Care Management: A Core Function in the BH/IDD Tailored Plan

NEWS UPDATE 2/11/20

Since the publication of the article below on the BH/IDD Tailored Plan Care Management application process NC DHHS has announced an extension before they begin the application process.  Originally they were to begin the first round of applications for Advanced Medical Home Plus practices and Care Management Agencies in February 2020.  That has now been extended until June 2020.  This will provide time to update the BH/IDD Tailored Plan Care Management provider manual based on the feedback received and update the application questions accordingly.

The vision for Medicaid Transformation includes many new concepts.  None may be as central to the achievement of whole person care as care management provided to Medicaid beneficiaries who are in the BH/IDD Tailored Plans.  Every member of a BH/IDD Tailored Plan, with few exceptions, will receive care management services.  NC DHHS recently released a draft provider manual for those organizations that are working to be certified as either an Advanced Medical Home Plus (AMH +) or as a Care Management Agency (CMA).  Only these agencies and the BH/IDD Tailored Plans will be able to provide the care management service.  The State has published an application for a first round of submissions by organizations that is due by February 21, 2020 (now extended to June, 2020) .   The BH/IDD Tailored Plan is tentatively scheduled to be implemented in July 2021. 

There are some advantages to seeking certification as an AMH+ or CMA early, including:

• Those organizations will have the benefit of being in network when Medicaid beneficiaries are initially assigned to care managers. 
• NC DHHS intends to provide some “capacity building” funding for organizations so providers who apply early “may have an advantage in accessing the capacity building funding.”

Health Home and Care Manager Designations

The BH/IDD Tailored Plans will be federally designated as the Health Home for Medicaid beneficiaries in the Tailored Plans.  A health home is an approach to ensure whole person care is achieved by integrating physical and behavioral healthcare needs and long-term services and supports, including services for individuals with intellectual or developmental disabilities, pharmacy needs, and unmet health-related needs.   Health Homes are also responsible for health promotion, care coordination, individual and family supports, comprehensive transitional care, and follow-up and referral to community supports and services.  The model is particularly pertinent to individuals with chronic and complex needs. 

Care management is a function that is managed under a Health Home and coordinates these service needs to address the whole person.  While LME/MCOs have been providing care coordination services for a long time, NC DHHS is intending for the care management role to be closer to the person and to include responsibilities related to integrated care.  For regions that participate in the Healthy Opportunities pilot, there will be additional responsibilities focusing on the unmet health-related needs in the pilot areas of focus. 

Medicaid beneficiaries in the BH/IDD Tailored Plan are able to switch their care managers twice a year without cause.  Each beneficiary in the Tailored Plan will be assessed and grouped in a high, medium or low acuity level based on their level of need.  Tailored Plans will be required to distribute care management assignments using two particular considerations:  1) giving preference to providers who are certified care managers and have an existing relationship with a consumer; 2) evenly distributing care management responsibilities based on the acuity levels of consumers (high, medium, low).  There are additional considerations for BH/IDD Tailored Plans to use when assigning individuals in the Innovations or TBI Waiver that allow for the Medicaid beneficiary to stay with their current care coordinator and to prohibit care management provided by employees of the same organization that provides services to that Medicaid beneficiary under the Innovations or TBI Waivers. 

Consumer Acuity/Diagnosis	# of Contacts	# of In-Person Contacts	# of Telephonic Contacts
High Acuity MI/SUD	4 per month	1 per month (included in the 4)
High Acuity I/DD	3 per month	2 per month (included in the 3)	1 per month (included in the 3)
Medium Acuity MI/SUD	3 per month	1 per quarter
Medium Acuity I/DD	3 per month	1 per quarter
Low Acuity MI/SUD	2 per month	2 per year
Low Acuity I/DD	1 per month	2 per year	1 per month (included in the 1)

Exemptions from Care Management

BH/IDD Tailored Plan members who participate in the following services will be exempt from care management because it is already imbedded in their service/program:

1. Individuals receiving Assertive Community Treatment;

2. Individuals residing in Intermediate Care Facilities for Individuals with Intellectual Disabilities;

3. Children participating in Care Management for At-Risk Children;

4. Children participating in the High Fidelity Wraparound program.

Data Sharing Expectations

BH/IDD Tailored Plans will have capacities to share the following data with care manager organizations:

• Assignment information including projections and new Tailored Plan members;
• Set acuity levels based on a standardized methodology;
• Risk scoring and stratification (see below) and sharing of this information with organizations providing care management;
• Feedback on quality scoring results;
• Historical medical encounter data and pharmacy data.

Risk in Managed Care:  Organizations accept a set amount of money calculated by the number of members they have each month, called a capitation, and the organization is at financial risk for the Medicaid services specified in their contracts.  This means that they must provide the Medicaid services in their contracts regardless of whether the capitation they are paid covers all of the services. 

Risk Scoring:  The process by which information about an individual is used to predict, or explain, uncertain events. (definition by Society of Actuaries)

Risk Stratification:  The process of separating patient populations into high-risk, low-risk, and the ever-important rising-risk groups is called risk stratification. Having a platform to stratify patients according to risk is key to the success of any population health management initiative. (definition by HealthCatalyst)

Criteria to be a BH/IDD Tailored Plan Care Management Organization

NC DHHS will certify those agencies that may provide care management under the Tailored Plan.  They will seek information from applicants in the following areas:

• Organizational standing/experience
• Staffing
• Structures to deliver services
• Health information technology
• Quality measurement and improvement
• Training

Care Management Staff Qualifications

Position	Education	Experience
Care Manager	Bachelor’s degree in a field related to health, psychology, sociology, social work, nursing, or another relevant human services area	2 years working with individuals with diagnosis of consumer, i.e. MI/SUD or I/DD, TBI
Care Manager LTSS	Same as above	2 years of LTSS or HCBS coordination, care delivery monitoring, care management
Supervisor MI/SUD	Master’s and fully licensed LCSW, LPC, LPA, BSN	3 years of supervisory experience working with this population
Supervisor I/DD, TBI OR below	Bachelor’s degree in human services field	5 years of supervisory experience working with this population
Supervisor I/DD, TBI	Master’s degree in human services field	3 years of supervisory experience working with this population