Care Management Manual
Dear care coordinators and case managers:
It is with great pleasure that I welcome you as a care coordinator or care manager to UCare Care Management Services. Clinical Services is pleased to present our most up-to-date Care Management Manual for your use. As you become familiar with the various chapters, tools and resources please provide feedback to our Clinical Liasions on improvement opportunities to our services and supports.
As a leading Managed Care Organization, our goals include ensuring member access to health care, community and waiver services, improved member outcomes, and supporting the living arrangement of choice for our members. Critical to meeting these goals is the well-planned, integrated coordination of care you provide.
Once again, welcome to our team, thank you for supporting our members, and we look forward to a long-term working relationship with you.
VP of Clinical Services
Introduction to the Care Management Manual
UCare developed this Care Management Manual as a means of disseminating instructions and guidance to care coordinators and case managers as they provide these services to our members in different UCare health plans.
Care coordination/case management supports UCare’s mission statement, which is “to improve the health of our members through innovative services and partnerships across communities.” Additionally, UCare is required through contracts with the Minnesota Department of Human Services (DHS) and by the Centers for Medicare & Medicaid Services (CMS) to provide care coordination and/or case management for specific UCare health plans.
UCare follows the requirements set forth by our regulators to set the requirements for case management/care coordination for UCare staff and delegated entities. UCare outlines these requirements on case management/care coordination requirement documents. UCare modifies these requirements from time to time, as regulatory requirements change and best practices evolve, and notifies care coordinators and case managers of the changes in several ways:
- Clinical Services Alerts (email)
- Clinical Services Update (newsletter)
- Quarterly training for care systems and county partners
UCare and/or delegated entities provide case management and care coordination for enrollees in the following UCare health plans:
- UCare Medicare Plans (case management)
- UCare’s MSHO (care coordination)
- UCare MSC Plus (case management)
- UCare’s I-SNP (care coordination)
- UCare Connect (case management)
- UCare Prepaid Medical Assistance (PMAP- Special Health Care Needs)
Case management is a collaborative process. It involves assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs, through communication and available resources, to promote high-quality, cost-effective outcomes. The goals of case management are to:
- Provide appropriate access to care.
- Integrate and improve the coordination of care by:
- Ensuring optimal health status or decrease the rate of health decline.
- Providing social or community support systems.
- Promoting a safe environment.
- Reducing or, if possible, eliminating the impact of behavioral health issues.
- Encouraging self-reliance.
UCare supports and follows the guidelines for the standards of practice from the Case Management Society of America (CMSA). These standards of performance include:
- Appropriate, timely, and beneficial service which promotes quality and cost-effective health care outcomes.
- Professional licensure, training and knowledge of health, social services, and funding sources.
- Collaborative, proactive, and patient-focused relationships.
- Practice in accordance with applicable laws.
- Ethical practice principles such as respect for the autonomy, dignity, privacy and rights of the individual.
- Advocacy for the member and the family, including awareness of and sensitivity to culturally appropriate care.
UCare and its delegated entities' case management practices must be consistent with relevant Minnesota Department of Human Services (DHS) contract provisions regarding care coordination/case management services.
Care coordination is the coordination of services for a member among different health and social service professionals and across settings of care. Care coordination can include case management as described above or can consist of a more limited coordination role such as referral to a service.
UCare Health Plans
Minnesota Health Care Programs (MHCP)
MinnesotaCare - A state-subsidized program for people and families without access to affordable health care coverage and living in UCare’s 55-county service area.
Prepaid Medical Assistance Program (PMAP) – A federally and state-funded program for people and families who meet income and other eligibility requirements, including living in UCare’s 38-county service area. This program provides medical services to Medical Assistance managed care enrollees.
Minnesota Senior Care Plus (MSC Plus) – A federally and state-funded program for people age 65 or older who meet income and other eligibility requirements and live in UCare’s 66-county service area. This program provides medical services to Medical Assistance managed care enrollees.
UCare Connect – A plan designed to meet the unique needs of adults with certified physical disabilities, developmental disabilities, and/or mental illness. It is for people ages 18-64 who are eligible for Medical Assistance and who live in UCare’s 62-county service area.
UCare Connect + Medicare – A plan that combines the benefits of Medicare and Medicaid. It is for people between the ages of 18-65 with a certified disability who are eligible for Medical Assistance and are enrolled in Medicare Parts A and B, and who live in UCare’s 62-county service area.
UCare’s Minnesota Senior Health Options (MSHO) – A plan that combines the benefits of Medicare and Medicaid. It is for people ages 65 and older who are eligible for Medical Assistance and are enrolled in Medicare Parts A and B, and who live in UCare’s 66-county service area.
