Providing CDSME coverage under the State Medicaid HCBS Waiver can be mutually beneficial to the state, the community-based organization offering CDSME programs, and Medicaid recipients.

• Benefits to the State: CDSME is a valuable program that can improve population health, prevent or delay institutionalization, and lower health care costs in the state.
• Benefits to Community-Based Organizations Offering CDSME Programs: The community-based organization (CBO) offering CDSME programs can increase their program reach to a vulnerable population and secure a funding stream to help sustain their efforts long term. Furthermore, once they prove the value of CDSME, they have an opportunity to discuss the potential of reimbursement for CDSME programming under other parts of the State Medicaid plan, such as Medicaid Managed Care or the Medicaid Medical Home.
• Benefits to Medicaid HCBS Waiver Members: Individuals who participate in a CDSME workshop learn how to manage their health, are more likely to become an active partner with their provider in maintaining their health, and have been shown to have positive health outcomes and increased quality of life.

State Successes

Some states have been successful in partnering with their State Medicaid Agencies to incorporate CDSME programs as a covered benefit in their Medicaid home and community-based care waiver programs, while health plans have incorporated CDSME into their managed long-term services and supports benefit packages in others, and some states are building the case for coverage. 

Medicaid Managed Care Organizations: Health plans in some states have incorporated CDSME into their managed long-term care services and supports benefit packages.

• California: California’s Partners in Care Foundation (Partners) has a strategic group purchasing partnership with America’s Physician Groups (APG), the leading association representing physician organizations practicing capitated, coordinated care. APG is an association and does not have contracts with Medicaid, instead it acts as a group purchasing partnership for its members. APG’s members have contracts with Medicaid, Medicare, and commercial insurers. Partners provides APG’s members a menu of services, including HomeMeds, care transitions, evidence-based self-management programs, and short-term care management. 
• Virginia makes CDSME available to Medicaid members through the Commonwealth Coordinated Care Plus program (managed long-term services and support programs). The Department of Aging and Rehabilitative Services (DARS) contracts with the Virginia Premier Health Plan (one of six MCOs that have contracted with the Department of Medical Assistance Services to enroll state Medicaid beneficiaries into their plans) to offer CDSME to their members. Virginia Premier is offering CDSME as an enhanced benefit to members that have been identified by nurse managers. DARS coordinates the referral and billing processes and reimburses area agencies on aging that deliver the program based on member attendance. Virginia Premier makes electronic referrals using Virginia’s “No Wrong Door” technology and reimburses DARS based on the number of workshop sessions attended by members. 

Medicaid Waivers: Some states have been successful in partnering with their State Medicaid Agencies to incorporate CDSME programs as a covered benefit in their Medicaid home and community-based care waiver programs

• Connecticut provides reimbursement for CDSME programs through their Eldercare Waiver. The state’s third-party payer approves providers that can offer CDSME programs and receive reimbursement under the state contract. The state unit on aging maintains an up-to-date listing of the leaders and the workshop locations. A per session reimbursement rate has been established.
• Maine’s home and community-based care waiver provides a payment mechanism for CDSME and A Matter of Balance. Spectrum Generations is enrolled as a provider to receive reimbursement for CDSME. Spectrum Generations has educated partners responsible for MaineCare (Medicaid) member care plans about the benefits of evidence-based programs to encourage use of the benefit. MaineCare reimburses up to $512.70 per member for participation in a CDSME workshop. The reimbursement is at the rate of $17.09 per 30-minute block of time.
• Massachusetts’ Elder Services of Merrimack Valley (ESMV) has a contract with a dual eligible plan (Medicare/Medicaid) to provide CDSME statewide. The plan is a comprehensive health plan that covers all the services reimbursable under Medicare and MassHealth through a senior care organization and its network of providers. ESMV receives referrals through self-referrals, sharing of an internal registry, and through providers. Overall revenue generated from the project over a recent 12-month period exceeded expectations by more than 60%.
• Michigan offers reimbursement for CDSME through the Michigan Choice Home and Community Based Medicaid Waiver. The state established billing codes for CDSME programs, as well as a general code for other evidence-based programs that may be recommended for Medicaid members.
• New York’s State Office for the Aging (NYSOFA) collaborated with the Center for Excellence in Aging and Community Wellness to implement the Balancing Incentive Program (BIP) for Evidenced-Based Health Interventions (EBIs) Initiative. This initiative was created under the Affordable Care Act of 2010 to provide financial incentives to States to increase access to non-institutional long-term services and supports (LTSS). The New York initiative, which took place over a two-year period (September 2015- September 2017), focused on expanding statewide capacity to deliver a select set of EBIs for adult Medicaid beneficiaries and individuals with intellectual and/or developmental disabilities. The project also served as a demonstration to explore uptake, interest, and the potential integration of the EBIs within the health care delivery system.
  • The results of this Partnership are:
    • 15,465 individuals (Medicaid and non-Medicaid) participated in the Chronic Disease Self-Management Program, Diabetes Self-Management Program, and the National Diabetes Prevention Program provided in English, Spanish and Chinese.
    • 43% (6650) of participants indicated they were Medicaid recipients.
    • 125 partner agencies throughout the state delivered workshops and over 400 physicians made direct referrals to programs.
    • Partnering agencies included area agencies on aging, county departments of health, independent living centers, senior centers, RSVP programs, federally qualified health centers, physician practices, faith communities, multi-purpose service agencies, hospitals, and community action organizations and coalitions.
    • Most of organizations that signed on to the BIP EBI Initiative continue to deliver programming in their various communities of service. Since the conclusion of the BIP EBI initiative in September 2017, a total of 634 additional EBI workshops have been held with a total 6,895 participants.
• Vermont’s Blueprint for Health was enacted in 2006, funded by a Centers for Medicare and Medicaid (CMS) Section 1115 Global Commitment for Health Waiver. Grants are made to community entities which have regional coordinators to implement self-management interventions in hospital and community locations for both Medicaid and non-Medicaid individuals. 
• Washington includes CDSME providers as qualified providers for the service “Client Support Training” in two of their 1915c waivers:
  • The Community Options Program Entry System (COPES) Waiver, designed to provide in-home and community-based services to help individuals who require nursing home level of care remain in a community setting, and
  • The New Freedom Waiver, a self-directed waiver, which provides participants with a monthly budget to purchase an array of services.
  • Any COPES or New Freedom participants can attend CDSME workshops under Client Support Training with the certified evidence-based CDSME trainer serving as the waiver qualified provider. Case managers document the client’s assessed need for Client Support Training during an individualized assessment, using the Comprehensive Assessment Reporting Evaluation. The reimbursement rate is $50 per session attended, up to $300 if all 6 sessions are attended.

