Appendix
6
Materials for Pennsylvania Leadership
Workshop 2
This
document was prepared for the Second
Roundtable on Children’s Health and
Managed Care to be held on May 10,
2005 in Harrisburg, Pennsylvania.
The more than 35 senior policy makers
and professionals attending the workshop
will discuss approaches to care coordination
for children enrolled in Medicaid
and SCHIP health plans. These documents
have not been endorsed by Federal
or State officials. The workshop was
based on work by Johnson Group Consulting
and the George Washington University
(GWU). This work is being conducted
with support from the Maternal and
Child Health Bureau (MCHB), Health
Resources and Services Administration
(HRSA), U.S. Department of Health
and Human Services. Thanks to the
Pennsylvania Perinatal Partnership
and other volunteer leaders on the
steering committee that designed this |
Pennsylvania Second Roundtable
on Children’s Health and Managed
Care
Topic: Care Coordination for Children
with Special Health Care Needs
May 10, 2005
Goal of the roundtable: To
begin development of a uniform care coordination
approach for
children with special health care needs
(CSHCN).
Whether Medicaid/EPSDT “case-management,”
Title V CSHCN “care coordination,”
the SCHIP
program, an AAP medical home project,
or managed care strategies, Pennsylvania
can do more to assist
families in meeting the needs of their
children, linking across service delivery
systems, and managing
care to reduce unnecessary spending. This
Roundtable is focused on identifying strategies
to improve
cross-system supports and build a common
framework for serving CSHCN.
There is no single definition of children
with special health care needs that is
commonly accepted.
Definitions vary among States (e.g., definitions
used by a state Title V agency may vary
from that used by
the same state's Medicaid agency). For
this Roundtable discussion, CSHCN are
defined as: “Children
who have or are at increased risk for
chronic physical, developmental, behavioral,
or emotional conditions
and who also require health and related
services of a type or amount beyond that
required by children
generally.”1
This definition is broad, incorporating
children with a range of conditions and
risk.
Recent national data and special initiatives
across the country indicate the following:
- An
estimated 12.8 percent – 9.4 million
– children under age 18 in the
United States have special
health care needs, and CSHCN needs are
present in 20 percent of U.S. households
with children.
- On
average, parents rated the severity
of their children’s conditions
as 4.2. This average rating
was higher for CSHCN in families with
incomes below the poverty level (5.3)
and lower among
CSHCN in families with incomes of 400
percent of poverty or more (3.5).
-
Among children with special health care
needs living in poverty, 40 percent
need emotional,
behavioral, or developmental services,
compared to 23 percent in higher-income
families.
-
Findings from a national survey indicate
that 8 percent of parents cited financial
problems as the
main reason that health care for their
CSHCN had been delayed or forgone in
the previous 12
months.
-
For pediatrics, the standard of care
for children with special health care
needs is that of a
“medical home” – an
approach to providing care that is accessible,
family-centered,
comprehensive, continuous, coordinated,
compassionate, and culturally competent.
-
Pilot projects coordinated by the Center
for Health Care Strategies found that:
overlapping care
coordination programs led to increased
costs and confusion, specific screening
tools and
protocols were effective, and effective
education and informing for parents
was essential.
This
document was prepared for the Second
Roundtable on Children’s Health and
Managed Care to be held on May 10,
2005 in Harrisburg, Pennsylvania.
The more than 35 senior policy makers
and professionals attending the workshop
will discuss approaches to care coordination
for children enrolled in Medicaid
and SCHIP health plans. These documents
have not been endorsed by Federal
or State officials. The workshop was
based on work by Johnson Group Consulting
and the George Washington University
(GWU). This work is being conducted
with support from the Maternal and
Child Health Bureau (MCHB), Health
Resources and Services Administration
(HRSA), U.S. Department of Health
and Human Services. Thanks to the
Pennsylvania Perinatal Partnership
and other volunteer leaders on the
steering committee that designed this
Roundtable. |
Summary of the Second Pennsylvania
Roundtable on Child Health and Managed
Care: Care
Coordination
for Children with Special Health Care
Needs
Welcome and Introductions
The meeting began with a welcome from
Cheryl Squire-Flint, Healthy Start Pittsburgh,
and Pat Yoder,
Chester County Health Department, representing
the Pennsylvania Perinatal Partnership
and local public
health leadership in maternal and child
health. They described how this second
roundtable was designed
as a follow-up to the first roundtable
held in March 2004. The agenda for the
day was designed to offer an
array of perspectives on strategies for
enhancing care coordination for CSHCN.
