Both enrollment mechanisms have advantages and disadvantages. 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. Control costs. This group, facilitated by CHCS . 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. Role of care management in Medicaid program. As described later in this section, after establishing program goals, staff must think about a measurement and evaluation strategy as a critical step early in the development process. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. 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. 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 Relevant Federal and State Authorities. Care management is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." 3 It also encompasses those care coordination activities needed to help manage chronic illness. 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. 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. 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. The program is intended to service Medicare patients with two or more chronic . Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. Active Medicaid coverage. For example, the goal of the care management program might be to increase the quality of life for program members. VigilanceHealth.com. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. . 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. 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. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. Internet Citation: Section 1: Planning a Care Management Program. 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. 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. 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. States contracted with a total of 285 Medicaid MCOs as of July 2020. The program coordinates services between health care providers, community program and supports, and family support programs. 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. You can decide how often to receive updates. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. 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. 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. Transitional Care Management Program Effective September 1, 2019. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. You can email in confidence to Senior Management at Care & Management Services Limited. 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. 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. 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 . 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 . Social Determinants of Health. California carved the pharmacy benefit out of managed care as of January 1, 2022. 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. 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. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. 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 Opt-out programs generally have higher member enrollment than opt-in programs. The provider's role in Superior's Care Management program is extremely important. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). Assess financial environment to determine most appropriate program. 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 . The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. After approval of the original State plan, program staff must submit to CMS all relevant changes (required by new statutes, rules, regulations, interpretations, and court decisions) to determine whether the plan continues to meet Federal requirements and policies. Demonstrations must be "budget neutral" over the life of the project, meaning they cannot be expected to cost the Federal Government more than it would cost without the waiver. 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. 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. 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 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." 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. 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. Accelerate claims processing. 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. RESTON, Va., July 8, 2020 /PRNewswire/ -- Altruista Health and North Carolina's Eastpointe Human Services today noted Eastpointe's successful launch of Altruista's care management technology, supporting whole-person care for Medicaid members in 10 counties. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. 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. As a result, most programs target specific populations because they are more "impactable.". Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. Please be aware that although this email has restricted access, it is not encrypted. Sign up to get the latest information about your choice of CMS topics. We work with youth between the ages of 5 and 21, who have a qualifying mental health diagnosis or other chronic condition that affects their daily functioning. o Care management for chronic conditions . 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. 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). We use cookies to ensure that we give you the best experience on our website. Establish program goals and identify short- and long-term objectives. 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. However, networks can be affected by overall provider supply shortages. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. This revised product comprises Subregulatory Guidance for the Transitional Care Management Services and its content is based on publicly available content from the 2021 Medicare Physician Fee Schedule Final Rule https://www.federalregister.gov/d/2012-26900 & 2015 Medicare Physician Fee Schedule Final Rule Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. 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. 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. 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. 5600 Fishers Lane Hepatitis-C, Hemophilia, HIV/AIDS, Women 60 days postpartum after delivery, and 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. Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. 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. The 2020 CMS Medicaid managed care final rule removed the requirement that states use time and distance standards to ensure provider network adequacy and instead lets states choose any quantitative standard. Communicating with hospital staffs, family doctors, specialists, etc. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. It is available for both adults and children. ) Case managers generally work indirectly with patients, often employed by healthcare facilities. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on opt-in and opt-out care management programs. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. Providing care for people living with chronic or complicated illnesses or conditions, is complex. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. 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. 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. o Patient access to care management services 24/7. Accessed February 11, 2008. c Available at: Robert Wood Johnson Foundation. 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). Their experiences and understanding of their own limitations might help in the early planning stage. The technical storage or access that is used exclusively for anonymous statistical purposes. Existing staff who can perform certain interventions, such as nurses or care managers, might be available. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. Select program model based on available staff and resources. A State must decide which population to target and how to identify and stratify members for enrollment into the program. ( lock 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. 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. 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. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. Every care management program should have an overarching aim, which might be as simple as "to maximize the quality of life and promote a regular source of care for patients with chronic conditions." 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. Medicaid waivers. These specially trained professionals can help find resources to make your daily life easier. You'll get a care plan designed just for you. Twenty-Four-Hour Coverage for Tailored Care Management Providers AMH+ practices and CMAs must arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis, 24 hours per day, seven days per week. 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. Rockville, MD 20857 Care Management Complaints, Grievances and Plan Appeals Disease Management Emergency Situations EPSDT Program Fraud, Waste and Abuse Get the Most from Your Coverage Interoperability and Patient Access Key Contacts Member Handbook LTC Newsletters Member Rights and Responsibilities Non-Discrimination Notice Prior Authorization Reviewing formal evaluations of other States' programs. 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.

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