UCare’s Institutional Special Needs Program (I-SNP) – One of three recognized Special Needs Plans that serve Medicare members who qualify for a nursing home level of care as determined by the state of Minnesota. These members reside in various care institutions such as long-term care, or assisted living facilities.
UCare Medicare Plans (Medicare Advantage, HMO-POS) – Affordable Medicare plana available throughout Minnesota and Wisconsin.
UCare’s Minnesota Senior Health Options (MSHO) Overview
Care Coordination Resources for UCare's MSHO:
Requirements, forms, letter templates and process guidelines.
Minnesota Senior Care Plus
Minnesota Senior Care Plus (MSC+) Overview
Care Management Requirements and Resources for MSC+:
Requirements, forms, letter templates and process guidelines.
Rate Cells | MSHO and MSC Plus
MSHO and MSC+ health plans are paid based on rate cells. Assignment of rate cell categories is done by the State of Minnesota, based on information in Medicaid Management Information Systems (MMIS) at the time of capitation. The rate cell is determined on the day of capitation for the following month. Managed care capitation normally occurs six working days before the end of the month. An example is that the day of capitation was March 24, 2009, for the month of April.
MSHO and MSC+ rate cell changes have been automated since January 2006.
- Rate Cell A: If no EW waiver span and the member’s living arrangement in MMIS is community.
- Rate Cell B: If an open EW waiver span and the member’s living arrangement in MMIS is community.
- Rate Cell D: If no EW waiver span and member’s living arrangement is institutional.
MSHO and MSC+ Responsibilities
- Nursing homes need to submit Form 1503 to the counties, to change living arrangements to institutional.
- The county is responsible to make sure status is changed in MMIS upon notification.
- Health plans must provide and pay for services based on identified need, regardless of rate cell paid for that month.
- Close the waiver span when a member is institutionalized or dies.
UCare Connect + Medicare Overview
Care management resources for UCare Connect + Medicare:
Requirements, forms, letter templates and process guidelines.
The UCare Provider Manual is a reference guide for direct service providers of all types who serve UCare members. Updated regularly, its guidelines are part of the contract between UCare and its provider network. The manual lays out policies and procedures as well as tools and guidelines to assist providers in working with UCare and our members.
View the UCare Provider Manual
Utilization review is a formal evaluation of the medical necessity, appropriateness and efficacy of the use of health care services, procedures and facilities. Reviews are completed by a person or entity other than the attending health care professional to determine the medical necessity of the service or admission.
UCare follows the standards set forth in Minnesota statue or provider contract (as applicable). Utilization review may be conducted prior to service (pre-service), concurrently or retrospectively (post-service).
Notification is required from providers for certain high-cost or high-utilization services. Services requiring notification are listed in the Authorization and Notification Requirements grids. The provider must inform UCare upon providing those services to a member.
Prior authorization is not required for members to access care from participating providers for services not on the prior authorization grids.
Delegation of Utilization Management occurs when UCare contracts with an external organization (“delegated entity”) to perform specific utilization management functions. Those functions can include utilization review for specified UCare plans or services. The contract between UCare and the delegated entity is called a delegation agreement. This agreement is mutually agreed upon by both organizations. It describes the delegated functions (or activities) and the specific responsibilities of both organizations.
UR Communication form
The UR Communication Form can be used for communicating the start, reduction, or termination of PCA and/or Home Health Care Services.
Examples for use:
- Reduce/Term PCA services
- 45 Day Temp Start/Increase
- PCA Extended services
- Communicate requests to reduce or terminate home care services that are discovered to be duplicative or exceed the waiver budget cap.
- Report inability to complete PCA assessment due to member refusal, inability to reach member, or denial of any early PCA reassessment.
NOTE: This form is not used to initiate medical services such as home health aide and skilled nursing visits. Those requests must come to UCare from the home care agency or provider delivering the service.
Delegation oversight has four main components:
- Pre-delegation Assessment: UCare conducts a pre-delegation assessment prior to formal delegation in order to assess the entity’s willingness and ability to perform the desired delegated functions.
- Delegation Agreement: Once UCare determines the delegate is willing and able to perform the functions appropriately, UCare enters into a delegation agreement with the delegate. The agreement specifies the agreed-upon activities of both UCare and the delegate.
- Ongoing Oversight: UCare is responsible for oversight monitoring and communication with all delegates which is conducted through face-to-face meetings, e-mails, phone conversations, audit reports/reviews/follow-up (including mock audits); and ongoing compliance/performance education as needed.
