Category: Amazing Free Content

Managed Long-Term Services and Supports – MLTSS refers to risk-based arrangements for the delivery of Medicaid long-term services and supports, which often include institutional and home and community-based services (e.g., adult day care), enabling Medicaid beneficiaries to live independently in their homes and communities rather than receive care in an institution.7 Some MLTSS programs provide only long-term services and supports (e.g., operate as PHPs), but, in other arrangements, MLTSS are provided through comprehensive MCOs.

Further reading –

https://www.medicaid.gov/medicaid/managed-care/ltss/index.html

Prepaid Health Plan – As distinct from an MCO, a PHP is a non-comprehensive health plan that provides only certain services, such as dental services or non-emergency medical transportation.4 Most PHPs are paid on a risk, or capitated, basis. There are several types of PHPs:

Prepaid Ambulatory Health Plan (PAHP): A PAHP is a non-comprehensive prepaid health plan that provides only certain outpatient services, such as dental services or outpatient behavioral health care, and does not cover any inpatient services.5
Prepaid Inpatient Health Plan (PIHP): A PIHP is a non-comprehensive prepaid health plan that provides only inpatient hospital or institutional services, such as inpatient behavioral health care, and does not have a comprehensive risk contract.6

Further reading –

https://www.michigan.gov/documents/RevisedPlanforProcurementFinalVersionSenttoHCFA_7983_7.pdf

Risk-based Managed Care – MCOs are health plans that contract with states to provide comprehensive Medicaid benefits to enrolled Medicaid beneficiaries for a pre-set per-member-per-month (PMPM) premium, or capitation payment.3  This arrangement is known as risk-based managed care because MCOs are at financial risk for the Medicaid services specified in their contracts. States develop and oversee their own Medicaid managed care programs, subject to federal requirements. MCOs must meet federal and state-specific requirements that address matters such as: protocols for enrollment, disenrollment, and member support; ensuring an adequate provider network and access to care; grievances and appeals, and collection and reporting of data. Although MCOs are at financial risk for comprehensive Medicaid benefits, many states “carve out” certain services from their MCO contracts, such as prescription drugs or behavioral health services. These carved-out benefits may be provided and financed under a separate contract with a prepaid health plan (see definition below) or on a FFS basis. Alternatively, some MCOs may subcontract with prepaid health plans to provide such benefits.

Further reading –

https://en.wikipedia.org/wiki/Medicaid_managed_care

Primary Care Case Management – PCCM is a model of Medicaid managed care that is outlined in the Medicaid statute. In PCCM programs, state Medicaid agencies contract with primary care providers to provide, locate, coordinate, and monitor primary care services for Medicaid beneficiaries who select them or are assigned to them by the state.1 2 In effect, the primary care provider – usually a physician or a physician practice, but sometimes a nurse practitioner, physician assistant, or other provider – serves as a beneficiary’s “medical home” for primary and preventive care. Under their contracts with primary care providers, states pay them a small monthly  case management fee in addition to regular FFS payments; unlike in risk-based managed care (see definition below), providers do not assume any financial risk under this model. States set requirements for the participating primary care providers, such as minimum hours of operation at each location, specific credentials or training, and responsibility for referrals to specialists. State staff carry out, or contract out, administrative functions related to PCCM (e.g., network development and credentialing). “Enhanced” PCCM refers to PCCM programs that include additional services and responsibilities to strengthen care coordination.

Further reading –

https://www.cga.ct.gov/2009/rpt/2009-R-0216.htm

Resource-based Relative Value Scale – The list of services and RVUs from which Medicare physician payment is determined; services are assigned a relative value that is adjusted by a geographic price cost index (GPCI) and multiplied by a conversion factor.

Further reading –

https://www.ama-assn.org/rbrvs-overview

Relative Value Units – One element in the formula used to calculate the Medicare allowance for a given service in a specific fee schedule area; each Medicare physician fee schedule service is assigned RVUs for physician work, for practice expenses and malpractice expenses.

Further reading –

https://en.wikipedia.org/wiki/Relative_value_unit

Regional Extension Center – One of as many as 70 organizations defined by a specific geographic area, funded through the Health Information Technology for Economic and Clinical Health (HITECH) Act, and charged with helping physicians choose, implement and achieve meaningful use of electronic health records.

Further reading –

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925411/