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). For example, the goal of the care management program might be to increase the quality of life for program members. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. Medical Care Management Services | Aetna Care management when it counts Aetna One care management is transforming the health care experience using predictive analytics, personal outreach and local access through CVS Health . 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. Secure .gov websites use HTTPSA The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. Preventative care is a core tenet of care management. 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. States contracted with a total of 285 Medicaid MCOs as of July 2020. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. In January 2023, CMS released guidance on the use of in lieu of services (ILOS) in Medicaid managed care to reduce health disparities and address unmet health-related social needs (HRSN). Increase accuracy. The program coordinates services between health care providers, community program and supports, and family support programs. MCOs represent a mix of private for-profit, private non-profit, and government plans. 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. Opt-in programs notify patients of their eligibility for the program; members then must actively choose to enroll. 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. Care management programs are designed to assist patients and their support systems in managing multiple health conditions more effectively, to improve health outcomes for the patient. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. 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. dedicated employees ~56M. Role of care management in Medicaid program. By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. Senior leadership might also have areas and directions that they have no interest in pursuing. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. ) Agency for Healthcare Research and Quality, Rockville, MD. 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). Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. Medicaid Management. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Secure Federal support and approval. 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. 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. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California. 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. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. 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. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. Community support workers. It works by activating patients own motivation for change and adherence to their Doctor's directives. Transitional Care Management Program Effective September 1, 2019. Please be aware that although this email has restricted access, it is not encrypted. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. The benefit information provided is a brief summary, not a complete description of benefits. 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. 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. 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. Case managers generally work indirectly with patients, often employed by healthcare facilities. 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. 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. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Care management operates within healthcare systems. Establish program goals and identify short- and long-term objectives. 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. This role is responsible for providing leadership and direction to a large team of clinical . A key challenge that States must address is targeting resources most effectively for members who are presently high risk and impactable versus members who might be low risk or medium risk currently but who can be prevented from migrating to high risk. 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. Rep. 23, Robert Wood Johnson Found., Princeton, NJ, Daniel Franco Montoya, Puneet Kaur Chehal, and E. Kathleen Adams, Medicaid Managed Cares Effects on Costs, Access, and Quality: An Update, Annual Review of Public Health 41:1 (2020):537-549, Medicaid and CHIP Payment and Access Commission (MACPAC), Managed cares effect on outcomes, (Washington, DC: MACPAC, 2018), https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/. This section provides the Secretary of Health and Human Services authority to grant waivers that allow States to implement managed care delivery systems or limit individuals' choice of provider under Medicaid. Created by the Balanced Budget Act of 1997, this SPA authority to mandate enrollment applies to primary care case management or MCO-model disease management programs. Jada Raphael Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. Managed care is the dominant delivery system for Medicaid enrollees. 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. Short term help at home. Share sensitive information only on official, secure websites. 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. Develop a measurement and evaluation strategy to demonstrate program value. Practitioners who have identified a member who they think would benefit from disease or case management should contact the Care Management Department, to speak with a Care Manager at 1-855-757-6567 or submit a referral request using the Secure Provider . Medicaid members covered. 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." 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. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. Nearly all states have some form of managed care in place comprehensive risk-based managed care and/or primary care case management (PCCM) programs.1,2 As of July 2022, 41 states (including DC) contract with comprehensive, risk-based managed care plans to provide care to at least some of their Medicaid beneficiaries (Figure 1). Care Management for At-Risk Children (CMARC) The Medicaid program currently offers a set of care management services for at-risk children ages zero-to-five. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. cost effective, non-duplicative services. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. 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. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. 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. 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. 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. 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. 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. or 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. However, there has been significant movement across states to carve these services in to MCO contracts. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Meals on wheels. 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. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. However, networks can be affected by overall provider supply shortages. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). 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. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. 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. Care Management Services for Medicaid Beneficiaries with Specific Conditions Care management services are available to Mississippi Medicaid fee-for-service beneficiaries not enrolled in MississippiCAN (MSCAN) who meet one of the five specific conditions below. States should explore funding issues during program planning to determine the most appropriate program for their State. Access Care Management services deliver innovative programs individualized and customized to Maximize value-based reimbursement Positively affect quality metrics Improved patient compliance Enhance health outcomes Increase patient satisfaction With experience in self-pay, Medicaid and underinsured populations, our outcomes are notable. The NC Medicaid Ombudsman can help Medicaid beneficiaries get access to health care and connect beneficiaries to resources like legal aid, social services and other programs. 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. 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 . If you have questions about getting service coordination or service management through your health plan, call the help line phone number listed on the back of your health plan ID card. 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 . For general correspondence via email please use the following address. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. It is more important now than ever to carefully consider the health of your patients and to know what is care management. 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. 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. States might consider implementing a care management program for a variety of reasons. Content last reviewed October 2014. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. To sign up for updates or to access your subscriberpreferences, please enter your email address below. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. They work with our members to help them understand the types of services we offer to them and how to participate in their own care. https:// 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. Based on program goals, program staff should develop a measurement and evaluation strategy. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. Many states are leveraging MCO contracts to promote strategies to address social determinants of health and to improve health equity and reduce health disparities. An official website of the United States government In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. 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 . Chronic conditions often manifest in multiple ways and benefit from a holistic understanding. Please go to Section 7: Measuring Value in a Care Management Program for more detailed information. 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. 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. Chronic pain and disease. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Sparer M. 2012. Become a shared lives carer. You can email in confidence to Senior Management at Care & Management Services Limited. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. in place in FY 2022. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. All five are publicly traded companies ranked in the Fortune 500.9 Earnings reports from 2022 for these five for-profit parent firms (Centene, Molina, Elevance, UnitedHealth Group, and Aetna/CVS) showed growth in Medicaid membership (2022 over 2021) ranging from 6 to 17% and for the three firms that provided Medicaid-specific revenue information (Centene, Molina, and UnitedHealth Group) growth in Medicaid revenues ranging from 11 to 21% (2022 over 2021). Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. lock A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. 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. About one-quarter of MCO states reported at least one MCO financial incentive tied to a health equity-related performance goal (e.g., reducing disparities by race/ethnicity, gender, disability status, 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). Managed care plans provide enhanced care management and "community supports" to targeted high-need beneficiaries. The Care Manager will be able to answer patient questions and complete requests for care. B24 9QR. 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. 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. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. info@caremanserve.com. Limitations, co-payments and . website belongs to an official government organization in the United States. The technical storage or access that is used exclusively for statistical purposes. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Creation of a "carve out" delivery system for specialty care, such as behavioral health care. Your care plan. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. The provider's role in Superior's Care Management program is extremely important.
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