). Together with your Care team, he or she can oversee your needs and coordinate your care. Select and target populations to allocate resources most effectively. 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). 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.