Vermont Chronic Care Initiative Enhanced Care Management (ECM) 1.hat W is Enhanced Care Management (ECM)? Sunshine Health is a managed care plan with a Florida Medicaid contract. Program staff also should consider factors such as target population, interventions, resource availability, time for a pilot program, and strategies for measurement and evaluation. 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. States should explore funding issues during program planning to determine the most appropriate program for their State. B24 9QR. 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). Chronic Care Management | Top Rated CCM for Healthcare Organizations 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. Learn . Care Management Entity - Wyoming Department of Health Transitional care management is a set of services that are provided for patients who have recently been discharged from the hospital. 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. Services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). State staff can learn from successes and "productive failures" of other State Medicaid care management programs. Care Management: Implications for Medical Practice, Health Policy, and Accessed July 26, 2007. Support of providers and patients. 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. Development of relationships with stakeholders, such as State legislators and their staff, the Governor's office, senior Medicaid leadership, and key Federal government staff. 7500 Security Boulevard, Baltimore, MD 21244 . The goal of TCM is for a provider to "oversee management and coordination of services, as needed, for all medical . In doing so, program staff will be better equipped to tailor appropriate interventions and resources to impact members most effectively. Case Management | Provider Resources | Superior HealthPlan Case Management Services - Alaska While the care is individualized, care management as an overarching strategy also provides benefits for wider populations. 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. Relevant Federal and State Authorities. A geriatric care manager, usually a licensed nurse or social worker who specializes in geriatrics, is a sort of "professional relative" who can help you and your family to identify needs and find ways to meet your needs. By involving consumers during the planning, implementation, and evaluation stages, program staff will be better able to gauge the possible impact of certain interventions and will be able to design a better, more effective program overall. Transitional Care Management Services | Guidance Portal - HHS.gov Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population. Select program model based on available staff and resources. 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. If you treat complex patients, chances are that social determinants of health (SDOH) are impacting your revenue stream. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Chronic pain and disease. 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. Medicaid Authorities and Options to Address Social Determinants of Linking a care management program with other Medicaid initiatives can increase the effectiveness of both programs. 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. 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. The new codes will be effective as of January 1, 2020, and provide reimbursement for managing a patient's care for a single high-risk disease or complex chronic condition. 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. Rockville, MD 20857 Chronic Care Management (CCM) | AAFP 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. 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 . 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). 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. Over three quarters of MCO states reported using at least one financial incentive to promote quality of care as of July 2021 (Figure 11). http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/01_Overview.asp. The Chronic Care Model. Medicaid and Social Determinants of Health - RWJF Consultation Services Payment Policy Effective October 1, 2019. In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. Two states report plans to carve out pharmacy from MCO contracts in FY 2023 or later (New York6 and Ohio7). Children's Medical Services Health Plan | Sunshine Health 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, . or In opt-out programs, members are enrolled automatically but have the option to disenroll themselves. For a patient to fully access all the advantages care management has to offer, some essential aspects must be present. Most States implement a program based on some combination of the following three reasons: States usually establish care management programs to meet multiple needs. Innovative MCO Eastpointe Human Services Launches Care Management In this model, States might assume that all of the members enrolled want to improve their health conditions through program participation. Considerations for developing a care management program. These requirements apply to both capitated and fee-for-service disease management providers. 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). Input from potential partners who will assume responsibility for implementing the program should be solicited as early as possible. By involving providers, States can improve program outcomes and physician practice in addition to building support for the care management program. We work with youth between the ages of 5 and 21, who have a qualifying mental health diagnosis or other chronic condition that affects their daily functioning. Of these states, about half reported that their MCO contracts included incentives or penalties for meeting or failing to meet APM targets. Engaging patients also can help program staff understand the program's effects on consumer behavior and identify areas for program improvement. 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. 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. This group, facilitated by CHCS . Medicaid programs that implement care management programs to meet multiple needs should understand the probable short-term and long-term results. The Deficit Reduction Act (DRA), passed in 2007, provides States additional flexibility to make changes to their Medicaid programs. Jim is Deloitte Consulting LLP's Medicaid Advisory Services lead. Previously Pennsylvania's Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. 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. 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 AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. 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 . As a result, most programs target specific populations because they are more "impactable.". What is Care Management | Health Services Management - InfoMC Careful program planning is critical to the success of the next stages of designing, implementing, and evaluating the impact of a care management program. Addressing their health concerns from a holistic point of view, integrating physical, behavioral, and social health improves overall well-being. 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. CMS Guidance: Primary Care Case Management Reporting, Updated | Medicaid Tailored plans will provide specialized services and care management to meet the needs of these individuals. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. For example, a State might want to improve the quality of care provided to beneficiaries with chronic conditions while containing costs in response to a legislative mandate. means youve safely connected to the .gov website. Content last reviewed October 2014. Managed care is the dominant delivery system for Medicaid enrollees. Comprehensive Care Management The Bridge Inc. Exhibit 1.1 provides information on ways to secure CMS approval through waivers, SPAs, and the Deficit Reduction Act. Speaking with colleagues in other States to better understand their programs. Care management refers to patient-centric, healthcare planning. 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 . Of the 14 parent firms, six are publicly traded, for-profit firms while the remaining eight are non-profit companies. Engage stakeholders to build program support. Secure Federal support and approval. Likewise, Virginia sets a lower percentage (10%) for its MLTSS program, Commonwealth Coordinated Care Plus, than for its Medallion 4.0 Medicaid physical and behavioral health managed care program that serves the states low-income children and families and the APM target is set at 25%. It is a comprehensive framework that enables care teams to address the physical, behavioral, and social needs their patients.

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