Care managers are responsible to collaborate with the care team and coordinate all necessary healthcare services and supports, including preventative care measures and community-based services. 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 . Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. B24 9QR. 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. 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 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 . VigilanceHealth.com. o Care management for chronic conditions . The program coordinates services between health care providers, community program and supports, and family support programs. Medicaid State Waiver Demonstration Projectsgeneral information. COPD. Encouraging patients with chronic diseases to enroll in the Connect CARRE Choice program. Increase accuracy. ) 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. To find out if you are eligible for NH Medicaid Care Management, visit NH EASY. Care Management is a free and voluntary service for Medicaid recipients who may need additional support navigating the health care system to meet a child's medical and behavioral health needs. An integral part of any care management program is a thorough understanding of the population it will affect. 907-770-7525 or 888-578-2547. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. 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. Other State agencies, such as the Department of Health or the Department of Education, might be stakeholders. It is available for both adults and children. Reviewing formal evaluations of other States' programs. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. The 2020 CMS Medicaid managed care final rule removed the requirement that states use time and distance standards to ensure provider network adequacy and instead lets states choose any quantitative standard. Preventative care is a core tenet of care management. Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM). 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. 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. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Under federal law, payments to Medicaid MCOs must be actuarially sound. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Determine program interventions that will be most effective for selected populations. o Patient access to care management services 24/7. Res. The program is intended to service Medicare patients with two or more chronic . 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. There's a change in your health status. 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. For general correspondence via email please use the following address. Accelerate claims processing. For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. Incentive Payment Program. 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. Internet Citation: Section 1: Planning a Care Management Program. a Available at: Cecil G. Sheps Center for Health Services Research. California carved the pharmacy benefit out of managed care as of January 1, 2022. Tailored plans will provide specialized services and care management to meet the needs of these individuals. These requirements apply to both capitated and fee-for-service disease management providers. (805) 823-0981. contact@vigilancehit.com. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. website belongs to an official government organization in the United States. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html. Support of providers and patients. An SPA may authorize disease management activities through expansions of the covered benefits for "other licensed practitioners" or "preventive services," as appropriate. For more information on patient activation strategies, please go to Section 2: Engaging Stakeholders in a Care Management Program. 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. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. 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. We assist you with scheduling the variety of appointments that your child may have to meet their needs. Birmingham. If you have any questions, please do not hesitate to contact us today! 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/. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . 7500 Security Boulevard, Baltimore, MD 21244 . 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, . 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. After considering each of the issues outlined above, program staff should answer the following questions in determining whether and how to proceed with a care management program. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states . means youve safely connected to the .gov website. The current Administration has identified advancing health equity as an important priority for the Medicaid program. A key challenge that States must address is targeting resources most effectively for members who are presently high risk and impactable versus members who might be low risk or medium risk currently but who can be prevented from migrating to high risk. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. lock 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. Attending national health policy meetings, such as meetings sponsored by the National Association of State Medicaid Directors, National Academy for State Health Policy, National Conference of State Legislatures, National Governors Association, or the Disease Management Association of America. States might consider implementing a care management program for a variety of reasons. Sparer M. 2012. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for more information on identification and stratification strategies. 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. The benefit information provided is a brief summary, not a complete description of benefits. 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. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. Assessing other social factors impacting health such as access to transportation, food and social connections that can impact wellbeing. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. 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. States should explore funding issues during program planning to determine the most appropriate program for their State. 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. As part of managed care plan contract requirements, state Medicaid programs have also been focused on the use of alternative payment models (APMs) to reimburse providers and incentivize quality. 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. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. RESTON, Va., July 8, 2020 /PRNewswire/ -- Altruista Health and North Carolina's Eastpointe Human Services today noted Eastpointe's successful launch of Altruista's care management technology, supporting whole-person care for Medicaid members in 10 counties.