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Similarly, case management also involves care planning. However, networks can be affected by overall provider supply shortages. 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. Care management refers to patient-centric, healthcare planning. 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. Increase accuracy. o Continuity of care with a designated provider or care team member. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. 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). Share on Facebook. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. Park Business CentreHastingwood Industrial ParkWood LaneErdingtonBirminghamB24 9QR, Tel: 0121 386 6605 Fax: 0121 386 6709. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. While the vast majority of states that contract with MCOs report that the pharmacy benefit is carved in to managed care (34 of 41), six states report that pharmacy benefits are carved out of MCO contracts as of July 2022 (Figure 7). Share sensitive information only on official, secure websites. 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. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. https:// Care management teams cover a wide variety of responsibilities, all with the aim of managing patients healthcare needs, improving patient engagement and experience, and improving their overall health outcomes. Complex Case Management 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. 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. If goals have not been set already by the State legislature or Governor's office, Medicaid program staff should determine program goals based on the motivations for establishing a care management program. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. 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. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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. 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 . In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . 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. It is more important now than ever to carefully consider the health of your patients and to know what is care management. Receiving personalized attention from a Care Manager helps patients to better understand their health and subsequently be more engaged in their healthcare and feel more in control. .gov For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. 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%. Medicaid managed care: costs, access, and quality of care. Note: This brief was updated on March 1, 2023 to incorporate the latest available data. The program is intended to service Medicare patients with two or more chronic . confidential@caremanserve.com. Community support workers. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. 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). 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. California carved the pharmacy benefit out of managed care as of January 1, 2022. Rockville, MD 20857 Together with your Care team, he or she can oversee your needs and coordinate your care. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. 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. The Chronic Care Model. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. Care management services Care management is a program we make available to eligible members who may need help getting the care they need. 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. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. 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. VigilanceHealth.com. Not consenting or withdrawing consent, may adversely affect certain features and functions. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Establish program goals and identify short- and long-term objectives. 5600 Fishers Lane When the continuous enrollment provision ends and states resume disenrollments, Medicaid MCOs may see the overall acuity of their membership increase, with implications for per member utilization and costs, and the return of member churn (i.e., the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time). Based on program goals, program staff should develop a measurement and evaluation strategy. Identify interventions needed for patients. . 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. You and your care manager will work together to figure out the care and services you need to help you meet your health care goals. 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. Opt-out programs generally have higher member enrollment than opt-in programs. 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. It works by activating patients own motivation for change and adherence to their Doctor's directives. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Care management operates within healthcare systems. o Patient access to care management services 24/7. 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. Consider pilot testing to test intervention on a smaller scale. Short term help at home. Medicaid members covered. In response to the COVID-19 pandemic, states had options and flexibilities under existing managed care rules to direct/bolster payments to Medicaid providers and to preserve access to care for enrollees. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. B24 9QR. Team Around the Person co-ordinated support for adults. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. Considerations for developing a care management program. Medicaid waivers. Relevant Federal and State Authorities. States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. 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. Please be aware that although this email has restricted access, it is not . You'll get a care plan designed just for you. A parent firm is a firm that owns Medicaid MCOs in two or more states. In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. Community supports address social drivers of health and build on and scale . For general correspondence via email please use the following address. Meals on wheels. 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. Self-directed Medicaid services means that participants, or their representatives if applicable, have decision-making authority over certain services and take direct responsibility to manage their services with the assistance of a system of available supports. http://www.nasmd.org/waivers/waivers.htmll#1915b. 907-770-7525 or 888-578-2547. Tables displaying the FMAPs by State and the District of Columbia are available at: http://aspe.hhs.gov/health/fmap.html. 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. Availability of necessary staff and resources. Partnering with patients to ensure that all of their health care is effectively coordinated. . 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. Their experiences and understanding of their own limitations might help in the early planning stage.