- Annual Oversight Audit: UCare conducts an annual oversight audit of all delegates. UCare uses audit tools designed to assess the performance of the delegate based on the delegation agreement and required regulations including technological systems used by delegates performing utilization review. UCare makes an effort to inform delegates of the expectations for compliance prior to the annual audit. This is done by disseminating the content of the audit tool and audit process to the delegates. Additionally, quarterly mock audits are conducted to determined compliance and offer feedback/education to delegates (when necessary) prior to the annual audit.
UCare delegates utilization management and case management/care coordination to selected care systems, counties and other agencies.
The clinical compliance team resides in UCare’s Corporate Compliance Department. The team’s primary function is to oversee the delegated utilization management and case management/care coordination activities performed by delegates of UCare to ensure that the delegates maintain compliance with regulatory and contractual obligations. UCare also provides clinical liaisons for care system and county delegates.
Delegation oversight has four main components.
Pre-delegation Assessment. UCare conducts a pre-delegation assessment prior to formal delegation, in order to assess the entity’s willingness and ability to perform the desired delegated functions.
Delegation Agreement. Once UCare determines that the delegate is willing and able to perform the functions appropriately, UCare enters into a delegation agreement with the delegate.
The agreement specifies the agreed-upon activities of both UCare and the delegate. Annual Oversight Audit. UCare conducts an annual oversight audit of all delegates. UCare uses audit tools designed to assess the performance of the delegate based on the delegation agreement and required regulations. System delegates performing utilization management are audited on an annual basis.
UCare makes an effort to inform delegates of the expectations for compliance prior to the annual audit. This is done by disseminating the content of the audit tool and audit process to delegates, as well as conducting compliance education for delegates.
Ongoing Oversight. UCare conducts ongoing oversight of all delegates throughout the year. This consists of ongoing communication with delegates, as well as review and follow-up related to the performance of all delegated activities by each delegate. The oversight is conducted through face-to-face meetings, e-mails, phone conversations, audit report reviews and follow-up, and ongoing compliance education for delegates.
Clinical Care System and County Liaisons
The Clinical Services Department's Clinical Liaisons have primary accountability and responsibility for:
- Establishing and maintaining positive working relationships with delegated care system and county entities.
- Acting as a key contact for care system and county delegate questions and problem resolution.
- Organizing and facilitating quarterly educational/training meetings for internal and external care coordinators.
- Developing and maintaining UCare’s Case Management Manual and delegate training manuals.
- Producing the monthly CLS Newsletter. Issuing CLS Alerts as needed.
The goal for Mental Health and Substance Use Disorder (MH & SUD) Case Management is to provide member centric advocacy and access to appropriate care for their mental health, substance use or social determinant needs. MH & SUD Case Management is offered to PMAP, MNCare, MSHO and MSC+ members with the goal of expanding to adding additional programs in 2021.
The criteria for members to qualify for MH & SUD case management are as follows:
- 2 mental health, substance use or eating disorder admissions in the past 12 months
- 2 admissions to Residential Treatment for mental health, substance use disorder, IRTS or eating disorder
- 3 admissions in the past 6 months for crisis residential
- 2 episodes in the past 12 months for partial hospitalization program
- 2 visits in the past 6 months of mental health, substance use or eating disorder related emergency room visits
- 2 admissions in the past 6 months for detox
Please note: Member must meet one or more of these criteria to be qualified for MH & SUD Case Management.
If you would like to refer a member to MH & SUD Case Management, please complete the MH & SUD Case Management referral form. If the member does not meet criteria for MH & SUD Case Management, there is an option to consult with a MH & SUD Case Manager to discuss the member’s mental health or substance use disorder needs via UCare’s MH & SUD Triage Phone Line.
UCare’s MH & SUD Triage Phone Line is available to all UCare member’s, providers and care coordinators. The MH & SUD Triage Line is designed to support member’s mental health or substance use disorder need, such as:
- Crisis Intervention
- MH & SUD Case Management Referrals
- MH & SUD Case Management Consultation
- MH & SUD Provider In-Network and Specialty Search
- MH & SUD Service Authorization and Notifications
- Identification and Connection to Community Resources
UCare’s MH & SUD Triage Line is available Monday through Friday, 8 am to 5 pm with afterhours support available. You may reach the MH & SUD Triage Line at 612-676-6533 or toll-free at 1-833-276-1185.
Disease management is a coordinated care approach focused on prevention, early identification, and intervention in the chronic disease process. Its goal is to provide cost-effective, holistic, and quality health care for a patient population identified as having a specific chronic illness or medical condition.
Disease management interventions and communications are targeted to members to promote self-care efforts and treatment plans that will help them better manage their conditions. The goal is to improve the health of these individuals by working more directly with them and their physicians to improve health outcomes.
