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. 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. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). Monday - Friday, 8:00am - 5:00pm AK Time. Enhanced Care Management and Community Supports (ILOS) - California Relevant Federal and State Authorities. Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. 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. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. Planning these components early will allow staff to design an appropriate care management program for their members. Accelerate claims processing. 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, . http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. 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. Medicaid and Social Determinants of Health - RWJF 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. 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. Enhanced Care Management (ECM) PDF CalAIM Enhanced Care Management and In Lieu of Services Frequently or 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. Identify interventions needed for patients. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. Understand motivations for establishing program. 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 Jada Raphael AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Improving Chronic Illness Care. To sign up for updates or to access your subscriberpreferences, please enter your email address below. 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. Accessed July 26, 2007. A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Determine program interventions that will be most effective for selected populations. Social Determinants of Health. means youve safely connected to the .gov website. More than half of MCO states reported requiring MCOs to screen enrollees for social needs, screen enrollees for behavioral health needs, provide referrals to social services, and partner with community-based organizations (CBOs). Our Care Management program is free and voluntary. info@caremanserve.com. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Section 1115 provides the Secretary of Health and Human Services broad authority to approve projects that test policy innovations likely to further Medicaid program objectives. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. 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. An SPA authorized under section 1932(a) of the Social Security Act provides much of the same flexibility available under waivers and also does not require the periodic renewals associated with programs operating under waiver authority. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . The relevant laws that come into play in the relationship between the State, the Managed Care Organizations (MCOs, including the HARPs), the Health Homes, the Care Management Agencies, the service providers and the recipients are as follows: The Health Insurance Portability and Accountability Act of 1996 . 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. Control costs. It is available for both adults and children. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. .gov This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. Chronic Care Management (CCM) | AAFP State staff can learn from successes and "productive failures" of other State Medicaid care management programs. 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. The program coordinates services between health care providers, community program and supports, and family support programs. Sign up to get the latest information about your choice of CMS topics. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. Medicaid members covered. NCDHHS Delays Implementation of the NC Medicaid Managed Care Behavioral Role of care management in Medicaid program. 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. Care Management Entity - Wyoming Department of Health 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. Become a shared lives carer. 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. Analysis of National Association of Insurance Commissioners (NAIC) data for the Medicaid managed care market show that average loss ratios in 2021 (in aggregate across plans) remained lower by three percentage points from 2019 (implying increased profitability) (Figure 6). 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. The program is intended to service Medicare patients with two or more chronic . Care Management - Horizon NJ Health Heres how you know. 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). A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Please go to Section 5: Selecting a Care Management Program Model for more information. 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. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. An official website of the United States government You can decide how often to receive updates. 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. Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. 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. Both enrollment mechanisms have advantages and disadvantages. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . a Available at: Cecil G. Sheps Center for Health Services Research. 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. They work with our members to help them understand the types of services we offer to them and how to participate in their own care. 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. Increase accuracy. Timing of other State initiatives to coordinate outreach and stakeholder support. States should coordinate and communicate routinely with these stakeholders. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. 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. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. http://www.nasmd.org/waivers/waivers.htmll#1915b. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. Care Management | Healthy Blue of North Carolina Care Management - CMCS Medicaid waivers. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. 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. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. 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. We'll help guide your family through the healthcare system. A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. 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. Care Management Providers | NC Medicaid Care Management Services | Behavioral Health Services North - BHSN 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. Care Management | NC Medicaid - NCDHHS 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. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. 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. 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. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. Community support workers. 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. The Chronic Care Management program was created by Medicare to close those communication gaps. We engage members in a more proactive, preventive and connected way. Our care managers help make health care easier and less overwhelming for our members. 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 this group is still less likely to be enrolled in MCOs than children and adults, over time, states have been moving to include adults ages 65+ and people eligible through disability in MCOs. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. 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. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. 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. 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/. This includes post-acute and long-term rehabilitation programs such as physical therapy, occupational or recreational therapies, speech-language pathology services, cognitive training, or neurorehabilitation. MCOs represent a mix of private for-profit, private non-profit, and government plans. 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. Some States are using DRA-related SPAs to provide targeted disease management for conditions such as chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, pediatric obesity, and pediatric asthma. A Look at Recent Medicaid Guidance to Address Social Determinants of 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. As an integral component of the Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans, Tailored Care Management (TCM) is a new care management model that reflects the goal of whole-person care management in NC Medicaid Managed Care. However, networks can be affected by overall provider supply shortages. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. 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. State Medicaid Director Letter: Guidance on how States can cover disease management. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. 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. Build on lessons learned from other States by attending national meetings and networking with other States. 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. 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. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. Preventative care is a core tenet of care management. 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.
