Care Coordination Model (CCM) Draft Principles
1. A CCM must provide or contract for all Medicaid long term care services in the benefit package. CCM will be at risk for the services in the benefit package and rates will be risk adjusted to reflect the population served.
The CCM benefit package includes both community-based and institutional Medicaid covered long term care services and makes consumer directed personal assistance services available for eligible individuals. The CCM is responsible for assessing the need for, arranging and paying for all Medicaid long term care services.
The CCM will receive a periodic payment to cover the services in the benefit package to promote the appropriate, efficient and effective use of services for which it is responsible. Payment to the CCM will be based on the functional impairment level and acuity of its members. Risk factors could include functional status, cognitive status, diagnoses, demographics or other measures found to be correlated to increased cost of services. CCM rates should be actuarially sound and sufficient to support provision of covered long term care services and care coordination and efficient administration. Payments shall incentivize community-based services.
2. A CCM must include a person-centered care management function that is targeted to the needs of the enrolled population.
Every individual must have a care manager or care management team that is responsible for person-centered assessment and reassessment, care plan development and implementation, care plan monitoring, service adjustment, safe discharge and transition planning, and problem solving. The care management function should address the varying needs of the population, and should encompass high-touch/low-touch as indicated by the needs of the member and informal supports/caregivers.
3. A CCM must be involved in care management of other services for which it is not at risk.
Transition to fully integrated models of care which include all Medicare and Medicaid services is the goal of NYS over the next three to five years. As an interim approach, the CCM must engage in coordinating care with primary and acute care services and other services not in the CCM service package to promote continuity of care and improve outcomes.
4. CCM care management must fully involve the individual and informal supports in the development and execution of the care plan.
Eliciting the goals and preferences of individuals and their informal supports is a critical component of person-centered care plan development and is essential to promoting quality of life. All individuals and, where appropriate, an individual's representative, shall be given the opportunity to participate in decisions about the type and quantity of service to be provided.
5. Care coordination is a core CCM function. For benefit package services, CCM members will have a choice of providers.
A CCM must have adequate capacity to assure that individualized care coordination is provided to all members. Members should be able to select among several providers of each benefit package service. CCMs should have a network that takes into account the cultural and linguistic needs of the population to be enrolled. However, there are geographic differences in the availability of service providers and CCMs should not be prevented from operating when market forces (lack of availability or unwillingness to contract) preclude a CCM from offering choice or, perhaps in some instances, a particular service. Members must have the ability to receive services from an out-of-network provider if no provider is available in-network that can adequately meet the needs of the member.
6. A CCM will use a standardized assessment tool to drive care plan development.
CCMs should use the same standardized assessment tool as other long term care entities (the UAS-NY when available) to be used for initial assessments, scheduled reassessments and other reassessments resulting from a change in condition.
7. A CCM will provide services in the most integrated setting appropriate to the needs of qualified individuals with disabilities.
Consistent with the federal Olmstead decision, CCM care planning should provide benefit package services in the most integrated setting appropriate to the needs of members, engage the members in decision-making, address quality of life, and actively support consumer preferences and decisions in order to improve consumer satisfaction.
8. A CCM will be evaluated to determine the extent to which it has achieved anticipated goals and outcomes and to drive quality improvement and payment.
CCMs will submit data to the State, which will be made available publicly, to compare and evaluate entities on an ongoing basis, determine the success of individual CCMs, and create transparency about CCM service delivery. Data will include, but not be limited to: financial reports, provider networks, consumer satisfaction, grievances and appeals, assessment data, care outcomes and encounter data, and disenrollment data. The CCM will use its own data and information to develop and conduct quality improvement projects. The Department will track experience of CCMs in relation to quality and costs.
9. A CCM will provide effective consumer protections for members.
Members must be entitled to and be informed of their rights as members of the CCM. This includes the right to make complaints about the care and services provided, to have requests for services addressed in a timely way and to appeal decisions by the CCM. Members shall have the right to disenroll from the CCM and join another provider of service consistent with CCM requirements. CCM must have clear criteria for involuntary disenrollment and members must be informed about them and the attendant appeals and grievance rights.
10. A CCM will be able to serve specified population(s).
Some populations have unique needs that can be best addressed by an entity that is skilled in the assessment, care plan development, service networks and monitoring of that group or to address specific medical conditions or illnesses. A CCM shall develop and use its expertise to serve specific populations.
11. Mandatory enrollment into Managed Long Term Care Plans and other Care Coordination Models will not begin until there is adequate capacity and choice for consumers in a county.
There should be an organized transition process that provides for continuity of care as individuals transition from other programs. Consumers and caregivers should be provided with appropriate materials educating them about their choices and have the opportunity to have questions answered before enrollment.