An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. 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 . For general correspondence via email please use the following address. 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. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. If you continue to use this site we will assume that you are happy with it. If you have any questions, please do not hesitate to contact us today! 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. 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. Learn . 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. Staff can demonstrate and communicate results by understanding program goals and identifying early outcomes that key stakeholders would consider a "success." Whether youre sharing risk in a value-based, The pandemic has placed additional strain on member health, creating new challenges not only around how to safely deliver care, but also what types of, 101 West Elm Street, Suite G10, Conshohocken, PA 19428. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Transitional Care Management Program Effective September 1, 2019. Social Determinants of Health. 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. Control costs. BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. 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. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. However, there has been significant movement across states to carve these services in to MCO contracts. States have traditionally used managed care models to increase budget predictability, constrain Medicaid spending, and improve access to care and value. 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. Although this group is still less likely to be enrolled in MCOs than children and adults, over time, states have been moving to include adults ages 65+ and people eligible through disability in MCOs. Your care plan. 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. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. To sign up for updates or to access your subscriberpreferences, please enter your email address below. 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. 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. o Continuity of care with a designated provider or care team member. States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. Chronic pain and disease. Our Care Management program is free and voluntary. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. 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. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Cognitive Assessment & Care Plan Services, Office-Based Opioid Use Disorder (OUD) Treatment Billing, Medicare PFS Locality Configuration and Studies, Psychological and Neuropsychological Tests, Diagnostic Services by Physical Therapists, Advance Care Planning Services Fact Sheet (PDF), Advance Care Planning Services FAQs (PDF), Behavioral Health Integration Fact Sheet (PDF), Chronic Care Management Frequently Asked Questions (PDF), Chronic Care Management and Connected Care, Billing FAQs for Transitional Care Management 2016. 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 . How do we help? 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. 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. 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. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. The Incedo Care Management Solution is a platform that not only houses all necessary clinical information for each patient, but also supports a collaborative process of assessment, planning, care management and care coordination. Senior leadership might also have areas and directions that they have no interest in pursuing. States contracted with a total of 285 Medicaid MCOs as of July 2020. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? 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. 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. Agency for Healthcare Research and Quality, Rockville, MD. 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. Provider Analytics Tool Scheduled Maintenance. 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. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. Availability of necessary staff and resources. States may also require MCOs to participate in Performance Improvement Projects (PIPs) focused on reducing health disparities. Case managers generally work indirectly with patients, often employed by healthcare facilities. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. Content last reviewed October 2014. 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. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. 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. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. Our care managers help make health care easier and less overwhelming for our members. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. 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. Under federal law, payments to Medicaid MCOs must be actuarially sound. Identify interventions needed for patients. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. 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%. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . Sparer M. 2012. 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. . Engage stakeholders to build program support. States should coordinate and communicate routinely with these stakeholders. An official website of the United States government Existing staff who can perform certain interventions, such as nurses or care managers, might be available. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Program staff should assess the type of interventions appropriate for their care management program. lock Determine whether program will be opt-in or opt-out. 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. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Medicaid members covered. This guidance document outlines the challenges states have faced when reporting primary care case management (PCCM) programs in the OT Claims file, Eligible file and the Managed Care file and recommends guidance for states' reporting. Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. Nominate a social care worker for a dignity award. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. 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." Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. Note: This brief was updated on March 1, 2023 to incorporate the latest available data. When choosing interventions, considering their outcomes, timing, and efficacy in managing certain diseases is important. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. Your patients may already be working with one of our care managers. 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. An SPA authorized under section 1932(a) of the Social Security Act provides much of the same flexibility available under waivers and also does not require the periodic renewals associated with programs operating under waiver authority.