The next speaker, representing the Pennsylvania
Secretary of Health, was Melita Jordan,
director of the
Bureau of Family Health and the designate
Title V program director for Pennsylvania.
Ms. Jordan
described the Title V mission and Federal-State
partnership. More specifically, she described
the
mandate under Title V to designate 30
percent of the State’s block grant
allocation to serving children
with special health care needs and their
families. In Pennsylvania, program activities
include:
comprehensive specialty care, Parent-to-Parent
support groups, a medical home initiative,
and other
projects and services. In terms of direct
medical services, the State supports staff
in each of the six
community health districts. Ms. Jordan
also reported on the results of a study
by Health Systems
Research, which found that: a) those covered
by Medicaid faced access problems outside
urban areas; b)
no mechanisms exist to link various systems
of care; c) provider payments and continuity
of care continue
to be important issues; and d) older CSHCN
are more likely to lack access to care
and need more
transition assistance.
Representing the Pennsylvania Department
of Public Welfare (DPW), Suzanne Campbell,
told the group
that that DPW welcomed ideas for improving
service delivery. She also encouraged
the group to think
about ways to increase efficiencies in
the current budget climate.
Perspectives
on the Challenge
Kate Maus, MCH leader for the Philadelphia
Department of Public Health, described
her experiences in
coordinating resources for CSHCN at the
local level. For example, care coordinators
in Philadelphia have
to manage: the interface among five tertiary
care hospitals, multiple specialty physicians,
Medicaid
eligibility staff; multiple health care
coordination projects, and managed care
special needs units, as well
as providers from mental health, education,
early intervention, childcare, and child
welfare systems. Ms.
Maus described the contrast between what
exists today and the dream of family-centered
care. She
described the vision of parents of children
with special needs as: “Nothing
about me without me.”
Speaking as an affected and concerned
parent of a child with special health
care needs, Melissa Parsons
described the challenges she faces in
coordinating care across medical and social
systems for a young
child with a chromosomal disorder that
affects multiple body systems. Despite
ongoing support from
Healthy Start, Mrs. Parsons has faced
challenges throughout her child’s
first two years, negotiating
through multiple surgeries, eleven doctors,
many specialty evaluations, early intervention
services, and
related support services.
Panel Presentations on Program
Models in Pennsylvania
-
SECCS Grant, Barbara Caboot,
Department of Health –
All State Title V programs
have used State Early Childhood Care
Systems (SECCS) grant funding to plan
for improved
linkages among early childhood health,
welfare, and education systems. Pennsylvania,
now in
the second year of the planning phase,
has done a gap analysis. Other potential
future activities
include: development of a system and/or
finance map, implementation of integrated
programs or
funding strategies, and reorganization
of administrative functions for early
childhood programs.
Efforts to better integrate care coordination
for CSHCN could be a focus for future
efforts.
-
Medical Home Initiative - Alan
Kohrt, MD, and Molly Gato, PA Chapter,
American
Academy of Pediatrics –
The American Academy of Pediatrics has
advanced principles for
providing a medical home to every child
with special health care needs. HRSA’s
Maternal and
Child Health Bureau (MCHB) and States
have supported model program initiatives
to advance
the concept of a medical home. Dr. Kohrt
described the current efforts in this
State. In
Pennsylvania, 26 physician (pediatrician)
practices currently are implementing
the medical home
model in the context of learning collaborative.
Additional practices are being added
incrementally. Each practice identifies
a family partner, quality improvement
team leader, and
care coordinator who work together to
change practice behavior. For 16 of
these practices, such
efforts are supported by small grants
($5,000 - $10,000). Molly Gato described
how outcomebased
data are being collected (through a
new time-tracking form and a patient
database) for the
purpose of evaluating change. The medical
home model is central to the discussion
and design of
a more uniform approach to care coordination
for CSHCN.
-
HIV/AIDS Case Management Model
– Dorothy Mann, Family Planning
Council –
Lessons learned from the HIV-AIDS program
case-management approach operating in
Philadelphia since the 1980s are useful
in the context of care coordination
for CSHCN. Ms.
Mann described how the State uses standardized
qualifications to certify case managers,
who, in
turn, can be hired by local service
agencies. In Southeastern Pennsylvania,
three managed care
organizations contract with these local
service agencies, despite the fact that
they could opt to do
this case management internally. Ms.
Mann described this HIV/AIDS case management
as
tailored to individual needs and functioning
as care coordination for outpatient
services. Current
reimbursement is $35 per hour, with
case managers carrying an average caseload
of 25
individuals/families. No evaluation
of the HIV model has been conducted.
-
Assessment of Office-based vs.
