Emerging Practices in Medicaid Primary Care Case Management Programs. Case Management Fees


Paying a case management fee plus fee-for-service is the dominant payment method among the eight case-study states. Only one, Oklahoma, did not use this reimbursement method, since it pays a capitated rate. (This system is detailed later in this section.)

Among the seven case-study states that pay case management fees, $3 per person per month is the most common fee.

  • Alabama, Florida, Maine (Maine PrimeCare), Texas (both Texas Health Network and STAR+PLUS), and Virginia all pay $3 per person per month.
  • Iowa pays $2 per person per month.
  • North Carolina pays
    • all PCPs $3 per person per month for the first 250 members and then $2.50 per person per month for the remainder; and
    • the sponsor network an additional $2.50 per person per month for each member in the ACCESS II and III programs
  • Maine pays all PCPs in its MaineNET program $5 per person per month. If the member is also a member of the Partnership program, the practice to which the PCP belongs receives a $20 per person per month case management fee (instead of $5).

Three PCCM programs in two case-study states (ACCESS II and III in North Carolina and MaineNET/Partnership in Maine) have begun to extend the case management fee method of payment to providers other than the PCCM provider. All three programs serve people with disabilities and the elderly.30 In all three programs, this method of payment is extended to other entities that play a large role in providing the type of care that PCCM members need.

All three programs pay an additional fee to an organization that supports the PCP's ability to practice.

  • In North Carolina's ACCESS II and III programs the case management fee is extended to the network to which the PCP belongs. The networks use this fee to perform care management activities, including conducting risk assessments to identify members at greatest risk, operating targeted disease management initiatives, and hiring care managers who work with the PCP to coordinate care delivered to individual members. (Please see the Service Management section for more information on these positions.)
  • Physicians participating in the MaineNET/Partnership receive a $5 case management fee for MaineNET members and a $20 case management fee for Partnership members. This fee is to compensate the practice for the time needed to coordinate the care of members, all of whom have very complex needs.

The MaineNET/Partnership is a separate contract between the Medicaid agency and a contractor that manages the care of all beneficiaries in the state who need community long-term care services. This contractor is paid $100 per member per month for eligible beneficiaries who are receiving Home and Community Based Services (HCBS) waiver services (regardless of their participation in Partnership). Care coordinators arrange, but do not pay, for the long-term care services a member needs to remain in the community. This contract is discussed here because the Partnership must co-locate one of their care coordinators at each MaineNET/Partnership physician's practice. The co-location of care coordinators enables the member to have both medical and long-term care needs addressed at a single location and often in a single visit. This arrangement is also an advantage for the physician, who gains the expertise of the care coordinator to help provide better care for patients with the most complex needs.

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