In December 2022, CMS released guidance about how states can address HRSN through Section 1115 demonstration waivers. 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. Availability of necessary staff and resources. 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. Only 16 MCO states reported coverage of 75% or more of adults ages 65+ and people eligible through disability. States should coordinate and communicate routinely with these stakeholders. In situations where Medicaid staff develop the program, program staff should involve senior leadership as early as possible to help shape expectations. The rationale behind its inception was to offer an avenue of compensation for practitioners who provided care to their patients outside of the normal confines of the average office visit. 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 . Upcoming Managed Care Organization Contract Changes Effective September 1, 2019. Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. WellCare was acquired by Centene in January 2020. 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. Please go to Section 6: Operating a Care Management Program for additional information on pilot care management programs. This role is responsible for providing leadership and direction to a large team of clinical . Referrals to community resources, specialists, counseling and a social worker Educational materials Follow-up calls and home visits will be scheduled, as needed How do I get more information? An SPA authorized under section 1932(a) of the Social Security Act provides much of the same flexibility available under waivers and also does not require the periodic renewals associated with programs operating under waiver authority. The week of October 11, Carolina Access practices will receive a new PCCM agreement from CCNC. As a result, during the planning stage, program staff should work with CMS staff, both at the regional and national levels, to solicit feedback and understand the type of authority that must be used to implement certain care management program components versus others. 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 should explore funding issues during program planning to determine the most appropriate program for their State. Since care management is a comprehensive coordination system, it benefits from fully understanding a patients individual situation and subsequent needs. Considerations for developing a care management program. If you continue to use this site we will assume that you are happy with it. 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. 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. 6 To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. The CCM program provides help for a person to. 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. Care management operates within healthcare systems. Therefore, approval procedures are individualized, usually depending on the care management program model. 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. 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. Support of potential program partners, such as other State agencies and local organizations. Building relationships with patients and caregivers, Administering assessments and developing individualized care plans, Connecting patients and caregivers to social and community support services, Establishing relationships with patients physicians and other providers, Facilitating administrative communication between healthcare providers, Monitoring care gaps and ensuring appointments are scheduled and kept, Comparing current care with proposed services. Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff. 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. 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. 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. Not consenting or withdrawing consent, may adversely affect certain features and functions. 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. lock In creating new care management programs or considering expansions to current programs, States have a wide variety of options. For general correspondence via email please use the following address. 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. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care and costs is both limited and mixed.3,4,5. California carved the pharmacy benefit out of managed care as of January 1, 2022. Under federal law, payments to Medicaid MCOs must be actuarially sound. Tel: 0121 386 6605 Fax: 0121 386 6709. More than half of MCO states reported requiring MCOs to screen enrollees for social needs, screen enrollees for behavioral health needs, provide referrals to social services, and partner with community-based organizations (CBOs). Similarly, case management also involves care planning. Understanding competing priorities will help State staff synchronize efforts between programs and increase program effectiveness. States should consider expectations from Medicaid and agency leadership during the initial planning stage to ensure their support. Creation of a "carve out" delivery system for specialty care, such as behavioral health care. 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. If they operate a Medicaid managed care program, states can require Medicaid managed care organizations (MCOs) to connect beneficiaries to social supports as part of their care management obligations. The current Administration has identified advancing health equity as an important priority for the Medicaid program. Medicaid Care Management (MCM), or managed care, delivers New Hampshire Medicaid health benefits and additional services through contracts between the Department of Health and Human Services (DHHS) and managed care organizations (MCOs) or Medicaid Health Plans. CCM allows healthcare professionals to be reimbursed for the time and resources used to manage Medicare patients' health between face-to-face appointments. Chronic pain and disease. 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. Innovative solutions for better health outcomes. 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. Active Medicaid coverage. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023. In FY 2022, states reported a range of state-mandated PIP focus areas with an emphasis on reducing disparities and improving health equity including related to maternal and child health; diabetes education and management; substance use disorder (SUD); and access to culturally and linguistically appropriate services. 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). At least one of the following: two or more chronic conditions (substance use disorder, diabetes, heart . This section provides the Secretary of Health and Human Services authority to grant waivers that allow States to implement managed care delivery systems or limit individuals' choice of provider under Medicaid. Community supports address social drivers of health and build on and scale . 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. Establish program goals and identify short- and long-term objectives. The program is intended to service Medicare patients with two or more chronic . A smaller, more focused project will allow State staff to thoroughly assess the pilot and make improvements to the program as it is expanded. . A State administering or operating a care management program should ensure that it has the internal capacity and budget to hire necessary personnel. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability. An integral part of any care management program is a thorough understanding of the population it will affect. o Patient access to care management services 24/7. The implementation was completed on a condensed timetable that has Eastpointe well-prepared for the state's transition to Medicaid managed . 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. 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. Subsequently, staff can define program success as a decrease in the number of school days missed due to illness. VigilanceHealth.com. Care management services Care management is a program we make available to eligible members who may need help getting the care they need. 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.
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