Medicare chronic care improvement program

Medicare chronic care improvement programs are valuable healthcare plans for those who struggle with repeat hospital visits. That is why it is so important for insurance providers to be well educated on the value and common questions associated with Medicare chronic care management improvement programs. From qualifying requirements to relevant Plan Sections, knowing the ins and outs of the program is important for insurers.

What is a Quality Improvement Organization?

The quality improvement organization program is “dedicated to improving health quality for Medicare beneficiaries.” It is also “an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at a lower cost.” A QIO is a dedicated group of healthcare professionals that are experts in their fields and contribute to the quality of care that is provided to beneficiaries by Medicare. CMS lists two different kinds of QIOs:

• Beneficiary and Family-Centered Care (BFCC)-QIOs: This is a tool for people who have Medicare to ensure their own healthcare quality. If the patient feels like they received a wrong diagnosis or a wrongful discharge, this is where they can find an answer.
• Quality Innovation Network (QIN)-QIOs: There are 14 quality innovation networks that focus on “data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality.”

Quality improvement programs include chronic care improvement initiatives that are especially created for those who have chronic conditions and are long-term hospital and healthcare users.

Medicare chronic care improvement programs

Medicare chronic care improvement programs are a type of Medicare Advantage Plan that was created to promote effective management of chronic diseases. Because of the uniquely high cost of healthcare for those who are impacted by chronic illnesses, the program is designed to serve those populations' needs. In addition, all Medicare Advantage Organizations (MAOs) Medicare must have chronic care management services programs which aim to increase overall American community health.

According to the Centers for Medicare & Medicaid Services, CCIPs have two components:

• Plan Section: This is where you will find the descriptions and the criteria for the programs. In addition, you can learn the best “methodology used for identifying participating enrollees, mechanisms for monitoring participants, and performance assessments.”
• Annual Update: Each year, the MAO must report on their progress using the CCIP. Other updates and status reports may be available.

CCIPs fall under the Special Needs Plans (SNPs), which provide unique care management for specific groups of people. Keep in mind that these sections are required to be completed annually by MAOs, but are not required to submit to CMS unless requested.

Project duration

CCIPs have a project duration of three years. This is the case for all quality improvement projects, regardless of qualification status.

Qualifying standards

As the name suggests, the target population to be enrolled and eligible for a CCIP must meet certain criteria. The participant must have a developed chronic illness that requires intense care coordination. Let's look at some examples of conditions that CMS lists as possibly qualifying, severe conditions:

• Cancer.
• Congestive Heart Failure.
• Dementia.
• Diabetes.
• Asthma.
• A variety of behavioral health conditions.
• HIV/AIDS
• Parkinson's Disease.

These are just a few examples, and there are many more qualifying conditions that require clinical care. According to the Centers for Disease Control (CDC), a good general definition of chronic disease is a condition that “lasts 1 year or more and requires ongoing medical attention or limit activities of daily living or both.” This is something that many Americans struggle with, making CCIPs a necessary implementation to provide long term services.

The CDC reports that chronic illnesses are the “leading drivers of the nation's $3.8 trillion in annual public health care costs.” Medicaid services strive to provide primary care to those who have a chronic disease, and quality measures ensure that CCIPs are effective. It is a requirement that all MAOs must have a quality improvement program, which includes CCIPs.

MAO requirements

There are requirements that every MAO must meet if they implement a CCIP. For example, a health plan management system must be used to report the status of their plan. The overall purpose of any active CCIP is to achieve certain objectives that promote effective management of a chronic condition through their health care provider. The following are a few objectives that support this goal:

• Improve health conditions and health outcomes.
• Increase the amount that health services are being used.
• Include important health interventions.
• Reduce potential health disparities in the community.
• Meet the CMS quality strategy.

CCI programs and prescription drug plans

The Coordinated Care Initiative is an initiative that applies in California only. It combines healthcare and other services, like prescription drug plans. According to the LA Care Health Plan, there are two major components of CCI which are Cal MediConnect and the Managed Medi-Cal Long-Term Supports & Services (LTSS). Cal MediConnect is a three-year program that enrollees must volunteer to be a part of it. For those that live in California, it is a great way to combine medical health, prescription plans, and potential chronic care plans.

As health insurance providers, it is imperative to be conscious of how CCIPs work and how to guide beneficiaries in the right direction. Legislation like the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, which was passed in 2018, is changing the way that Americans are treated in their pursuit of health.