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. A key component of the MCPD-PI was a care management workgroup. 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). Opt-out programs generally have higher member enrollment than opt-in programs. States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. An integral part of any care management program is a thorough understanding of the population it will affect. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Innovative solutions for better health outcomes. You'll get a care plan designed just for you. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. o Patient access to care management services 24/7. While MCOs are the predominant form of Medicaid managed care, millions of other beneficiaries receive at least some Medicaid services, such as behavioral health or dental care, through limited-benefit risk-based plans, known as prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs). For example, the goal of the care management program might be to increase the quality of life for program members. For example, in Pennsylvania, the APM target for the HealthChoices physical health MCO program and the behavioral health managed care program is 50% and 20%, respectively, for calendar year 2021. 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. 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. Meals on wheels. 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). In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. https:// 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. Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. 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. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. 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." Chronic pain and disease. States determine how they will deliver and pay for care for Medicaid beneficiaries. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. The NC Medicaid Ombudsman can help Medicaid beneficiaries get access to health care and connect beneficiaries to resources like legal aid, social services and other programs. 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. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. Care management refers to patient-centric, healthcare planning. Despite activity in this area, detailed performance information at the plan-level is not frequently made publicly available by state Medicaid agencies, limiting transparency and the ability of Medicaid beneficiaries (and other stakeholders) to assess how plans are performing on key indicators related to access, quality, etc. 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). Share sensitive information only on official, secure websites. Medical Care Management Services | Aetna Care management when it counts Aetna One care management is transforming the health care experience using predictive analytics, personal outreach and local access through CVS Health . Identify interventions needed for patients. 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 . Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. 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. The program coordinates services between health care providers, community program and supports, and family support programs. Your patients may already be working with one of our care managers. Medicaid managed care: costs, access, and quality of care. 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. In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. 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. 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 . 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. 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. AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. For most states, the requirements for APMs were in the 25 50% range. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). 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. 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. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. Accelerate claims processing. The technical storage or access that is used exclusively for anonymous statistical purposes. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. As well as having ideas to share on clinical aspects of the care management program, large provider groups, hospitals, provider associations, and individual providers can serve as ambassadors to patients for the program. Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. 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. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. Copyright 2020 - 2021 Care & Management Services. There's a change in your health status. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Managing your child's medical issues can be hard. means youve safely connected to the .gov website. 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). 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. As a result, most programs target specific populations because they are more "impactable.". Speaking with colleagues in other States to better understand their programs. Learn . If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. This group, facilitated by CHCS . 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). 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. Heres how you know. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. . 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. Support of potential program partners, such as other State agencies and local organizations. This review discusses the application of the chronic care model in the care of complex diabetes and its translation in the current reimbursement structure designed by Centers for Medicare and Medicaid Services (CMS). http://www.nasmd.org/waivers/waivers.htmll#1915b. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). A gentle form of counseling - extremely effective in fostering change in wide range of health behaviors for all demographics. Texas worked closely with its regional and central offices to communicate its care management program design and to identify a model that it could use to seek CMS approval for its program. Integrating Social Supports Into Health Plan Care Management. 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. . In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. Encourage members to take advantage of the program. Tailored plans will provide specialized services and care management to meet the needs of these individuals. If you're enrolled in a care management program, you can get personalized help from: Outreach workers Registered nurses Social workers Your care management team will help coordinate your healthcare. 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. Medicaid State Waiver Demonstration Projectsgeneral information. Filling the need for trusted information on national health issues, Elizabeth Hinton and Practitioners who have identified a member who they think would benefit from disease or case management should contact the Care Management Department, to speak with a Care Manager at 1-855-757-6567 or submit a referral request using the Secure Provider . 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. 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. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Planning these components early will allow staff to design an appropriate care management program for their members. Managed care is the dominant delivery system for Medicaid enrollees. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. The Chronic Care Management program was created by Medicare to close those communication gaps.