Community-based Care Coordination –
Ed Spahr,
MD, Department of Health –
Dr. Spahr described the medical home
training project operated
by the Department of Health. He also
discussed the attributes of office-based
versus communitybased
approaches to care coordination. Finally,
he stressed the importance of measuring
family
satisfaction, including measures to
capture perceptions of the degree to
which care coordination
results in services that are family
centered, culturally competent, and
well coordinated.
-
Current Managed Care Contracts
– Allison McCanemy, Department
of Public
Welfare – In Pennsylvania,
as in most States, Medicaid uses several
types of managed care
arrangements, including full-risk capitated
HMOs and primary care case management
(PCCM).
DPW has contracts with private consultants
to implement chronic disease management
projects,
which include asthma in children. These
projects are designed to test the impact
of a system of
rewards and incentives for improved
quality and effectiveness in chronic
disease management.
In addition, Ms. McCanemy said, in the
context of full-risk contracts, Medicaid
managed care
organizations have responsibility for
operating “special needs”
case management/care
coordination units. Questions have been
raised about the role of these units,
that is, whether they
are charged with family-focused care
coordination or plan-focused cost containment.
Also,
anecdotal evidence suggests that some
families mistrust these HMO-operated
units.
-
Care Coordination Model –
Loware Holiman, Department of Insurance
– The
Department of Insurance (DOI) operates
the State Children’s Health Insurance
Program (SCHIP)
plan in Pennsylvania, which is designed
similar to a standard Blue Cross/Blue
Shield private plan.
Ms. Holiman reported that SCHIP does
not currently use a care coordination
model and lacks
data to monitor such services. The State’s
SCHIP plan does use HEDIS indicators
and data to
monitor program/plan performance. Right
now, DOI is investigating the higher
than average use
of Emergency Room services by covered
children. They also have survey data
indicating that 92
percent of children in SCHIP have an
identified regular source of care (a
doctor or a nurse).
Lunchtime Presentation: What can
we learn from other states?
Kay Johnson, Johnson Group Consulting
Ms. Johnson gave a presentation about
what other States are doing to improve
care coordination for
CSHCN, particularly through the lens of
Medicaid and Medicaid managed care. She
briefly described
other States approaches, particularly
SECCS planning grants and AAP/MCHB medical
home initiatives,
stating that Pennsylvania has undertaken
many of the same projects and activities
as other States. For
example, North Carolina and other States
have developed data collection and referral
forms similar to the
one being tested in pediatric practices
in Pennsylvania. Other States, such as
Colorado and Connecticut
have used their SECCS planning process
and medical home initiatives to achieve
greater coordination and
support services for CSHCN. Ms. Johnson
also set out a framework for thinking
about these issues. She
clarified that Medicaid does not finance
a category called “care coordination”
but does have several types
of case management benefit categories
that States can use. One important category
is “targeted case
management,” which is an optional
benefit category financed at the State’s
medical assistance matching
rate. Other categories are administrative
case management, which qualify for the
50/50 administrative
matching rate. Both categories may be
or have been used by other States to finance
support services for
CSHCN. This is only possible, however,
where clear definitions and specific dollars
have been
identified. Ms. Johnson concluded by encouraging
the group to acknowledge that lack of
shared
definitions (and not financing) were the
greatest obstacles to achieving their
goal of better integrated care
coordination for CSHCN.
[D]
Summary
of Discussion regarding Care Coordination
for CSHCN
-
Participants discussed the need to define
and achieve greater consensus
on the vision for what
they are hoping to achieve through care
coordination.
-
The characteristics of care coordination
they envisioned would ideally:
- make one individual the primary point
of contact;
- assign one individual to each family
as the primary care coordinator;
- be responsible for cross-system linkages;
- use existing resources;
- provide more than just benefits management;
- offer a variety of entry points;
- be independent (of providers or payors);
- be able to be varied by intensity
& need (not one size fits all);
- link to medical home (e.g., through
paper reports, co-location); and
- have accountability (e.g., data reporting,
grievance procedures).
-
The group also identified a basic
set of principles, including
many often cited as essential for
CSHCN and their families and other desirable
characteristics more related to public
administration. They suggested services
should be: safe, effective, efficient,
timely, equitable,
unduplicated, family-driven and family-centered,
and culturally competent.
-
The Roundtable participants discussed
the need for a shared definition
of care
coordination/case management
for CSHCN. In order to be useful
for policy and finance
discussions, this definition must be
one that can be operationalized and
would include:
- provider qualifications;
- certification standards;
- outcome and process measures/benchmarks;
- criteria for service eligibility (i.e.,
which children/families have need for
this service).
