Covering the Cost of Chronic Disease Self-Management Education with Medicaid

Engaging in discussions with Medicaid can help you to align your chronic disease self-management education (CDSME) program delivery and billing strategy with Medicaid services that cover CDSME programs and explore options for including programs in future Medicaid initiatives.

Medicaid Health Home Benefit

Medicaid Health Homes is a benefit that was established by the Affordable Care Act. States that wish to implement Medicaid Health Homes must submit a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) for approval. Under the Medicaid Health Home benefit, states can establish Health Homes to coordinate care for Medicaid beneficiaries with chronic conditions. The Health Home provides “whole-person” care by coordinating primary, acute, behavioral health, and long-term services and supports. Health Home Services include:

1. Comprehensive care management;
2. Care coordination
3. Health promotion
4. Comprehensive transitional care/follow-up, patient and family support; and
5. Referral to community and social support services.

Evidence-based CDSME programs, which help individuals take control of their health, foster communication between patients and their health care providers, and promote clinical and community linkages, align well into the Health Home model.

Health Home providers can include physicians, clinical/group practices, community health centers, home health agencies, and other providers. If your state offers the Health Home benefit, ask your State Medicaid Agency how to get connected with the Health Home providers. When making the case to embed CDSME to Health Home providers, emphasize the value of the program in reinforcing a whole-person approach to care, as well as its proven ability to achieve positive health outcomes.

Home and Community-Based Services (HCBS) Waivers

States can offer a variety of standard medical and non-medical services in home and community-based settings under the HCBS Waivers. Within the broad federal guidelines, HCBS services vary by state. The services are designed to meet the needs of individuals who prefer to receive services in a home or community setting, rather than in an institutional setting. Services may include case management, home health aide services, personal care, adult day health services, respite care, nutrition assessments, home delivered meals, and “other” types of services that may assist in diverting and/or transitioning individuals from institutional settings into their homes and community.”

Many beneficiaries that are eligible for HCBS Waiver services have two or more chronic diseases. These same beneficiaries may be good candidates for a CDSME program. A few states – Connecticut, Michigan, and Washington — have been successful in making CDSME a covered service. If CDSME programs are not a covered in your state, it is worthwhile to have a conversation about adding this service as a HCBS waiver benefit.

Medicaid Incentives for the Prevention of Chronic Diseases

Through the Affordable Care Act, some states receive grants to provide incentives to Medicaid beneficiaries who demonstrate changes in health risks and outcomes, such as adopting healthy lifestyle behaviors. The program used must address at least one of the following prevention goals: tobacco cessation, weight reduction, lowering cholesterol, lowering blood pressure, preventing diabetes, and improving management of diabetes. CDSME programs can help achieve all of these goals.

Visit the Centers for Medicare & Medicaid Services (CMS) website to learn whether your state is participating in this model. Work with your State Medicaid Agency to connect with stakeholder groups implementing the prevention of chronic diseases model and share the importance of including CDSME as a core service delivery component.

State Innovation Models Initiative (SIM)

This Affordable Care Act initiative provides some states financial and technical support for developing and testing statewide, multi-payer health care payment and service delivery models through SIMs. The goal of the initiative is to increase quality of care and decrease costs for Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) beneficiaries. If your state participates in a SIM demonstration, you have an opportunity to promote CDSME as a program that can improve quality of care and health outcomes, while saving costs. Many states have stakeholder groups that participate in the development of the SIM model. If your state has a SIM, work with your State Medicaid Agency to get connected with their stakeholder groups. Visit the Centers for Medicare & Medicaid Services (CMS) website to learn whether your state has received a SIM award.

Medicaid Managed Care

Since Medicaid Managed Care Organizations (MCOs) are responsible for managing utilization and costs and demonstrating positive health outcomes and quality of care for beneficiaries, they stand to benefit from offering CDSME programs to their members. Below are some steps that you should take before you contract with an MCO to help prepare you for developing a partnership. By doing your homework first, you will be prepared to develop and present a persuasive value proposition to the MCO.

• Conduct research about MCOs in your state, specifically the one that you want to approach regarding coverage of CDSME. Review the mandated coverage requirements, geographic region covered, current enrollment, and any quality and cost data that is available for the specific MCO.
• Conduct an external assessment to determine competition in the marketplace, as well as an internal assessment of the cost of offering CDSME programs, so that you will be prepared to negotiate a contract with an MCO.
• Determine in advance how you will meet the volume demands that may come as a result of a partnership with an MCO.
• Describe what processes you have in place for tracking and reporting information to the MCO.
• Be prepared to explain how you will ensure fidelity and quality of the programming and to discuss factors such as patient satisfaction, performance measures, and outcomes.

As you work with the MCO, you will want to assure that the partnership is mutually beneficial with a return on investment for both your organization and the MCO.