WellCare was acquired by Centene in January 2020. 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. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. 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). In creating new care management programs or considering expansions to current programs, States have a wide variety of options. 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. CMS has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements, including guidance outlining how managed care plans can support states in promoting continuity of coverage. 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. Relevant Federal and State Authorities. Speaking with colleagues in other States to better understand their programs. Complex Case Management 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. in place in FY 2022. 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. Learn . The Chronic Care Model. All five are publicly traded companies ranked in the Fortune 500.9 Earnings reports from 2022 for these five for-profit parent firms (Centene, Molina, Elevance, UnitedHealth Group, and Aetna/CVS) showed growth in Medicaid membership (2022 over 2021) ranging from 6 to 17% and for the three firms that provided Medicaid-specific revenue information (Centene, Molina, and UnitedHealth Group) growth in Medicaid revenues ranging from 11 to 21% (2022 over 2021). Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. Residential and nursing care. Integrating Social Determinants of Health to Improve Outcomes and Profitability, How Risk Bearing Entities Can Extract Value from Care Management Programs, Integrated Behavioral Health: The Time is Now, Health Systems and Community-Based Networks. 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. Select program model based on available staff and resources. B24 9QR. Official websites use .govA As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. 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. You can email in confidence to Senior Management at Care & Management Services Limited. If you continue to use this site we will assume that you are happy with it. 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. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . 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). Support of providers and patients. Together with your Care team, he or she can oversee your needs and coordinate your care. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. 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. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. Similarly, case management also involves care planning. 10 Things to Know About Medicaid Managed Care, has grown substantially since the start of the coronavirus pandemic, National Association of Insurance Commissioners (NAIC) data, report that the pharmacy benefit is carved in, 2020 CMS Medicaid managed care final rule, to direct/bolster payments to Medicaid providers, reported using at least one financial incentive, reported at least one MCO financial incentive, state-mandated PIP focus areas with an emphasis on reducing disparities, https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/, https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager, https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf, https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf, Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans. You'll get a care plan designed just for you. Centers for Medicare and Medicaid Services (CMS) recognizes care management as a critical tool to achieve the Quadruple Aim (better care, better patient and provider experiences, . Jada Raphael Chronic pain and disease. 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. 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. 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. 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. Share on Facebook. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. .gov Therefore, approval procedures are individualized, usually depending on the care management program model. A State must decide which population to target and how to identify and stratify members for enrollment into the program. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. 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. 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. Powerful pivot table data reporting makes . dedicated employees ~56M. This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program. 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. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. CCM services provided by a physician or other qualified health care professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management . This section of the Guide, Planning a Care Management Program, incorporates information from the 13 State Medicaid care management programs in the initial AHRQ Learning Network and additional literature to provide information to State Medicaid staff and policymakers about: Although each State faces a unique environment, all States share several considerations in developing a Medicaid care management program. 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. 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. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. Care management refers to patient-centric, healthcare planning. Active Medicaid coverage. Transitional Care Management Program Effective September 1, 2019. 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. 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). States contracted with a total of 285 Medicaid MCOs as of July 2020. For example, the goal of the care management program might be to increase the quality of life for program members. The Chronic Care Management program was created by Medicare to close those communication gaps. The technical storage or access that is used exclusively for statistical purposes. Limitations, co-payments and . Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Accelerate claims processing. 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 The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . 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. Providing care for people living with chronic or complicated illnesses or conditions, is complex. What Does Successful Care Management Look Like? Linking the medical home and care management can provide additional benefits to both Medicaid and the care management program, including the following: Implementation of another State initiative might enhance or hinder implementation of a care management program. To sign up for updates or to access your subscriberpreferences, please enter your email address below. ) Planning these components early will allow staff to design an appropriate care management program for their members. Assess financial environment to determine most appropriate program. Considerations for developing a care management program. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? 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. The Care Manager will be able to answer patient questions and complete requests for care. 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. 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. o Continuity of care with a designated provider or care team member. Whether it's finding a community resource, making health appointments or assessing next steps for a health goal, your Care Manager will lead the way. 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. 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. 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. 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. 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. Establish program goals and identify short- and long-term objectives. 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. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . Become a shared lives carer. A parent firm is a firm that owns Medicaid MCOs in two or more states. Provider Analytics Tool Scheduled Maintenance. It is more important now than ever to carefully consider the health of your patients and to know what is care management. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. 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. Tailored plans will provide specialized services and care management to meet the needs of these individuals. Sparer M. 2012. 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. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. 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. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. Medicaid managed care: costs, access, and quality of care. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. http://www.nasmd.org/waivers/waivers.htmll#1915b. Medicaid members covered. Opt-out programs generally have higher member enrollment than opt-in programs. States often choose to implement a pilot of their care management program as a way to test the intervention on a smaller scale or if they have limited resources. 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.) 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. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. ECM is a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of high-cost and/or highneed - Medi-Cal managed care health plan (MCP) Members through systematic coordination of services and comprehensive, community-based care . 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. COPD. or 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. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. The nature of the relationship to the patient is distinguishing factor between these terms. States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. Community supports address social drivers of health and build on and scale . The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . 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. 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. 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). 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. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. 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 Secure Federal support and approval. . Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. The program is intended to service Medicare patients with two or more chronic . 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. 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. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. 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). Existing staff who can perform certain interventions, such as nurses or care managers, might be available. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. 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. Internet Citation: Section 1: Planning a Care Management Program. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. Team Around the Person co-ordinated support for adults. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content 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. 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. These requirements apply to both capitated and fee-for-service disease management providers. Select and target populations to allocate resources most effectively. Res. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. Understand motivations for establishing program. By involving consumers during the planning, implementation, and evaluation stages, program staff will be better able to gauge the possible impact of certain interventions and will be able to design a better, more effective program overall. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). If appropriate or adequate staff are unavailable, States can contract with a vendor, share staff with other State agencies, or partner with local organizations to perform needed services. The delayed start of Tailored Plans allows Local Management Entity/Managed Care Organizations , which will operate the Tailored Plans, more time to contract with additional providers to ensure a smooth transition for people using the plans and their care providers. cost effective, non-duplicative services. Addressing their health concerns from a holistic point of view, integrating physical, behavioral, and social health improves overall well-being. Communicating with hospital staffs, family doctors, specialists, etc. . We'll help guide your family through the healthcare system. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. 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. 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. 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. Assessing various risks in the patients home and environment, Improves coordination of necessary healthcare, leading to better quality care, Patients feel understood, listened to, and properly cared for. 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.