o Care management for chronic conditions . Birmingham. Care managers establish direct relationships with patients, at times representing them as care is planned and coordinated. Our Care Management program is free and voluntary. Res. 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 . Program staff should assess the type of interventions appropriate for their care management program. Providing care for people living with chronic or complicated illnesses or conditions, is complex. Kansas' model assists providers in implementing evidence-based treatment plans while supporting members to better manage their health care choices. Transitional Care Management Program Effective September 1, 2019. Integrating Social Supports Into Health Plan Care Management. 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/. 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. 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. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. http://www.nasmd.org/waivers/waivers.htmll#1915b. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. State Medicaid Director Letter: Guidance on how States can cover disease management. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. CMS allowed states to modify managed care contracts in response to unanticipated COVID-19 costs and conditions that led to decreased utilization. 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. Medicaid Management. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. Encourage members to take advantage of the program. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. B24 9QR. States should coordinate and communicate routinely with these stakeholders. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. 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. An important consideration that will affect how programs approach and enroll their members is whether the program is opt-in or opt-out. Speaking with colleagues in other States to better understand their programs. Fewer states reported requiring MCO community reinvestment (e.g., tied to plan profit or MLR) compared to other strategies. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. 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. This group, facilitated by CHCS . 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. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Innovative solutions for better health outcomes. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. 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). States should explore funding issues during program planning to determine the most appropriate program for their State. However, networks can be affected by overall provider supply shortages. Care management is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." 3 It also encompasses those care coordination activities needed to help manage chronic illness. Care Management Services. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. 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. An integral part of any care management program is a thorough understanding of the population it will affect. 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. As of July 2022, 36 MCO states reported covering 75% or more of all children through MCOs (Figure 3). Select program model based on available staff and resources. Published: Mar 01, 2023. You can decide how often to receive updates. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. Partnering with patients to ensure that all of their health care is effectively coordinated. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. Sunshine Health is a managed care plan with a Florida Medicaid contract. 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). Managing your child's medical issues can be hard. 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. Specifically, among other requirements, the DRA allows States to impose cost-sharing requirements on services such as prescriptions, increase copayments on emergency services, and alter existing Medicaid benefits packages to mirror certain commercial insurance packages through use of "benchmark" plans. Under federal Medicaid managed care rules, Medicaid MCOs can be given flexibility to pay for non-medical services through "in-lieu-of" authority and/or "value-added" services. 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). Coordinating and managing health care for complex patients is a complicated task, but organizations like InfoMC have innovated to provide solutions for care teams to serve those in need more efficiently. In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). BHSN's Care Management Program consists of Health Home Care Management for Medicaid clients, as well as Non-Medicaid Care Coordination services. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. 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. lock The Chronic Care Model. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. Internet Citation: Section 1: Planning a Care Management Program. Official websites use .govA Team Around the Person co-ordinated support for adults. The Care Manager will be able to answer patient questions and complete requests for care. 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. Medicaid waivers. At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . VigilanceHealth.com. or website belongs to an official government organization in the United States. To learn more, call the NC Medicaid Ombudsman toll free at 1-877-201-3750 , 8 a.m. to 5 p.m., Monday through Friday, except state holidays. o Continuity of care with a designated provider or care team member. 4.3 (18) FAMCare is powerful, cloud-based case management software for human services agencies who are looking to manage cases faster and make data reviews and reporting simpler to allow you to help more clients. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. 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. . What Does Successful Care Management Look Like? Four types of authorities exist under Section 1915(b) that States may request: The State Medicaid plan is a document that defines how the State will operate its Medicaid program. 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. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. This review discusses the application of the chronic care model in the care of complex diabetes and its translation in the current reimbursement structure designed by Centers for Medicare and Medicaid Services (CMS). Providers of care and support. The CCM program provides help for a person to. 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. 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. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. If you don't know who your Care Manager is, please call Member Services at 1-855-475-3163 (TTY: 1-800 . The technical storage or access that is used exclusively for statistical purposes. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. Similarly, case management also involves care planning. 1 Care Management Framework The following framework (see other side) outlines . Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Opt-out programs generally have higher member enrollment than opt-in programs. 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. Care Management Triage medical needs, validate medical necessity and efficiently coordinate patient care throughout the path to recovery Navigating the healthcare system can be daunting for those with new healthcare needs or a surprise workplace injury. Chronic Care Management Services Fact Sheet (PDF) Chronic Care Management Frequently Asked Questions (PDF) .