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. Care management refers to patient-centric, healthcare planning. The program is intended to service Medicare patients with two or more chronic . The benefit information provided is a brief summary, not a complete description of benefits. Increase accuracy. Determine program interventions that will be most effective for selected populations. 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). For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. . Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Your care plan. When the continuous enrollment provision ends and states resume disenrollments, Medicaid MCOs may see the overall acuity of their membership increase, with implications for per member utilization and costs, and the return of member churn (i.e., the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time). Attending national health policy meetings, such as meetings sponsored by the National Association of State Medicaid Directors, National Academy for State Health Policy, National Conference of State Legislatures, National Governors Association, or the Disease Management Association of America. You can decide how often to receive updates. 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. 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. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. 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. 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. The current Administration has identified advancing health equity as an important priority for the Medicaid program. The nature of the relationship to the patient is distinguishing factor between these terms. Similar to the Governor's office, the State legislature or individual legislators can greatly influence some of the key questions around a care management program's design, such as whether a mandatory savings requirement exists or whether the program can be operated in-house or with a vendor. 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. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. 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. 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. Health goes well beyond care. 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. 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. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. 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). 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/. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. 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. 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%. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. 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 contracted with a total of 285 Medicaid MCOs as of July 2020. As of July 2021, about half of MCO states identified a specific target in their MCO contracts for the percentage of provider payments or plan members that MCOs must cover via APMs. For most states, the requirements for APMs were in the 25 50% range. After approval of the original State plan, program staff must submit to CMS all relevant changes (required by new statutes, rules, regulations, interpretations, and court decisions) to determine whether the plan continues to meet Federal requirements and policies. 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. Improving Chronic Illness Care. Their experiences and understanding of their own limitations might help in the early planning stage. Speaking with colleagues in other States to better understand their programs. Reviewing formal evaluations of other States' programs. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Cognitive Assessment & Care Plan Services, Office-Based Opioid Use Disorder (OUD) Treatment Billing, Medicare PFS Locality Configuration and Studies, Psychological and Neuropsychological Tests, Diagnostic Services by Physical Therapists, Advance Care Planning Services Fact Sheet (PDF), Advance Care Planning Services FAQs (PDF), Behavioral Health Integration Fact Sheet (PDF), Chronic Care Management Frequently Asked Questions (PDF), Chronic Care Management and Connected Care, Billing FAQs for Transitional Care Management 2016. 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. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. Rockville, MD 20857 Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. 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. What Does Successful Care Management Look Like? . Care Management Services. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. 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. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Not consenting or withdrawing consent, may adversely affect certain features and functions. Identify interventions needed for patients. 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. 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. 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. 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. lock Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. 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. Learn . By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. Medicaid members covered. 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. MCOs represent a mix of private for-profit, private non-profit, and government plans. Please be aware that although this email has restricted access, it is not encrypted. These specially trained professionals can help find resources to make your daily life easier. 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. Enrollment growth has been primarily attributed to the Families First Coronavirus Response Act (FFCRA) provision that required states to ensure continuous enrollment for Medicaid enrollees in exchange for a temporary increase in the Medicaid match rate. Short term help at home. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. 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. .gov Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. 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. For example, the goal of the care management program might be to increase the quality of life for program members. Your patients may already be working with one of our care managers. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. 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. 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? Based on program goals, program staff should develop a measurement and evaluation strategy. Under federal law, payments to Medicaid MCOs must be actuarially sound. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. 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). 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. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. Synth. 1 Care Management Framework The following framework (see other side) outlines . These requirements apply to both capitated and fee-for-service disease management providers. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. We'll help guide your family through the healthcare system. Medicaid managed care: costs, access, and quality of care. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. . Monday - Friday, 8:00am - 5:00pm AK Time. We use cookies to ensure that we give you the best experience on our website. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . 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. 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 . Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. An official website of the United States government (805) 823-0981. contact@vigilancehit.com. States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. Tel: 0121 386 6605 Fax: 0121 386 6709. Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework, (McLean, VA: The MITRE Corporation, 2017), https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. 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 of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. Active Medicaid coverage. 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. Please be aware that although this email has restricted access, it is not . Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. ) o Care management for chronic conditions . 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. 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). By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. 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. 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. The share of Medicaid spending on MCOs varies by state, but over three-quarters of MCO states directed at least 40% of total Medicaid dollars to payments to MCOs (Figure 5). Chronic pain and disease. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. 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. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. 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. 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. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. Accelerate claims processing. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). State staff can learn from successes and "productive failures" of other State Medicaid care management programs. Official websites use .govA Content last reviewed October 2014. 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. 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. If you have any questions, please do not hesitate to contact us today! Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. A parent firm is a firm that owns Medicaid MCOs in two or more states. 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. https:// Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and 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." Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services.