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. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. 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. For example, the Department of Education might be interested if the care management program focuses on children's health, such as environmental management for asthma. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. Meals on wheels. The provider's role in Superior's Care Management program is extremely important. 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. We engage members in a more proactive, preventive and connected way. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. 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). Develop a measurement and evaluation strategy to demonstrate program value. 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." 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. Internet Citation: Section 1: Planning a Care Management Program. 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. that have received an approval letter from the New York State Department of Health identifying them as a "Designated Provider-lead Health Home") and any converting care management agencies such as OMH TCM, and COBRA providers that are billing directly for health home services. Interventions may target the patient or the provider and generally range from "low-touch" interventions, such as mailings, to "high-touch" interventions, such as home visits by nurse care managers. . A key component of the MCPD-PI was a care management workgroup. 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. ( As a result, staff would want to track incremental progress in performance measures related to this goal or conduct a formal program evaluation. 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. Learn . The Chronic Care Model. Their experiences and understanding of their own limitations might help in the early planning stage. 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. 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. Determine program interventions that will be most effective for selected populations. The program is intended to service Medicare patients with two or more chronic . 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. The technical storage or access that is used exclusively for statistical purposes. This group, facilitated by CHCS . Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. 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. 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. 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 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 . CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. 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). 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. 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. info@caremanserve.com. In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. Synth. Provider Analytics Tool Scheduled Maintenance. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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). Through the hard work and attention of care managers and an effective technology solution, the integration of healthcare systems and services can revolutionize the experience for patients. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. 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). The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Our care managers help make health care easier and less overwhelming for our members. 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. Program staff should assess the type of interventions appropriate for their care management program. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. 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 . WellCare was acquired by Centene in January 2020. This role is responsible for providing leadership and direction to a large team of clinical . 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. 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. In addition to more empowered patients, there are numerous other benefits of care management and a care management solution. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. Agency for Healthcare Research and Quality, Rockville, MD. The technical storage or access that is used exclusively for anonymous statistical purposes. The program coordinates services between health care providers, community program and supports, and family support programs. For more information on these topics, please go to Section 3: Selecting and Targeting Populations for a Care Management Program, Section 4: Selecting Care Management Interventions, Section 6: Operating a Care Management Program, and Section 7: Measuring Value in a Care Management Program. Engage stakeholders to build program support. 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. VigilanceHealth.com. 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. Comagine Health. We use cookies to ensure that we give you the best experience on our website. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. 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. 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. Short term help at home. . Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. You can decide how often to receive updates. 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. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. Secure .gov websites use HTTPSA For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 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. Timing of other State initiatives to coordinate outreach and stakeholder support. Rockville, MD 20857 In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. B24 9QR. California carved the pharmacy benefit out of managed care as of January 1, 2022. Incentive Payment Program. 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. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. Transitional Care Management Program Effective September 1, 2019. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program.