Case Management Services

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Case Management Services

• Improving Health by Partnering with Medicaid

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Medicaid A Federal-State Partnership

• Medicaid Title 19 of Social Security Act
• Medicaid covers low-income categorically
  eligible pregnant women, children, aged, blind
  and disabled. May cover adults with children.
• Almost never covers single adults unless they are
  permanently disabled

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Financing Medicaid Services

• Feds and states share the cost of operating
  Medicaid
• Feds pay 50 to 83 of medical services costs
• Administrative costs shared 50/50
• Medicaid is an entitlement program cost control
  is difficult to achieve!

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SCHIP The State Childrens Health Insurance
Program

• Title 21 of the Social Security Act, covers
  uninsured children up to 250 of poverty
• Passed in 1997 first new coverage initiative
  since Medicaid in mid-60s
• States may expand Medicaid or create a separate
  type of insurance
• All states have SCHIP programs,
• 6 million children enrolled
• Federal pay an enhanced share of SCHIP

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States design their Medicaid/ SCHIP Programs

• Some discretion in eligibility criteria income
  limits, property limits, other criteria
• Some benefits are mandatory, others optional.
  States have some discretion in what is covered
• States decide how to pay for care how much, how
  payment is structured

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State Plan Amendments vs Waivers

• Every State has a Medicaid Plan that is regularly
  updated by State Plan Amendments or SPAs
• Waivers are needed only if a state wants to
  suspend a fundamental federal requirement
• Waivers may take years of negotiation and must be
  cost neutral for federal side
• SPAs may increase overall Medicaid costs and
  should be approved in 90 days (more or less)

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Why Should you Partner with Medicaid and SCHIP ?

• Medicaid/SCHIP has a mission to provide efficient
  effective care
• Medicaid/SCHIP serves your clients
• Medicaid/SCHIP provides long-term, stable support
  for services
• Working with big government programs can improve
  the system for everyone look up stream!

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Medicaid Case Management Options

• Targeted Case Management (TCM)
• Medicaid Administrative Claiming (MAA)
• EPSDT
• Preventive Services
• Federally Qualified Health Centers

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Targeted Case Management or TCM

• Targeted Case Management assists Medicaid clients
  to access a wide range of health and social
  services
• States have the option of creating TCM services
  for specific populations, in defined geographic
  regions. Statewide-ness requirement does not
  apply to TCM
• TCM is a health service, an encounter (not
  Medicaid administration).

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What is included in a TCM Visit?

• Assessment of client needs
• Develop a service plan
• Information and referral to resources health,
  substance abuse, housing, food, education,
  social...
• Coordination with providers, family
• Arrange care, transportation, translation
• Monitor outcomes
• Crisis planning

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How TCM Works

• The state includes TCM as a covered benefit in
  its Medicaid Plan
• The Plan specifies the target population(s),
  region, provider requirements, payment mechanisms
• Providers bill per encounter or monthly
  Reimbursement usually related to actual costs
  ranges from 7 to 1,000

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What TCM is not

• Not the provision of a direct medical care
  service not counseling, primary care
• Not billable if part of a medical care service
  already reimbursed by Medicaid or another program
  
• Not usually a one-time contact
• Not usually included in managed care capitation
  rates

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TCM Examples

• Home visiting to women and children
• Mental health case management
• Case management for the homeless
• Services to help frail elderly
• Case management for TB, HIV patients
• Helping disabled clients remain independent
• Helping troubled teens with substance abuse,
  risky behaviors

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Is it TCM?

• Face to face encounters
• with
• Medicaid enrolled clients
• by
• Qualified providers
• who
• Document the service in a client record

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Administrative Case Management

• Medicaid can subcontract with public and private
  entities for administration
• No cap on Medicaid administrative costs, SCHIP
  admin capped at 10
• Administration includes outreach, eligibility
  activities, arranging care, program planning and
  development, utilization review, quality
  improvement

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Medicaid Administrative Activities

• Not client specific, not an encounter
• Qualifies for federal match (usually 50/50)
• State contracts for the service with an entity,
• No requirement for state-wideness
• No waiver required, Plan must be updated

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Examples of Administrative Case Management

