care management services medicaid

States reported setting different percentage requirements depending on the services and population served under the managed care contract.10 Thirteen states11 reported that their APM targets were linked to the Health Care Payment Learning & Action Networks (LANs) APM Framework that categorizes APMs in tiers.12, While there is some evidence of positive impacts from state use of financial incentives to engage managed care plans around quality and outcomes, the results are more mixed and limited at the provider level.13,14,15. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. Incentive Payment Program. 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). 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. 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. Share sensitive information only on official, secure websites. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). 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. Filling the need for trusted information on national health issues, Elizabeth Hinton and 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. Please go to Section 5: Selecting a Care Management Program Model for more information. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. In response to the COVID-19 pandemic, states had options and flexibilities under existing managed care rules to direct/bolster payments to Medicaid providers and to preserve access to care for enrollees. Engage stakeholders to build program support. 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. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content In creating new care management programs or considering expansions to current programs, States have a wide variety of options. Therefore, approval procedures are individualized, usually depending on the care management program model. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Select and target populations to allocate resources most effectively. Considerations for developing a care management program. 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. Build on lessons learned from other States by attending national meetings and networking with other States. It is also contracting with a Pharmacy Pricing and Audit Consultant (PPAC) who provides operational and consulting support in the areas of pharmacy reimbursement, benefit design, oversight, and auditing. 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. Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. Establish program goals and identify short- and long-term objectives. 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 https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. Using the Incedo Care Management Solution, it is infinitely simpler to develop the programs needed to serve their patients, manage the quality of care, and improve health outcomes. Official websites use .govA Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. 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 Receiving personalized attention from a Care Manager helps patients to better understand their health and subsequently be more engaged in their healthcare and feel more in control. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. Planning these components early will allow staff to design an appropriate care management program for their members. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). 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. For most states, the requirements for APMs were in the 25 50% range. For example, the goal of the care management program might be to increase the quality of life for program members. . Endorse the concepts of the interventions with patients. 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. 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 . Innovative solutions for better health outcomes. Consultation Services Payment Policy Effective October 1, 2019. Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. 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). 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 . 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. Complex Case Management The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Existing staff who can perform certain interventions, such as nurses or care managers, might be available. Timing of other State initiatives to coordinate outreach and stakeholder support. Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. Learn . Secure .gov websites use HTTPSA Providing care for people living with chronic or complicated illnesses or conditions, is complex. Develop a measurement and evaluation strategy to demonstrate program value. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? 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. However, networks can be affected by overall provider supply shortages. 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). dedicated employees ~56M. Internet Citation: Section 1: Planning a Care Management Program. 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. Plan efforts to recruit and maintain their provider networks can affect enrollees access to care through factors such as travel times, wait times, or choice of provider. 7500 Security Boulevard, Baltimore, MD 21244 . States should coordinate and communicate routinely with these stakeholders. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Share on Facebook. Health goes well beyond care. The service is intended to provide additional care to patients with a single chronic condition or allowing a provider to treat a patient with multiple chronic conditions by focusing care solely on one of those . Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. 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. Chronic pain and disease. 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. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. Agency for Healthcare Research and Quality, Rockville, MD. ( At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . Your care plan. As a result, during the planning stage, program staff should work with CMS staff, both at the regional and national levels, to solicit feedback and understand the type of authority that must be used to implement certain care management program components versus others. Not consenting or withdrawing consent, may adversely affect certain features and functions. Additional information about the program change is available at Ohio Medicaid Managed Care, Ohio Medicaid Single Pharmacy Benefit Manager (SPBM), https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager. The current Administration has identified advancing health equity as an important priority for the Medicaid program. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. Care management operates within healthcare systems. 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. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. 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. 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. 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? Identify interventions needed for patients. 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. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Senior leadership might also have areas and directions that they have no interest in pursuing. a Available at: Cecil G. Sheps Center for Health Services Research. Medicaid members covered. Most MCO states reported leveraging Medicaid MCO contracts to promote at least one strategy to address social determinants of health in FY 2022 (Figure 12). Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. 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. 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 disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. Role of care management in Medicaid program. Most States implement a program based on some combination of the following three reasons: States usually establish care management programs to meet multiple needs. 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. (805) 823-0981. contact@vigilancehit.com. 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. 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. Based on program goals, program staff should develop a measurement and evaluation strategy. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. 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. VigilanceHealth.com. There's a change in your health status. 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. 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. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. Heres how you know. The technical storage or access that is used exclusively for statistical purposes. o Care management for chronic conditions . Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. 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. 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. A parent firm is a firm that owns Medicaid MCOs in two or more states. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. Determine program interventions that will be most effective for selected populations. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. As a result, staff would want to track incremental progress in performance measures related to this goal or conduct a formal program evaluation. 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). An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. 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. 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. Powerful pivot table data reporting makes . Synth. 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. Copyright 2020 - 2021 Care & Management Services. States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). The Care Manager will be able to answer patient questions and complete requests for care. Understand motivations for establishing program. Accelerate claims processing. 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. 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. 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. 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. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. You can email in confidence to Senior Management at Care & Management Services Limited. Your patients may already be working with one of our care managers. 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. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. We engage members in a more proactive, preventive and connected way. These requirements apply to both capitated and fee-for-service disease management providers. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. 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. If goals have not been set already by the State legislature or Governor's office, Medicaid program staff should determine program goals based on the motivations for establishing a care management program. 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. 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). 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. 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. 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.