-
The group also saw a need to
quantify the need and assess gaps in
funding and services.
Specific questions that need to be addressed
include: a) how many children by age,
type of
condition/severity, and level of need
of family, b) how many dollars are now
being spent on care
coordination for CSHCN, and c) how many
existing providers are available to
deliver these
services?
Discussion of Opportunities for Action
The Roundtable participants discussed
two types of next steps. First, the group
“brainstormed” about
what type of activities might continue
the momentum generated during the Roundtable
and lead to
progress in improving care coordination
for CSHCN. The main ideas were:
-
prepare a fact sheet summarizing the
current situation and making the case
for change;
-
prepare a more detailed analysis that
states the “business case;”
-
continue meetings to respectfully discuss
differences in models and in purposes
of care
coordination/case management. This is
an essential step toward reaching consensus
on a working
definition;
-
conduct a needs/gap analysis, particularly
focusing on current spending and provider
capacity;
develop a consensus definition;
-
develop guidelines and/or a provider
handbook that can be used to increase
knowledge and
change practices;
-
develop a core, common training curriculum;
-
write and execute interagency agreements
that support better integrated care
coordination (e.g.,
billing codes, shared staff, pooled
training funds, common definitions);
-
develop a model for tiered billing,
based on severity of need or intensity
of services;
convene additional State-level meetings
to discuss and continue progress;
-
encourage local meetings (particularly
if tools such as a fact sheet, training
materials, or
guidelines can be shared).
-
Finally, several members of this leadership
group agreed to take future steps to
advance the day’s
work.
Handout for the Second Pennsylvania
Roundtable
Extracted sections from the GWU Purchasing
Specifications.
Purchasing Specifications for
Children with Special Health Care Needs
Extracted Sections related to Care Coordination
for CSHCN
… §104. Care Coordination Services
Commentary: The following illustrative
language assumes that the Purchaser wishes
to provide care
coordination services to children with
special health care needs through the
contracting MCOs in which
they are enrolled. It should be noted
that States are not required to offer
care coordination services to
Medicaid beneficiaries generally or to
this population in particular, and some
States do not cover these
services for this population. In addition,
not all MCOs are organized to provide
care coordination services
to children with special health care needs
or other enrolled populations through
separate care
coordinators; instead, they rely upon
the treating physician to perform care
coordination functions. Finally,
if a State Medicaid program elects to
cover care coordination services for this
population, it may also elect
to "carve out" such services
from its purchasing agreements with MCOs
and provide them on a fee-forservice
basis through the State Title V agency
or other State or local agencies, or through
private
organizations. For a review of the care
coordination models used by Colorado,
Delaware, New Mexico,
Oregon, and Washington, see Rosenbach
and Young, Care Coordination in Medicaid
Managed Care: A
Primer for States, Managed Care Organizations,
Providers, and Advocates (March 2000)
www.chcs.org.
The federal Medicaid statute and implementing
regulations do not contain a “care
coordination services”
category. Thus, it is not possible to
state with certainty that the care coordination
services set forth in the
following illustrative language would
qualify for federal Medicaid matching
funds. That determination can
be made only by HCFA. HCFA's published
guidance on coverage of case management
services is set
forth in State Medicaid Manual at §430216,
www.hcfa.gov/pubforms/pub45pdf/smm4t.htm.
(a) In General — Contractor shall
comply with the requirements of this section
relating to:
(1) assignment or selection of a care
coordinator (as defined in §108(b))
under subsection (b);
and
(2) the duties of the care coordinator
(as defined in §108(b))
under subsection (d).
Commentary: The following illustrative
language assumes that the family or caregiver
of an enrolled child
with special health care needs has the
option of refusing to accept a care coordinator
for the child. It also
assumes that the family or caregiver has
the option of declining to accept the
particular care coordinator
that Contractor wishes to assign to the
child. The language would not, however,
require Contractor to hire
or subcontract with any particular care
coordinator in order to meet the wishes
of the family or caregiver.
The family or caregiver’s choice
would be limited to those care coordinators
(including a primary care
provider, if the family or caregiver so
chooses) available within Contractor’s
provider network under §204.
(b) Assignment or Selection of Care Coordinator
(1) In General
(A) Contractor shall, within [ ] days
of the date described in paragraph (5),
notify in writing
the family or caregiver of an enrolled
child with special health care needs (as
defined in
§108(c))
of the identity of the care coordinator
that Contractor proposes to assign to
the
child to furnish care coordination services
under subsection (d).
