The Balanced Budget Act of 1997 included provisions specifically affecting PCCM programs. For example, states can now require Medicaid beneficiaries to enroll in managed care, including PCCM programs, by amending their state plans rather than seeking a waiver. The only populations excluded from this state plan option are certain children with spec
Emerging Practices in Medicaid Primary Care Case Management Programs. External Drivers for Evolving PCCM Programs
Both external and internal factors have driven the evolution of states' PCCM programs. The most significant external factors are the Balanced Budget Act and the changing marketplace for risk-based MCOs.
States are increasingly monitoring quality of care in PCCM programs using multiple strategies.
Allowable PCCM primary care providers (PCPs) are typically those who can provide the full range of Medicaid primary care services.
States are increasingly mandating enrollment in PCCM for their Medicaid beneficiaries. As Chart C illustrates, in 1990, 63 percent of the 19 states with PCCM programs (a total of 12 states) mandated enrollment; 47 percent (nine states) made enrollment voluntary. (These add up to over 100 percent, as states may use both mandatory and voluntary enro
Since 1990, states have primarily used PCCM programs to enroll people in the following Medicaid categories of eligibility: AFDC/TANF, poverty level pregnant women, and poverty level children. Medicaid use of PCCM programs for these populations has been fairly stable and very high. Also relatively stable is the use of PCCM for institutionalized pop
As of 1998, 13 percent of all Medicaid beneficiaries (4.1 million people) were served through PCCM providers in 29 states. 15 Although the number of states has fallen from a high of 33 in 1994 (see Chart A), the number of beneficiaries since that time has risen (from 2.4 million in 1994). 16
PCCM programs have been successful in increasing the access of Medicaid beneficiaries to primary care physicians and creating medical homes, but the impact on costs is more mixed. In certain studies, access and utilization of primary care were noticeably improved, due largely to these provider-patient relationships.
In typical PCCM programs, the PCP is paid a monthly case management fee for each enrolled Medicaid beneficiary, in addition to fee-for-service reimbursement for all non-emergency primary care services that he/she provides. In return, the PCP is responsible for providing primary care and for prior authorizations to hospitals and specialty care prov
States began enrolling beneficiaries in their PCCM programs by the mid-1980s. In 1986, seven states had implemented PCCM programs, 4 and by 1990, 19 states had such programs. 5 Several factors motivated decisions to implement PCCM programs.
The Omnibus Budget Reconciliation Act (OBRA) of 1981 allowed state Medicaid programs to implement both PCCM and risk-based managed care programs, pending HCFA(now known as CMS) waiver approval. HCFA(now known as CMS) approval required that the state satisfy two requirements.
1. HCFA(now known as CMS), letter from Sally K. Richardson, Director, Center for Medicaid and State Operations, PCCM Services Without Waiver , Jan. 21, 1998. 2. Neva Kaye, Cynthia Pernice, Helen Pelletier (Editor), Medicaid Managed Care: A Guide for
The eight states studied (Alabama, Florida, Iowa, Maine, North Carolina, Oklahoma, Texas, and Virginia) were chosen for the range of strategies used in their PCCM programs. These programs vary in age (from one to ten years) and size (from several pilot sites to statewide). What also varies is the place of PCCM within the Medicaid managed care pict
Primary care case management (PCCM) is a system of managed care used by state Medicaid agencies in which a primary care provider (PCP) is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment.
Primary care case management (PCCM) is a system of managed care used by state Medicaid agencies in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment. States began enrollin
This document could not have been produced without the support of the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (HHS/ASPE). Special thanks go to Jennifer Tolbert for her direction and encouragement. Thanks also go to the many state officials who participated in interviews and revi
June 2001 Joanne Rawlings-Sekunda, Deborah Curtis, and Neva Kaye National Academy for State Health Policy Produced for the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health and Human Services Rationing Case Management: Six Case Studies Mary E. Jackson, Ph.D. The MEDSTAT Group November 30, 1994 PDF Version (43 PDF pages)