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. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. 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. Beginning July 1, 2021, North Carolina implemented its first MCO program, enrolling more than 1.8 million Medicaid beneficiaries in MCOs as of January 2023. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). lock The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . Addressing their health concerns from a holistic point of view, integrating physical, behavioral, and social health improves overall well-being. 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. Considerations for developing a care management program. Determine program interventions that will be most effective for selected populations. website belongs to an official government organization in the United States. These requirements apply to both capitated and fee-for-service disease management providers. State Medicaid Director Letter: Guidance on how States can cover disease management. Garnering support from leadership and other stakeholders, developing realistic program expectations early in the process, and designing a strategic evaluation process affect program success and sustainability significantly. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . For example, the goal of the care management program might be to increase the quality of life for program members. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. For general correspondence via email please use the following address. 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). Your patients may already be working with one of our care managers. States should consider relevant components from multiple States and develop a care management program best suited to that State's individual needs while building on the experiences of other State Medicaid programs. Chronic pain and disease. 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. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). Relevant Federal and State Authorities. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) . Content last reviewed October 2014. Increase accuracy. 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. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. Meals on wheels. Participate in reporting and data exchange included in the program. 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. As a result, most programs target specific populations because they are more "impactable.". The provider's role in Superior's Care Management program is extremely important. By understanding a persons complete medical history, current conditions, behavioral health, and other relevant factors, the most effective healthcare plan can be created. 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, . 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. 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%. Senior leadership within the Medicaid program, its umbrella agency or department, and the Governor's office might have specific program goals that program staff must understand as they plan and develop the program. 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 . Five firms UnitedHealth Group, Centene, Anthem (renamed Elevance in 2022), Molina, and Aetna/CVS each have MCOs in 12 or more states (Figure 8) and accounted for 50% of all Medicaid MCO enrollment (Figure 9). Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Please go to Section 5: Selecting a Care Management Program Model for more information. Care Management Complaints, Grievances and Plan Appeals Disease Management Emergency Situations EPSDT Program Fraud, Waste and Abuse Get the Most from Your Coverage Interoperability and Patient Access Key Contacts Member Handbook LTC Newsletters Member Rights and Responsibilities Non-Discrimination Notice Prior Authorization 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. Dedicated planning can help a State consider various program design options, assess existing internal resources and capacity, and understand the needs of Medicaid members. Section 1905(b) of the Social Security Act specifies the formula for calculating FMAP. Please be aware that although this email has restricted access, it is not encrypted. 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. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. The current Administration has identified advancing health equity as an important priority for the Medicaid program. 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. Medicaid waivers. It coordinates the care you get from different doctors. 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. 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. 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 . 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). 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. 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. CMS might also be able to provide points of contact in other States to share their SPA or waiver documents. Res. Improving Chronic Illness Care. Comagine Health. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. 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. Understanding the other programs the State is already operating ensures that the care management program is not duplicating efforts and encourages sharing of ideas. CMS has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements, including guidance outlining how managed care plans can support states in promoting continuity of coverage. If you still need help, call the Office of the HHS Ombudsman at 866-566-8989. 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. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. info@caremanserve.com. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. MCOs represent a mix of private for-profit, private non-profit, and government plans. States incorporate quality metrics into the ongoing monitoring of their programs, including linking financial incentives like performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. 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. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Senior leadership might also have areas and directions that they have no interest in pursuing. Assessing various risks in the patients home and environment, Improves coordination of necessary healthcare, leading to better quality care, Patients feel understood, listened to, and properly cared for. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Similarly, case management also involves care planning. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. While MCOs are the predominant form of Medicaid managed care, millions of other beneficiaries receive at least some Medicaid services, such as behavioral health or dental care, through limited-benefit risk-based plans, known as prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs). Under federal law, payments to Medicaid MCOs must be actuarially sound. Your Medicare Coverage Principal care management services Principal care management services Medicare Part B (Medical Insurance) covers disease-specific services to help you manage a single, complex chronic condition that puts you at risk of hospitalization, physical or cognitive decline, or death. Incentive Payment Program. You can email in confidence to Senior Management at Care & Management Services Limited. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. 5600 Fishers Lane Rockville, MD 20857 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. These specially trained professionals can help find resources to make your daily life easier. 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. Establish program goals and identify short- and long-term objectives. 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. Accessed November 12, 2007. b The Federal Medical Assistance Percentages (FMAP) are used in determining the amount of Federal matching funds for Medicaid expenditures. Managed care is the dominant delivery system for Medicaid enrollees. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. States should coordinate and communicate routinely with these stakeholders. Understand motivations for establishing program. 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. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. 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. 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. ( 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. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. Care management attempts to reduce the need for more intensive services and therefore costs by preventing more serious illnesses.