(B) This paragraph shall not be construed
to require Contractor to assign to a child
a care
coordinator who does not participate in
Contractor’s provider network under
§204(e)
or
with whom Contractor does not have an
out-of-network arrangement under §204(f).
(2) Option to Receive Care Coordination
Services from Primary Care Provider17
—
Contractor shall allow the family or caregiver
of an enrolled child with special health
care needs to
select as the child’s care coordinator
a primary care provider participating
in Contractor’s provider
network who is willing to assume the responsibilities
enumerated under subsection (d) with
respect to the child.
(3) Option to Receive Care Coordination
Services from Care Coordinator —
Contractor shall
allow the family or caregiver of an enrolled
child with special health care needs to
receive care
coordination services from a care coordinator
(as defined in §108(b))
other than a primary care
provider if the care coordinator is selected
by the child’s primary care provider
in consultation with
the child’s family or caregiver.
(4) Option to Refuse a Care Coordinator
— Contractor shall not assign an
enrolled child with
special health care needs to a care coordinator
(as defined in §108(b))
unless the child’s family or
caregiver (or, in the case of an adolescent,
the adolescent):
(A) agrees in writing to receive care
coordination services under this section
from a care
coordinator; and
(B) has selected a care coordinator under
paragraph (2) or consulted with a primary
care
provider under paragraph (3).
(5) Date — The date described in
this paragraph is the earlier of:
(A) the effective date of enrollment of
the child; or
(B) the date on which the enrolled child
has been identified as a child with special
health
care needs (as defined in §108(c))
by a provider participating in Contractor's
provider
network (whether or not such provider
is the child’s primary care provider).
(6) Responsibilities of Care Coordinator
— If a care coordinator has been
selected by or
assigned to an enrolled child or the child’s
family or caregiver under paragraphs (2)
and (3),
Contractor shall ensure that the care
coordinator carries out the duties required
under subsection
(d).
(c) Use of State Title V CSHCN Program
Personnel
(1) Option — Contractor may meet
the requirements of subsection (b) through
the use of care
coordinators (as defined under §108(b))
affiliated with [drafter insert name of
State Title V
CSHCN Agency].
(2) Written Agreement — If Contractor
elects to use care coordinators under
paragraph (1),
Contractor shall enter into a written
agreement with [drafter insert name of
State Title V CSHCN
Agency] under §206(b)(3).…
(d) Responsibilities of Care Coordinator18
— Contractor shall ensure that,
in the case of an enrolled
child with special health care needs (as
defined under §108(c))
who has selected a care coordinator
under subsection (a), the care coordinator,
consistent with §107(b)
relating to utilization management,
shall:
(1) make every effort to meet with the
family or caregiver of the child, in person
or by telephone,
within [ ] days of being assigned, in
order to learn about the child’s
diagnosis and treatment needs
and the needs of the family or caregiver
in supporting the child;
(2) assist:
(A) the primary care provider in developing
the child's care plan under §105(b)(1)(D);
and
(B) the child (and the child’s family
or caregiver) in understanding the contents
of the
plan;
(3) assist the child in accessing items
and services specified in the child’s
care plan under §105
that are:
(A) the duty of Contractor under §103(a);
and
(B) required under each of the following
plans (if any) that has been developed
for the
child:
(i) an IFSP (as defined in §108(g));
(ii) an IEP (as defined in §108(f));
(iii) a plan developed for the child by
[drafter insert name of State child welfare
agency]; and
(iv) [drafter insert references to other
applicable treatment plans];
(4) if requested by the child (or, except
in the case of an adolescent, the child’s
family or
caregiver), assist the child, in manner
consistent with §209(d) (relating
to confidentiality
protections), in accessing items and services
that are specified in the child’s
care plan under
§105
and are the responsibility of Purchaser
under §103(b);
Commentary: The illustrative language
in paragraph (5)
assumes that the MCO's care coordinator
has the
responsibility for assisting an enrolled
child's family or caregiver in having
payment made for services
covered under a State's Medicaid program
that are not the duty of the MCO. Another
approach would be
for the family or caregiver to be referred
to appropriate State or local agencies.
(5) if requested by the child (or, except
in the case of an adolescent, the child’s
family or
caregiver), assist the child, in manner
consistent with §209(d)
(relating to confidentiality
protections), in accessing and identifying
payment sources for items and services
that are
specified in the child’s care plan
under §105
and not the responsibility of Contractor
under
§103(a)
or Purchaser under §103(b);
66
(6) consistent with §203(f),
assist the child in accessing pediatric
specialists (as defined in
§108(j))
and other providers participating in Contractor’s
provider network that are identified in
the
child’s care plan under §105;
(7) refer the child to the [drafter insert
reference to responsible agencies under
Part B and Part C
of the Individuals with Disabilities Education
Act, 20 U.S.C. §1400 et seq.] unless
the child is
receiving services under an IEP (as defined
in §108(f))
or an IFSP (as defined in §108(g));
(8) if appropriate, in the case of a child
age 16 or older, refer the child to the
State Vocational
Rehabilitation Agency under Title I of
the Rehabilitation Act of 1973, 29 U.S.C.
