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. Similar to the Governor's office, the State legislature or individual legislators can greatly influence some of the key questions around a care management program's design, such as whether a mandatory savings requirement exists or whether the program can be operated in-house or with a vendor. MCOs represent a mix of private for-profit, private non-profit, and government plans. In FY 2022, similar numbers of states (about one quarter) reported requiring MCOs to have a health equity plan in place, meet health equity reporting requirements, and train staff on health equity and/or implicit bias. Signing this agreement allows practices to receive or continue to receive practice assignment data or quality data for NC Medicaid Direct beneficiaries. confidential@caremanserve.com. A State must decide which population to target and how to identify and stratify members for enrollment into the program. They may not be used to expand eligibility to individuals ineligible under the approved Medicaid State plan. Complex Case Management 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. Care management and case management are two terms frequently used interchangeably or confused due to their extremely similar names. A pilot can be approached by targeting one location, by using a regional rollout, or by focusing on a specific population. However, with an opt-in program, a stronger likelihood exists that the vendor will be able to engage most of the members successfully. If appropriate or adequate staff are unavailable, States can contract with a vendor, share staff with other State agencies, or partner with local organizations to perform needed services. We'll help guide your family through the healthcare system. http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf. Medicaid managed care: costs, access, and quality of care. .gov Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). Managed care is the dominant delivery system for Medicaid enrollees. In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Providing care for people living with chronic or complicated illnesses or conditions, is complex. Mandatory requirements include an increase of the look-back period for long-term care beneficiaries to 5 years and proof of citizenship for all new Medicaid applicants and current Medicaid beneficiaries. Filling the need for trusted information on national health issues, Elizabeth Hinton and The benefit information provided is a brief summary, not a complete description of benefits. PCCM is a managed fee-for-service (FFS) based system in which beneficiaries are enrolled with a primary care provider who is paid a small monthly fee to provide case management services in addition to primary care. 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. A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. States need a variety of staff to oversee and perform care management program operations, identify areas for improvement, and monitor the program. The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. As of July 2020, 57 million Medicaid enrollees received their care through risk-based MCOs. Control costs. Every care management program should have an overarching aim, which might be as simple as "to maximize the quality of life and promote a regular source of care for patients with chronic conditions." Care management integrates all of a patients healthcare needs into a single individualized care plan that is maintained by the Care Management in a system, such as the Incedo Care Management Solution. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes. There's a change in your health status. 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. 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). For more information on strategies to engage providers, please go to Section 2: Engaging Stakeholders in a Care Management Program. Program staff should assess the type of interventions appropriate for their care management program. Planning these components early will allow staff to design an appropriate care management program for their members. States often choose to implement a pilot of their care management program as a way to test the intervention on a smaller scale or if they have limited resources. The Incedo Care Management Solution is a platform that not only houses all necessary clinical information for each patient, but also supports a collaborative process of assessment, planning, care management and care coordination. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. Understanding available resources and considering program design options will help State Medicaid staff decide whether to move forward with a care management program, determine the most appropriate program design for the Medicaid population, and decrease the need for program refinements. 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 services. However, networks can be affected by overall provider supply shortages. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. Please be aware that although this email has restricted access, it is not . CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Skip to main content Our care managers help make health care easier and less overwhelming for our members. Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. State staff can learn from successes and "productive failures" of other State Medicaid care management programs. Develop a measurement and evaluation strategy to demonstrate program value. Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions. States also receive enhanced FMAPs for the State Children's Health Insurance Program under Title XXI of the Social Security Act. or As well as having ideas to share on clinical aspects of the care management program, large provider groups, hospitals, provider associations, and individual providers can serve as ambassadors to patients for the program. The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery . Creation of a "carve out" delivery system for specialty care, such as behavioral health care. Published: Mar 01, 2023. In FY 2021, state and federal spending on Medicaid services totaled over $728 billion. States reported setting different percentage requirements depending on the services and population served under the managed care contract.10 Thirteen states11 reported that their APM targets were linked to the Health Care Payment Learning & Action Networks (LANs) APM Framework that categorizes APMs in tiers.12, While there is some evidence of positive impacts from state use of financial incentives to engage managed care plans around quality and outcomes, the results are more mixed and limited at the provider level.13,14,15. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . The 2020 Medicare Physician Fee Schedule (the "Final Rule"), released on November 1, 2019, finalized two new codes in a new category of reimbursement titled "Principal Care Management" (PCM) Services. o Patient access to care management services 24/7. Social Determinants of Health. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives. Twenty-eight MCO states covered more than 75% of Medicaid beneficiaries in MCOs (Figure 2). Care management operates within healthcare systems. WellCare was acquired by Centene in January 2020. Heres how you know. o Care management for chronic conditions . For most states, the requirements for APMs were in the 25 50% range. 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). A parent firm is a firm that owns Medicaid MCOs in two or more states. After a State targets a specific population for its program, it should consider specific interventions that will prove most effective for that population. Select and target populations to allocate resources most effectively. ECM is a benefit that provides extra services to help you get the care you need to stay healthy. 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. Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. 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. 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. 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. Care management is a person-centered, coordinated strategy utilizing many aspects of the healthcare system. You can decide how often to receive updates. As of July 2021, about half of MCO states identified a specific target in their MCO contracts for the percentage of provider payments or plan members that MCOs must cover via APMs. 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. States that contract with managed care plans may also have uniform dollar or percentage increase payment requirements in place, most commonly for hospitals. How do we help? Communicating with hospital staffs, family doctors, specialists, etc. FAMCare automates casework with queued to-do lists, so nobody falls through the cracks. Secure Federal support and approval. 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. 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.
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