CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content o Patient access to care management services 24/7. confidential@caremanserve.com. 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. Health goes well beyond care. Team Around the Person co-ordinated support for adults. Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. We use cookies to ensure that we give you the best experience on our website. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Rockville, MD 20857 To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. You can call 800-727-7536 and press option 3 for Medical Management, then option 4 for Case/Care Management. Communicating with hospital staffs, family doctors, specialists, etc. Please be aware that although this email has restricted access, it is not encrypted. 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. States pay Medicaid managed care organizations a set per member per month payment for the Medicaid services specified in their contracts. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. Speaking with colleagues in other States to better understand their programs. 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. Program staff should assess the type of interventions appropriate for their care management program. Share sensitive information only on official, secure websites. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. website belongs to an official government organization in the United States. The Chronic Care Model. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. Identify interventions needed for patients. The CalAIM Incentive Payment Program is intended to support the implementation and expansion of ECM and Community Supports by incentivizing managed care plans (MCPs), in accordance with 42 CFR Section 438.6(b), to drive MCP delivery system investment in provider capacity and delivery system infrastructure; bridge current silos across physical and behavioral health . 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. Note: This brief was updated on March 1, 2023 to incorporate the latest available data. The current Administration has identified advancing health equity as an important priority for the Medicaid program. http://www.nasmd.org/waivers/waivers.htmll#1915b. Medicaid members covered. The Chronic Care Management program was created by Medicare to close those communication gaps. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. 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. The CCM program provides help for a person to. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. https:// ) They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). This section of the Guide, Planning a Care Management Program, incorporates information from the 13 State Medicaid care management programs in the initial AHRQ Learning Network and additional literature to provide information to State Medicaid staff and policymakers about: Although each State faces a unique environment, all States share several considerations in developing a Medicaid care management program. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. Select program model based on available staff and resources. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. lock A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. Engage stakeholders to build program support. Endorse the concepts of the interventions with patients. This role is responsible for providing leadership and direction to a large team of clinical . Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. 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. In creating new care management programs or considering expansions to current programs, States have a wide variety of options. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. However, networks can be affected by overall provider supply shortages. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. Increase accuracy. WellCare was acquired by Centene in January 2020. 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. 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. Today, Medicaid-focused startups can leverage these new behaviors to engage and educate patients in a more continuous fashion, through such tools as asynchronous telemedicine, Food and Drug Administration-approved digital therapeutics, and home testing around infection and chronic disease managementtools that can change what and where care is delivered and at a lower cost. 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. A disease management SPA must meet the requirements of section 1902(a) of the Social Security Act, including statewideness, comparability, and freedom of choice. 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. It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. 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). Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Senior leadership might also have areas and directions that they have no interest in pursuing. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. a Available at: Cecil G. Sheps Center for Health Services Research. Understand motivations for establishing program. 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. Similar to waivers, a section 1932(a) SPA authority provides flexibility with respect to limiting providers, eligible populations, and geographic areas that normally is unavailable under traditional SPAs. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. For 50 years, our technology, services and solutions have empowered agencies to transform the lives of those they serve. Chronic pain and disease. Medicaid Management. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. MCOs represent a mix of private for-profit, private non-profit, and government plans. Powerful pivot table data reporting makes . In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. 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. 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. States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. 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. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. (805) 823-0981. contact@vigilancehit.com. 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. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. 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. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients. If you continue to use this site we will assume that you are happy with it. Most MCO states reported leveraging Medicaid MCO contracts to promote at least one strategy to address social determinants of health in FY 2022 (Figure 12). 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 . Synth. Whether it's finding a community resource, making health appointments or assessing next steps for a health goal, your Care Manager will lead the way. Many states implemented COVID-19 related risk corridors leading to the recoupment of funds. 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. 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. Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. The 2020 Medicare Physician Fee Schedule (the "Final Rule"), released on November 1, 2019, finalized two new codes in a new category of reimbursement titled "Principal Care Management" (PCM) Services. Secure Federal support and approval. Incentive Payment Program. 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.