§720 et seq., 34
C.F.R. 300.347(b);
(9) facilitate, consistent with the confidentiality
protections under §209,
the exchange of
information and medical records among
Contractor, the child’s primary
care provider, and [drafter
insert reference to responsible agencies
under Part B and Part C of the Individuals
with
Disabilities Education Act, 20 U.S.C.
§1400 et seq.];
(10) meet (in person or by telephone)
with the child and the child’s family
or caregiver in order to
track the child’s progress under
the child’s care plan under §105
and, based on the experience of
the child and the child’s family
or caregiver, make recommendations to
the child’s primary care
provider with respect to updating the
care plan under §105(b)(5);
(11) establish working arrangements with
care coordinators or case managers (other
than those
employed by, or under contract to, Contractor)
who have responsibilities with respect
to the child;
(12) assist the child (and the child’s
family or caregiver) in:
(A) understanding the child’s entitlement
to a fair hearing under 42 C.F.R. §430.220
and
to the continuation of services pending
the fair hearing under 42 C.F.R. §430.230
and, in
the case of denial, termination, or reduction
of items and services covered under §103(a),
in effectuating these entitlements; and
(B) accessing, under §209(c),
Contractor’s grievance procedures
and the State fair
hearing process;
(13) assist the child (and the child’s
family or caregiver) in documenting, establishing,
and
maintaining the child’s eligibility
for [drafter insert reference to State
Medicaid program], the
Supplemental Security Income (SSI) program
under Title XVI of the Social Security
Act, 42
U.S.C. §1381 et seq., and other public
program benefits;
(14) inform the child's family or caregiver
of the manner in which the child’s
family or caregiver
may participate in:
(A) voluntary networks organized for mutual
support by families or caregivers of children
with special health care needs; and
(B) the Family Advisory Board established
and maintained by Contractor under
§101(d)(3);
and
(15) in the case of a child with special
health care needs who is an adolescent
as defined
in §108(a),
assist the adolescent in identifying and
overcoming transitional issues relating
to accessing items and services described
in paragraph (3).19
Handout for the Second Pennsylvania Roundtable
Medicaid Case Management: Examples*
TYPE |
SAMPLE
ACTIVITIES |
MATCH
RATE |
EPSDT
administrative
case management |
•
Outreach & informing
• Assisting with covered transportation |
50/50 |
Administrative
case
management |
•
Assisting with applications
• Processing prior authorization
requests |
50/50 |
Targeted
case
management |
•
Help in identifying necessary services
• Care coordination for persons
with
disabilities or chronic illnesses
• Components of home visits
to highrisk
pregnant women and infants |
Medical
services
FFP rate |
Case
management as
part of a service |
•
Care plan development in a home
health visit |
Medical
services
FFP rate |
Case
management
requiring expertise of
skilled medical
personnel |
•
Reviewing care plans
• Approving provider payments
• Certain referrals for specialty
care |
75/25 |
* Table prepared by Kay Johnson for the
Managed Care Technical Assistance Project,
Second
Pennsylvania Roundtable on Child Health
and Managed Care: Care Coordination for
Children
with Special Health Care Needs
Definitions from Federal Regulation
(www.cms.gov)
4-302. OPTIONAL TARGETED CASE
MANAGEMENT SERVICES - BASIS, SCOPE
AND PURPOSE …
A. Background.--Case management
is an activity which assists individuals
eligible for Medicaid in
gaining and coordinating access to necessary
care and services appropriate to the needs
of an individual.
Prior to the enactment of P.L. 99-272,
States could not provide case management
as a distinct service
under Medicaid without the use of waiver
authority. However, aspects of case management
have been an
integral part of the Medicaid program
since its inception. The law has always
required interagency
agreements under which Medicaid patients
may be assisted in locating and receiving
services they need
when these services are provided by others.
Prior to the enactment of P.L. 99-272,
Federal financial
participation (FFP) for case management
activities may be claimed in any of four
basic areas:
1. Component of Another Service.--Case
management may be provided as an integral
and
inseparable part of another covered Medicaid
service. An example of this type of case
management is the preparation of treatment
plans by home health agencies. …separate
payment for the case management component
cannot be made, but is included in the
payment
made for the service at the Federal Medical
Assistance Percentage (FMAP) rate.
