In creating new care management programs or considering expansions to current programs, States have a wide variety of options. 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. 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. lock . It works by activating patients own motivation for change and adherence to their Doctor's directives. Medicaid members covered. While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, it is estimated that millions will lose coverage. 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. Select program model based on available staff and resources. 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. 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. These requirements apply to both capitated and fee-for-service disease management providers. Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. 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. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. 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. 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 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). Share on Facebook. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Active Medicaid coverage. The provider's role in Superior's Care Management program is extremely important. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. You'll get a care plan designed just for you. An official website of the United States government Birmingham. 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. http://www.nasmd.org/waivers/waivers.htmll#1915b. Program staff should assess the type of interventions appropriate for their care management program. To learn more, call the NC Medicaid Ombudsman toll free at 1-877-201-3750 , 8 a.m. to 5 p.m., Monday through Friday, except state holidays. Five firms UnitedHealth Group, Centene, Anthem (renamed Elevance in 2022), Molina, and Aetna/CVS each have MCOs in 12 or more states (Figure 8) and accounted for 50% of all Medicaid MCO enrollment (Figure 9). Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. Preventative care is a core tenet of care management. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. 1 Care Management Framework The following framework (see other side) outlines . 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. Build on lessons learned from other States by attending national meetings and networking with other States. 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). The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . State Medicaid Director Letter: Guidance on how States can cover disease management. 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 Care Management (MCM), or managed care, delivers New Hampshire Medicaid health benefits and additional services through contracts between the Department of Health and Human Services (DHHS) and managed care organizations (MCOs) or Medicaid Health Plans. Determine program interventions that will be most effective for selected populations. 7500 Security Boulevard, Baltimore, MD 21244 . 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. States contracted with a total of 285 Medicaid MCOs as of July 2020. 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. Community supports address social drivers of health and build on and scale . When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. Team Around the Person co-ordinated support for adults. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Interventions may target the patient or the provider and generally range from "low-touch" interventions, such as mailings, to "high-touch" interventions, such as home visits by nurse care managers. Share sensitive information only on official, secure websites. 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. 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. Res. website belongs to an official government organization in the United States. 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. 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 You can email in confidence to Senior Management at Care & Management Services Limited. 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. Accelerate claims processing. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. in place in FY 2022. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. 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. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Therefore, approval procedures are individualized, usually depending on the care management program model. Relevant Federal and State Authorities. 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. 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. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). lock B24 9QR. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. 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. 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/. Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. Consultation Services Payment Policy Effective October 1, 2019. Managing your child's medical issues can be hard. 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. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. 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). Rockville, MD 20857 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. 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 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. 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. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . 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. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. A key component of the MCPD-PI was a care management workgroup. Assess financial environment to determine most appropriate program. 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. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Providers of care and support. dedicated employees ~56M. Content last reviewed October 2014. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Nominate a social care worker for a dignity award. 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. 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. 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. 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. 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.) Medicaid managed care: costs, access, and quality of care. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. How do we help? Our care managers help make health care easier and less overwhelming for our members. 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. 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. 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. 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. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. 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. Determine whether program will be opt-in or opt-out. 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). 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. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Agency for Healthcare Research and Quality, Rockville, MD. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Existing staff who can perform certain interventions, such as nurses or care managers, might be available. Opt-out programs generally have higher member enrollment than opt-in programs. Dental Care Early and Periodic Screening, Diagnostic, and Treatment Hospice Benefits Mandatory & Optional Medicaid Benefits Prevention Telehealth Assurance of Transportation Prescription Drugs Branded Prescription Drug Fee Program Drug Utilization Review Federal Upper Limit Medicaid Drug Policy Medicaid Drug Rebate Program Pharmacy Pricing 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. It coordinates the care you get from different doctors. Integrating Social Supports Into Health Plan Care Management. 5600 Fishers Lane Community support workers. 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). Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. The Chronic Care Management program was created by Medicare to close those communication gaps. Identify interventions needed for patients.
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