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. Providing care for people living with chronic or complicated illnesses or conditions, is complex. Establish program goals and identify short- and long-term objectives. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. The program is intended to service Medicare patients with two or more chronic . If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. 907-770-7525 or 888-578-2547. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. 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. Based on program goals, program staff should develop a measurement and evaluation strategy. Medicaid Managed Care Provider Resource Communication. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington. Addressing their health concerns from a holistic point of view, integrating physical, behavioral, and social health improves overall well-being. 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). or 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 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. Community supports address social drivers of health and build on and scale . 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. 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. As part of managed care plan contract requirements, state Medicaid programs have also been focused on the use of alternative payment models (APMs) to reimburse providers and incentivize quality. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. The provider's role in Superior's Care Management program is extremely important. The rationale behind its inception was to offer an avenue of compensation for practitioners who provided care to their patients outside of the normal confines of the average office visit. COPD. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. This group, facilitated by CHCS . However, they are quite different. Agency for Healthcare Research and Quality, Rockville, MD. Additionally, while we can track state requirements for Medicaid managed care plans, plans have flexibility in certain areas including in setting provider payment rates and plans may choose to offer additional benefits beyond those required by the state. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. CMS announced a Request for Information (in early 2022) to inform development of a comprehensive access strategy across Medicaid fee-for-service and managed care delivery systems. 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. Integrating Social Supports Into Health Plan Care Management. 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. States determine how they will deliver and pay for care for Medicaid beneficiaries. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). Team Around the Person co-ordinated support for adults. 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. As a result, most programs target specific populations because they are more "impactable.". .gov CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. 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. 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. lock Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. Sign up to get the latest information about your choice of CMS topics. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. 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. 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. Preventative care is a core tenet of care management. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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). 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. 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 . 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. 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). Health goes well beyond care. Provider Analytics Tool Scheduled Maintenance. States might consider implementing a care management program for a variety of reasons. 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. Providers of care and support. If you have any questions, please do not hesitate to contact us today! Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. 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. Meals on wheels. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. Secure .gov websites use HTTPSA 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. 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. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. Senior leadership might also have areas and directions that they have no interest in pursuing. As states expand Medicaid managed care to include higher-need, higher-cost beneficiaries, expensive long-term services and supports, and adults newly eligible for Medicaid under the ACA, the share of Medicaid dollars going to MCOs could continue to increase. Their experiences and understanding of their own limitations might help in the early planning stage. Opt-out programs generally have higher member enrollment than opt-in programs. Care management services Care management is a program we make available to eligible members who may need help getting the care they need. For example, a State might want to improve the quality of care provided to beneficiaries with chronic conditions while containing costs in response to a legislative mandate. Attending national health policy meetings, such as meetings sponsored by the National Association of State Medicaid Directors, National Academy for State Health Policy, National Conference of State Legislatures, National Governors Association, or the Disease Management Association of America. 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). o Continuity of care with a designated provider or care team member. 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. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Medicaid managed care operates within a complex legal framework that includes contracts spelling out a state's performance expectations regarding coverage, care, access, payment, quality improvement, and other matters. Select and target populations to allocate resources most effectively. If you continue to use this site we will assume that you are happy with it. 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. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. . 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). Control costs. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. cost effective, non-duplicative services. These specially trained professionals can help find resources to make your daily life easier. 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. 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. 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. 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. Medicaid waivers. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. website belongs to an official government organization in the United States. Transitional Care Management Program Effective September 1, 2019. 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. 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. 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. Increase accuracy. Accessed July 26, 2007. 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. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Availability of necessary staff and resources. Res. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. 7500 Security Boulevard, Baltimore, MD 21244 . Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. 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. 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 potential program partners, such as other State agencies and local organizations. The nature of the relationship to the patient is distinguishing factor between these terms. 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. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. 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 . 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. Medicaid members covered. 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. A key component of the MCPD-PI was a care management workgroup. In FY 2022, states reported a range of state-mandated PIP focus areas with an emphasis on reducing disparities and improving health equity including related to maternal and child health; diabetes education and management; substance use disorder (SUD); and access to culturally and linguistically appropriate services. 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. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. Your care plan. 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? Community support workers. 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.