2. Administration.--Case management
may be provided as a function necessary
for the proper
and efficient operation of the Medicaid
State plan, as provided in §1903(a)
of the Act. Activities
such as utilization review, prior authorization
and nursing home preadmission screening
may be
paid as an administrative expense. The
payment rate is either the 50 percent
matching rate or the
75 percent FFP rate for skilled professional
medical personnel, when the criteria in
42 CFR
432.50 are met.
3.Section 1915(b) Waivers.--Case
management may be provided in a waiver
granted under
§1915(b) of the Act….
4.Section 1915(c) Waivers.--Case
management may be provided as a service
in a waiver granted
pursuant to §1915(c) of the Act....
… (2) For purposes of this subsection,
the term ‘case management services’
means services which will
assist individuals eligible under the
plan in gaining access to needed medical,
social, educational, and
other services.
B. Legislation.--P.L. 99-272
adds case management to the list of optional
services which may be
provided under Medicaid. Section 9508
of P.L. 99-272 adds a new subsection (g)
to §1915 of the Act.
This subsection, as amended by P.L. 100-203,
provides that:
"(g)(1) A State may provide, as medical
assistance, case management services
under the plan without regard to the requirements
of section 1902(a)(1) and
section 1902(a)(10)(B). The provision
of case management services under this
subsection shall not restrict the choice
of the individual to receive medical
assistance in violation of section 1902(a)(23).
A State may limit the provision of
case management services under this subsection
to individuals with acquired
immune deficiency syndrome (AIDS); or
with AIDS-related conditions, or with
either, and a State may limit the provision
of case management services under
this subsection to individuals with chronic
mental illness. The State may limit the
case managers available with respect to
case management services for eligible
individuals with developmental disabilities
or with chronic mental illness in order
to
ensure that the case managers for such
individuals are capable of ensuring that
such individuals receive needed services.
…
4302.2 State Plan Amendment Requirements.--Any
State plan amendment request to provide
optional
case management services must address
all of the requirements of this section.
-
Target Group.--Identify the target group
to whom case management services will
be provided.
This targeting may be done by age, type
or degree of disability, illness or
condition (e.g., Acquired
Immune Deficiency Syndrome (AIDS) or
Chronic Mental Illness), or any other
identifiable
characteristic or combination thereof.
The following examples are target groups
currently
receiving case management services under
§1915(g) of the Act:
-
Developmentally disabled persons
(as defined by the State);
-
Children between the ages of birth
and up to age 3 who are experiencing
developmental
delays or disorder behaviors as
measured and verified by diagnostic
instruments and
procedures;
-
Pregnant women and infants up to
age 1;
-
Individuals with hemophilia;
-
Individuals 60 years of age or older
who have two or more physical or
mental diagnoses
which result in a need for two or
more services; and
-
Individuals with AIDS or HIV related
disorders.
In defining the target group, you must
be specific and delineate all characteristics
of the
population.…
NOTE: Although FFP
may be available for case management
activities that identify the specific
services
needed by an individual, assist recipients
in gaining access to these services,
and monitor to assure that
needed services are received, FFP is
not available for the cost of these
specific services unless they are
separately reimbursable under Medicaid.
Also, FFP is not available for the cost
of the administration of
the services or programs to which recipients
are referred….
-
Differentiation Between Targeted Case
Management Services and Case Management
Type
Activities for Which Administrative
Federal Match May Be Claimed.--You
must differentiate between
case management services which may properly
be claimed at the service match under
§1915(g) and
case management activities which are
appropriate for FFP at the administrative
match under the State
plan, based upon the appropriate criteria.
These two payment authorities do not
result in mutually
exclusive types of services.
There are certain case management activities
which may appropriately be eligible
for FFP at either the
administrative or the service match
rate. Examples of case management activities
that may be claimed at
either the administrative or the service
match rate entail providing assistance
to individuals to gain access
to services listed in the State plan,
including medical care and transportation.
In cases where an activity
may qualify as either a Medicaid service
or an administrative activity, you may
classify the function in
either category. This decision must
be made prior to claiming FFP because
of the different rules which
apply to each type of function under
the Medicaid program.