• Asking clients if they have health insurance,
  telling them about public insurance,
• Assisting with applications for Medicaid/SCHIP
• Helping clients use the health system choose a
  health plan, find a provider, make an
  appointment, get to care

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Differences between TCM and Administrative Case
Management

• There is some overlap between these types of Case
  management
• TCM covers referral to all types of services
• Administration covers referrals to health
  services (i.e. services covered by Medicaid)
• Administrative services more likely to be one
  time encounters TCM on-going
• Different billing mechanisms one a Medicaid
  service, one a contractual arrangement
• TCM is client specific, Administration is not
• May have different federal match rates

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How to get Started with Medicaid

• Contact your Medicaid program find out what case
  management services are currently covered, how to
  enroll as a provider
• Web sites may have good information
• If Medicaid currently covers TCM, would your
  services qualify or would a new SPA be required?
• If your services qualify as administrative case
  management, is there a precedent for buying
  administrative services in the public/private
  sectors? Medicaid often contracts with schools

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Determine what you offer to Medicaid

• You can help control costs, save money
• You can help improve health outcomes
• You can pilot innovative approaches
• You can develop local resources, provider
  networks
• You can reach underserved populations
• You can help Medicaid win friends by being your
  good partner

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Think Strategically

• IF you are asking for a new type of service to be
  covered or a new type of contract, youll need
  to identify your contacts, your champions an
  elected official, the governor, the state Health
  Director, a managed care firm, a hospital?
• Approach Medicaid in a problem solving mode
  explore all the options
• Medicaid may need permission to proceed from
  the legislature, the governor, the feds

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Financial Considerations

• What percent of those receiving services are
  Medicaid/SCHIP enrollees?
• How much are you spending to provide case
  management services?
• Will the state reimburse full costs?
• Will the state pay the local (i.e. state) match
  or will they expect you to pay it?

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Using Existing Funds

• Feds permit the states share of Medicaid/ SCHIP
  funds to come from public entities other than the
  state
• Public funds from a county, city, school
  district, district hospital, public university
  hospital can be used as local match under certain
  conditions

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Intergovernmental Transfer

• IGT (intergovernmental transfer) is the process
  whereby a state uses funds from another public
  entity as part of a Medicaid expenditure
• Some states certify a local expenditure as
  being part of the Medicaid program California
• Federal funds cannot be used to match Medicaid
  Prohibitions/limits exist on provider donations

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Understanding the Context

• State and Federal relationships are particularly
  tense at this time
• Feds are restricting certain types of IGTs
  (important that providers keep the money paid to
  them)
• If there are no precedents and state staff is not
  knowledgeable, get help!
• It takes time to develop new options

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Medicaid Case Management A Win/Win Proposition

• Community organizations can help Medicaid
  accomplish its mission economically
• Medicaid can help community organizations have a
  secure source of long-term funding

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Additional resources

• Listing of States TCM Programs
• http//207.22.102.105/medicaidbenefits/targetedc
  asemgt.html
• WWW.Google.com, search Medicaid Targeted Case
  Management
• Letter to Medicaid Directors from CMS re TCM and
  Child Welfare www.cms.hhs.gov/states/letters/sm
  d119c1.asp
• California Department of Health, PowerPoint on
  its TCM program www.dhs.ca.gov/mcs/mcpd/mbb/acss/
  Ppt/TCMweb.ppt
• on their MAA program www.dhs.ca.gov/mcs/mcpd/MB
  B/ACSS/MAAdescription.htm www.dhs.ca.gov/mcs/mcp
  d/MBB/ACSS/Ppt/15
• Article from Health Affairs, Survey of Medicaid
  Case Management programs Spring 1987,
  http//content.healthaffairs.org/cgi/reprint/6/1/6
  1.pdf
• Older reference for states Center for Medicare
  and Medicaid Services, Medicaid Manual Section
  4302 Optional Targeted Case Management
  Services- Basis, Scope and Purpose
  www.cms.hhs.gov/manuals/pub45/pub_45.asp

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Making the Most of MedicaidYou can do it!

• Elinor Hall, MPH
• Health Policy and Management Consulting
• 503-292-3240
• ElliHall_at_comcast.net