The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. 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. Accessed July 26, 2007. California carved the pharmacy benefit out of managed care as of January 1, 2022. 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. 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. Chronic Care Management. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Timing of other State initiatives to coordinate outreach and stakeholder support. . 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 . States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. 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. The technical storage or access that is used exclusively for anonymous statistical purposes. Medicaid members covered. States determine how they will deliver and pay for care for Medicaid beneficiaries. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Copyright 2020 - 2021 Care & Management Services. 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). The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. Complex Case Management http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. 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. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. 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. Accelerate claims processing. 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. Build on lessons learned from other States by attending national meetings and networking with other States. You'll get a care plan designed just for you. 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. Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. 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. Sign up to get the latest information about your choice of CMS topics. Innovative solutions for better health outcomes. 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. Sparer M. 2012. The program is intended to service Medicare patients with two or more chronic . This does not apply to Carolina Access providers participating in the EBCI Tribal Option. 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. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. 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. Please go to Section 5: Selecting a Care Management Program Model for more information. Providing care for people living with chronic or complicated illnesses or conditions, is complex. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). 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). 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. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. A State must decide which population to target and how to identify and stratify members for enrollment into the program. Monday - Friday, 8:00am - 5:00pm AK Time. Consultation Services Payment Policy Effective October 1, 2019. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Published: Mar 01, 2023. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. 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. Please go to Section 4: Selecting Care Management Interventions for a comprehensive discussion of types of interventions and a comparison of the relative costs of various interventions. 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. States often choose to implement a pilot of their care management program as a way to test the intervention on a smaller scale or if they have limited resources. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. Tailored plans will provide specialized services and care management to meet the needs of these individuals. COPD. The Chronic Care Model. Likewise, Virginia sets a lower percentage (10%) for its MLTSS program, Commonwealth Coordinated Care Plus, than for its Medallion 4.0 Medicaid physical and behavioral health managed care program that serves the states low-income children and families and the APM target is set at 25%. 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. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. Medicaid Managed Care Provider Resource Communication. Res. 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 . 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. Rockville, MD 20857 Care management integrates all of a patients healthcare needs into a single individualized care plan that is maintained by the Care Management in a system, such as the Incedo Care Management Solution. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. 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, . 7500 Security Boulevard, Baltimore, MD 21244 . 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. 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 . States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. 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). 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. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. 1 Care Management Framework The following framework (see other side) outlines . However, there has been significant movement across states to carve these services in to MCO contracts. Learn . 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. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. 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. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. 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. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. 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. 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. 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. Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. 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. The CCM program provides help for a person to. PCCM is a managed fee-for-service (FFS) based system in which beneficiaries are enrolled with a primary care provider who is paid a small monthly fee to provide case management services in addition to primary care. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. 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. 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. o Care management for chronic conditions . 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. o Continuity of care with a designated provider or care team member. ECM helps coordinate primary care, acute care, behavioral health, developmental, oral health, community-based long-term services and supports (LTSS), and referrals to available community . 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. 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. Team Around the Person co-ordinated support for adults. 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. Sunshine Health is a managed care plan with a Florida Medicaid contract. While there is an increasing emphasis on care management for older adults who are dually eligible for Medicare and Medicaid that is focused on long-term services and supports, care managers based in healthcare organizations typically have a broader scope, including serving older adults who are not Medicaid-eligible. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. Based on program goals, program staff should develop a measurement and evaluation strategy. Residential and nursing care. For general correspondence via email please use the following address. 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. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. After considering each of the issues outlined above, program staff should answer the following questions in determining whether and how to proceed with a care management program. 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. To estimate program costs and understand program financing, they should consider the following issues: Many programs require Federal approval from CMS in the form of a State plan amendment (SPA) or a waiver. 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. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. 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. Our care managers help make health care easier and less overwhelming for our members. Similar to the Governor's office, the State legislature or individual legislators can greatly influence some of the key questions around a care management program's design, such as whether a mandatory savings requirement exists or whether the program can be operated in-house or with a vendor. We engage members in a more proactive, preventive and connected way. Recent findings: Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the . Partnering with patients to ensure that all of their health care is effectively coordinated.