Sign up to get the latest information about your choice of CMS topics. 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. Support of providers and patients. 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. 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. Increase accuracy. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. In 2022, CMS released guidance, reporting templates, and toolkits related to monitoring and oversight of Medicaid managed care programs. Consultation Services Payment Policy Effective October 1, 2019. Community supports address social drivers of health and build on and scale . 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. Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. 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. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. 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. Chronic Care Management. Assess financial environment to determine most appropriate program. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. 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. Twenty-Four-Hour Coverage for Tailored Care Management Providers AMH+ practices and CMAs must arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis, 24 hours per day, seven days per week. 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 . 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 . Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. website belongs to an official government organization in the United States. Care management programs often are linked with primary care case management (PCCM) programs or medical home initiatives, because Medicaid fee-for-service (FFS) might not offer the consistency of care typically provided at medical homes and necessary for successful patient interventions. However, there has been significant movement across states to carve these services in to MCO contracts. Please go to Section 8: The Care Management Evidence Base for more information on the related care management literature. Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. Sunshine Health is a managed care plan with a Florida Medicaid contract. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature. 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. Federal rules require that states establish network adequacy standards, but states have flexibility to define those standards. You can decide how often to receive updates. 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. 7500 Security Boulevard, Baltimore, MD 21244 . Limitations, co-payments and . 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). 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. Monday - Friday, 8:00am - 5:00pm AK Time. Coordinating services provided by the professionals involved in a recipient's care to work together to best meet health management goals. 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. The nature of the relationship to the patient is distinguishing factor between these terms. The program coordinates services between health care providers, community program and supports, and family support programs. Planning these components early will allow staff to design an appropriate care management program for their members. The provider's role in Superior's Care Management program is extremely important. In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. cost effective, non-duplicative 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. 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. Accessed July 26, 2007. 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. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. http://www.cms.hhs.gov/smdl/downloads/smd022504.pdf. Chronic care management (CCM) made its debut in 2015 when it was rolled out by the Centers for Medicare and Medicaid Services (CMS) as a separately paid service under the Medicare fee schedule. 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. 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). Dental Care Early and Periodic Screening, Diagnostic, and Treatment Hospice Benefits Mandatory & Optional Medicaid Benefits Prevention Telehealth Assurance of Transportation Prescription Drugs Branded Prescription Drug Fee Program Drug Utilization Review Federal Upper Limit Medicaid Drug Policy Medicaid Drug Rebate Program Pharmacy Pricing Their experiences and understanding of their own limitations might help in the early planning stage. Additionally, while we can track state requirements for Medicaid managed care plans, plans have flexibility in certain areas including in setting provider payment rates and plans may choose to offer additional benefits beyond those required by the state. The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. means youve safely connected to the .gov website. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. Reviewing formal evaluations of other States' programs. 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). Develop a measurement and evaluation strategy to demonstrate program value. Care management teams will usually assign one person or team member as the Care Manager to handle the patients needs. Although MCOs provide comprehensive services to beneficiaries, states may carve specific services out of MCO contracts to fee-for-service systems or limited benefit plans. dedicated employees ~56M. With 72% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs) nationally, plans have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the unwinding of the continuous enrollment requirement. 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. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. Published: Mar 01, 2023. 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 . 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. 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. Select and target populations to allocate resources most effectively. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). 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. A State must decide which population to target and how to identify and stratify members for enrollment into the program. The benefit information provided is a brief summary, not a complete description of benefits. 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). Providers of care and support. The program is intended to service Medicare patients with two or more chronic . An official website of the United States government 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. a Available at: Cecil G. Sheps Center for Health Services Research. The plan addresses the areas of administration, eligibility, service coverage, and provider reimbursement. 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. By easing the enrollment process, the opt-out model allows members to try the program even if they are hesitant. 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. 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." 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. Heres how you know. Nominate a social care worker for a dignity award. Identify interventions needed for patients. Rockville, MD 20857 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.) This revised product comprises Subregulatory Guidance for the Transitional Care Management Services and its content is based on publicly available content from the 2021 Medicare Physician Fee Schedule Final Rule https://www.federalregister.gov/d/2012-26900 & 2015 Medicare Physician Fee Schedule Final Rule The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . It is also contracting with a Pharmacy Pricing and Audit Consultant (PPAC) who provides operational and consulting support in the areas of pharmacy reimbursement, benefit design, oversight, and auditing. There's a change in your health status. Jada Raphael The relevant laws that come into play in the relationship between the State, the Managed Care Organizations (MCOs, including the HARPs), the Health Homes, the Care Management Agencies, the service providers and the recipients are as follows: The Health Insurance Portability and Accountability Act of 1996 . For more information on these topics, please go to Section 3: Selecting and Targeting Populations for a Care Management Program, Section 4: Selecting Care Management Interventions, Section 6: Operating a Care Management Program, and Section 7: Measuring Value in a Care Management Program. Share on Facebook. This does not apply to Carolina Access providers participating in the EBCI Tribal Option. 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. Accessed December 11, 2006. e Available at: National Association of State Medicaid Directors. o Patient access to care management services 24/7. B24 9QR. In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. This group, facilitated by CHCS . Please be aware that although this email has restricted access, it is not encrypted. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. or By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. .gov In addition to financial incentives, states can leverage managed care contracts in other ways to promote health equity-related goals (Figure 13). Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. 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. Case managers generally work indirectly with patients, often employed by healthcare facilities. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. 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). 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. Accessed February 11, 2008. d Available at: Centers for Medicare and Medicaid Services. Accessed December 11, 2006. f Available at: Centers for Medicare and Medicaid Services. For most states, the requirements for APMs were in the 25 50% range. 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 . Support of potential program partners, such as other State agencies and local organizations. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Content last reviewed October 2014. Official websites use .govA It is difficult to keep track of health conditions across multiple disciplines, as well as schedules, medications, appointments, etc. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. 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. Plan efforts to recruit and maintain their provider networks can affect enrollees access to care through factors such as travel times, wait times, or choice of provider. Birmingham. After approval of the original State plan, program staff must submit to CMS all relevant changes (required by new statutes, rules, regulations, interpretations, and court decisions) to determine whether the plan continues to meet Federal requirements and policies.