Other: Some states have partnered with their state Medicaid agencies in unique ways to make CDSME available to members or to help build the case for inclusion of CDSME as a covered service. 

• Colorado has completed a claims study of Medicaid members who have participated in a CDSME workshop to document pre- and post-program health care costs. The results, which are based on actual Medicaid claims data, indicate a potential for cost reductions in inpatient, outpatient, and emergency room visits among individuals who complete CDSME classes, although statistical significance of the results could not be determined due to the small size of the intervention group (n = 100).
• Oregon has a system of Medicaid Coordinated Care Organizations (CCO), networks of different types of health care providers (physical health care, addictions and mental health care) who have agreed to work together in their local communities to serve people who receive health care coverage under the Oregon Health Plan (Medicaid). CCOs can reimburse for CDSME through their administrative budget as part of their global budget structure. These administrative dollars can be used to cover the cost of health-related services; however, it varies for each CCO. Some CCOs have grant dollars and they encourage area agencies on aging to submit a proposal for the provision of evidence-based programs.  CCOs also have a medical budget that follows the coverage guidance recommended by the Health Evidence Review Commission in Oregon. This commission determines what health services are reimbursable through the CCO’s medical budgets and links them to billing codes for provider use.

Challenges

The process of obtaining Medicaid reimbursement can be lengthy, requiring negotiations with the State Medicaid Agency, the legislature, and other partners, as well as approval by CMS.

• Physical and cognitive limitations of individuals who are served by the State Medicaid Wavier can result in a small pool of members who are able to participate in a community-based workshop.
• Under a capitated reimbursement system, Medicaid providers (organizations that provide and bill for Medicaid services) receive a finite amount of funding for each slot approved in their service area. Because some Medicaid members require a great deal of care, providers may hold a certain amount of funding in a risk pool to fund individuals who are considered “higher need.” Consequently, they may be less likely to consider offering preventive and health promotion programs, such as self-management education.
• Quantifying usage can be a challenge in self-directed programs or capitated systems in which the State Medicaid Agency purchases training and support, but the types of training and support are not specified. It is recommended that specific codes be established for CDSME so that use of the program can be monitored and appropriate steps taken to ensure that individuals who can benefit are being offered the service.
• Staff turnover and large caseloads are barriers to making referrals to CDSME programs. New care managers might not make referrals because they are not sufficiently trained to understand the benefits of CDSME. Further, they might miss opportunities to make referrals due to large caseloads, which limit the time that they can spend with any one patient.
• In some states, care managers are not employees of the Medicaid provider. Instead, their services are provided through a contractual agreement, which can limit the degree of control the Medicaid provider has to enforce its policies and procedures.

Lessons Learned and Recommendations for Future Efforts

• Develop relationships with the State Medicaid Agency, Medicaid MCOs, Medicaid Waiver providers, and consumer organizations to determine which evidence-based programs will best meet the needs of the Medicaid population in your state.
• Secure buy-in for the programs at the local and regional levels, in addition to the state level.
• Use the CDSMP Cost Calculator or develop a worksheet to help determine an accurate cost of the program before approaching your State Medicaid Agency.
• When negotiating the reimbursement rate, build in the costs for wraparound services, such as transportation and respite care, so that members have the support they need to attend the workshops.
• Meet with State Medicaid Agency, Medicaid MCOs, Medicaid providers, and other stakeholders to ensure they have a clear understanding of CDSME and can explain the program and its benefits to Medicaid members, their family members, and caregivers. Be sure to include care managers in conversations, as they are responsible for assessment, referrals, and care planning.
• Work collaboratively to establish written policies and processes to guide the referral and enrollment process. Be sure to develop referral criteria for CDSME programs.
• Establish effective, ongoing communication channels through regular meetings and conference calls to develop, review, and improve processes.
• Work with your State Medicaid Agency and Medicaid MCOs to develop an orientation and ongoing training process for ensuring that care managers and other key staff are knowledgeable about CDSME programs and their value.
• Discuss strategies for marketing the programs early in the process and develop shared responsibilities. As part of your marketing strategy, include information about CDSME in newsletters or other communications that are sent to Medicaid members.
• Develop a user-friendly packet of information about the CDSME programs and their benefits that can be shared with key personnel and distributed to Medicaid members, their family members, and caregivers.
• Consider including CDSME as a standard component of the standard assessment tool that is used to identify and plan for the needs of Medicaid members. By doing so, care managers will be expected to identify and make needed referrals as a routine part of the assessment process.

Helpful Resources

• Home and Community-Based Services (HCBS) Waivers
• CDSMP Cost Calculator