-
Case Management as a Service Under
§1915(g).--FFP is
available at the FMAP rate for
allowable case management services
under §1915(g) when the following
requirements are met:
Expenditures are made on behalf
of eligible recipients included
in the target group (i.e. there
must
be an identifiable charge related
to an identifiable service provided
to a recipient);
-
Case management services are provided
as they are defined in the approved
State plan;
-
Case management services are furnished
by individuals or entities with
whom the Medicaid
agency has in effect a provider
agreement;
-
Case management services are furnished
to assist an individual in gaining
or coordinating
access to needed services…
Because §1915(g) of the Act
defines case management services
as services which assist
individuals eligible under the plan
in gaining access to needed medical,
social, educational, and
other services, recipients may obtain
access to services not included
in the Medicaid State plan.
The costs of case management services
provided under §1915(g) that
involve gaining access to
non-Medicaid services are eligible
for FFP at the service match rate.
Examples of case management services
provided under §1915(g) of
the Act may include
assistance in obtaining Food Stamps,
energy assistance, emergency housing,
or legal services.
All case management services provided
as medical assistance pursuant to
§1915(g) of the Act
must be described in the State plan.
In addition, they must be provided
by a qualified provider as
defined in the State plan.
When case management is provided
pursuant to §1915(g) of the
Act, the service is subject to the
rules pertaining to all Medicaid
services. If you choose to cover
targeted case management
services under your State plan,
as defined in §1915(g) of the
Act, you cannot claim FFP at the
administrative rate for the same
types of services furnished to the
same target group.
-
Case Management as an Administrative
Activity. ….
…The following list of functions
provides examples of activities
which may properly be claimed as
administrative case management activities,
but not as targeted case management
services. The
omission of any particular function
from this list does not represent
a determination on HCFA’s
part that the function is not necessary
for the administration of the plan.
-
Medicaid eligibility determinations
and redeterminations;
-
Medicaid intake processing;
- Medicaid
preadmission screening for inpatient
care;
-
Prior authorization for Medicaid
services and utilization review;
and
-
Medicaid outreach (methods to
inform or persuade recipients
or potential recipients
to enter into care through the
Medicaid system).
Because activities related to services
which Medicaid does not cover are
not considered
necessary for the administration
of the Medicaid plan, the accompanying
costs are not eligible for
Medicaid FFP at the administrative
rate. For example… setting
up an appointment with a
Medicaid participating physician
and arranging for transportation
for a recipient may be
considered case management administrative
activities necessary for the proper
and efficient
administration of the Medicaid plan.
However, arranging for baby sitting
for a recipient’s child,
although beneficial to the recipient,
is not an activity for which administrative
FFP can be
claimed…. when a caseworker
suspects that physical abuse of
a recipient has occurred, the
referral to medical care could be
considered a reimbursable administrative
activity under the
Medicaid program. However, assisting
the victim in obtaining emergency
housing and legal
services, although in the best interest
of the recipient, is not an activity
for which administrative
FFP may be claimed….
Administrative case management activities
may be performed by an entity other
than the single
State agency. However, there must
be an interagency agreement in effect…
-
Case Management Under the Early and
Periodic Screening, Diagnostic and Treatment
(EPSDT)
Program.--Care coordination,
including aspects of case management,
has always been an integral
component of the EPSDT program... Section
1905(r) requires that States provide
any services included in
§1905(a) of the Act, when medical
necessity for the service is shown by
an EPSDT screen, whether such
services are covered under the State
plan. While case management is required
under the expanded
EPSDT program when the need for the
activity is found medically necessary,
this does not mean
§1915(g) targeted case management
services. Therefore, when the need for
case management activities
is found to be medically necessary,
the State has several options to pursue:
-
Component of an Existing Service.--Case
management services may be provided
to persons
participating in the EPSDT program
by an existing service provider
such as a physician or clinic
referring the child to a specialist.
-
Administration.--Case management
services may be provided to EPSDT
participants by the
Medicaid agency or another State
agency such as title V, the Health
Department or an entity with
which the Medicaid agency has an
interagency agreement. Administrative
case management
activities must be found necessary
for the proper and efficient administration
of the State plan
and therefore must be limited to
those activities necessary for the
proper and efficient
administration of Medicaid covered
services. FFP is available at the
administrative rate.
-
Medical Assistance.--Case management
services may be provided under the
authority of
§1905(a)(19) of the Act. The
service must meet the statutory
definition of case management
services, as defined by §1915(g)
of the Act. Therefore, FFP is available
for assisting recipients in
gaining access to both Medicaid
and non-Medicaid services. FFP for
case management services
furnished under §1905(a)(19)
of the Act is available at the FMAP
rate.
Any combination of two or more of
the above is possible, as long as
FFP is not available for duplication
of
services.
1
McPherson et al. A New Definition of Children
with Special Health Care Needs. Pediatrics.
1998;102:137-140. |