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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. The program coordinates services between health care providers, community program and supports, and family support programs. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. Tel: 0121 386 6605 Fax: 0121 386 6709. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. Preventative care is a core tenet of care management. Team Around the Person co-ordinated support for adults. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. Accelerate claims processing. There's a change in your health status. Opt-out programs generally have higher member enrollment than opt-in programs. 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. 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. 5600 Fishers Lane In FY 2022, similar numbers of states (about one quarter) reported requiring MCOs to have a health equity plan in place, meet health equity reporting requirements, and train staff on health equity and/or implicit bias. You'll get a care plan designed just for you. 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. 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. Res. Encourage members to take advantage of the program. Your care plan. These requirements apply to both capitated and fee-for-service disease management providers. 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. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. 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. Senior leadership might also have areas and directions that they have no interest in pursuing. 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. For general correspondence via email please use the following address. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. 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, . 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. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Heres how you know. While managed care is the dominant Medicaid delivery system, states decide which populations and services to include in managed care arrangements which leads to considerable variation across states. Support of providers and patients. Considerations for developing a care management program. This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program. These specially trained professionals can help find resources to make your daily life easier. 1 Care Management Framework The following framework (see other side) outlines . in place in FY 2022. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." B24 9QR. 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. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. 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. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. 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. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. 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. 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. The benefit information provided is a brief summary, not a complete description of benefits. Existing staff who can perform certain interventions, such as nurses or care managers, might be available. 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. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . 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. Share on Facebook. 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/. Your Medicare Coverage Principal care management services Principal care management services Medicare Part B (Medical Insurance) covers disease-specific services to help you manage a single, complex chronic condition that puts you at risk of hospitalization, physical or cognitive decline, or death. Speaking with colleagues in other States to better understand their programs. Determine whether program will be opt-in or opt-out. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. However, networks can be affected by overall provider supply shortages. For more information, or to enroll in our Care Management program call 1-800-682-9094 x 89634, Monday through Friday, 8 a.m. to 5 p.m., Eastern Time. 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. What Does Successful Care Management Look Like? 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. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. 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. 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. Meals on wheels. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care and costs is both limited and mixed.3,4,5. Managed care is the dominant delivery system for Medicaid enrollees. 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 . States determine how they will deliver and pay for care for Medicaid beneficiaries. States design and administer their own Medicaid programs within federal rules. Community supports address social drivers of health and build on and scale . 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? In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. Care Management Entity The Medicaid Care Management Entity acts as a central accountable hub to deliver community-based intensive care coordination services for children and youth with complex behavioral health needs using an evidence-based practice called "High Fidelity Wraparound." Most States implement a program based on some combination of the following three reasons: States usually establish care management programs to meet multiple needs. 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). It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. 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. Please go to Section 5: Selecting a Care Management Program Model for more information. Our Care Management program is free and voluntary. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. With 72% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs) nationally, plans have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the unwinding of the continuous enrollment requirement. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. 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. Internet Citation: Section 1: Planning a Care Management Program. 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. 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. Communicating with hospital staffs, family doctors, specialists, etc. 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. http://www.nasmd.org/waivers/waivers.htmll#1915b. 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. An integral part of any care management program is a thorough understanding of the population it will affect. Providing care for people living with chronic or complicated illnesses or conditions, is complex. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). 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. 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 might consider implementing a care management program for a variety of reasons. Case managers generally work indirectly with patients, often employed by healthcare facilities. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. Please be aware that although this email has restricted access, it is not . Official websites use .govA A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. Created by the Balanced Budget Act of 1997, this SPA authority to mandate enrollment applies to primary care case management or MCO-model disease management programs. Medicaid State Waiver Demonstration Projectsgeneral information. Short term help at home. State Medicaid Director Letter: Guidance on how States can cover disease management. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. If you continue to use this site we will assume that you are happy with it. Health goes well beyond care. Innovative solutions for better health outcomes. Chronic Care Management. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. COPD. 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. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. 7500 Security Boulevard, Baltimore, MD 21244 . States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. 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. Consider pilot testing to test intervention on a smaller scale. Sunshine Health is a managed care plan with a Florida Medicaid contract. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. 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. 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). Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. The Chronic Care Model. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. Active Medicaid coverage. 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. Jada Raphael Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. Copyright 2020 - 2021 Care & Management Services. 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. Learn . If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . 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. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. 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. For general correspondence via email please use the following address. Your Care Plan is a tool for Healthy Blue care management members to help you: Stay connected with your care coordinator; Find your care coordinator . 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. California carved the pharmacy benefit out of managed care as of January 1, 2022. 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. 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). Incentive Payment Program. Content last reviewed October 2014. A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. 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). 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. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. Under federal law, payments to Medicaid MCOs must be actuarially sound. 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). States use an array of financial incentives to improve quality including linking performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. We engage members in a more proactive, preventive and connected way. 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 . 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. Therefore, approval procedures are individualized, usually depending on the care management program model.