UCare Disease Management programs apply a multi-disciplinary, continuum-based approach to improve the health of members with a specific chronic illness or medical condition by:
- Supporting the physician/patient relationship and place of care.
- Empowering members, by the use of health coaching, to set short- and long-term health and wellness goals.
- Emphasizing the prevention of exacerbations and complications, using cost-effective and evidence-based practices, and using patient empowerment strategies such as self-management through health coaching.
- Continuously evaluating the clinical, human, and economic outcomes with the goal of improving overall health.
State and federal requirements affect UCare’s Disease Management programs. The 2019 Department of Human Services (DHS) contract for Families and Children and the 2019 Special Needs Basic contract mandate a Population Health Management strategy. UCare provides disease management programming as part of our Population Health Management strategy.
Currently, UCare’s disease management services are targeted to members with the following chronic illnesses or medical conditions:
- Asthma (eligible products: PMAP, MNCare, Connect, Connect+, IFP plans)
- Chronic kidney disease (all products are eligible)
- Diabetes (all products are eligible)
- Heart failure (all products are eligible)
- Migraine (eligible products: PMAP, MNCare, Connect, Connect+ and MSC+)
- Telemonitoring for coronary artery disease, heart failure, chronic obstructive pulmonary disease, diabetes and hypertension (eligible products: PMAP and MNCare)
- Interactive Voice Response (IVR)/Texting Program: Pediatric and adult members in our IVR/texting program receive regularly scheduled education phone calls providing chronic condition education and condition-related questions to respond to. Answers are triaged for follow up support provided by an asthma educator where the call is triaged for further education, referral to PCP or enrollment in the asthma action program.
- Asthma Action Program: Pediatric and adult members (under 65) in our asthma program receive a home asthma visit (if within 60 miles of the metro area) followed by regular asthma education and care management phone calls. This program helps members and families manage their asthma to lead a healthy lifestyle. Asthma management tools, such as pillowcase covers, medication chambers and other informative materials, are provided to participating members.
- Members enrolled in PMAP, MNCare, Connect, Connect+, IFP plans are eligible for the asthma programs.
- Interactive Voice Response (IVR)/Texting Program: Adult members in our IVR/texting program receive regularly scheduled education phone calls providing chronic condition education and condition-related questions to respond to. Answers are triaged for follow up support provided by a health coach where the call is triaged for further education, referral to PCP or enrollment in the health coaching program.
- Health Coaching: Adult members in our diabetes program receive regularly scheduled health coaching calls with a UCare health coach. Our team of coaches partner with members to discover their barriers and vision for the future, establishes short- and long-term behavior change goals, and empowers members to achieve their goals. Health coaches use active listening, motivational interviewing and behavior change techniques. Diabetes management tools, such as our award-winning Health Journey education book, pedometer, diabetic bracelets, cookbooks and wrist blood pressure cuff, are provided to participating members.
- Healthy Hearts: Adult members in our Healthy Hearts heart failure program receive regularly scheduled health coaching calls with a UCare health coach. Our team of coaches partner with members to discover their barriers and vision for the future, establishes short- and long-term behavior change goals, and empower members to achieve their goals. Health coaches use active listening, motivational interviewing and behavior change techniques. Heart failure management tools, such as our award-winning Health Journey education book, bathroom scale, wrist blood pressure cuff and cookbooks, are provided to participating members.
- Telemonitoring program: Adult members in our high-risk heart failure program receive a Medtronic telemonitoring device to assess daily weight and heart failure symptoms. Member data is transmitted to a Medtronic RN for triage, assessment and follow up. If member data suggest a flare up of heart failure, the PCP is contacted. In addition, the member receives monthly RN phone calls with education on heart failure, co-morbid conditions and lifestyle management. Recent telemonitoring data is made available for member physician office visits. The telemonitoring device is available in English and Spanish.
MIGRAINE MANAGEMENT PROGRAM
- Adult members in our migraine management program receive regularly scheduled health coaching calls with a UCare health coach. Our team of coaches partner with members to discover their barriers and vision for the future, establishes short- and long-term behavior change goals, and empowers members to achieve their goals. Health coaches use active listening, motivational interviewing and behavior change techniques. Migraine management tools including a headache management book and migraine action plan are provided to participating members. Members enrolled in PMAP, MNCare, Connect, Connect+ and MSC+ are eligible for the migraine management program.
CHRONIC CONDITION MANAGEMENT TELEMONITORING PROGRAM
- Adult members in our chronic condition management telemonitoring program diagnosed with CAD, CHF, COPD, diabetes and/or hypertension are eligible to participate in the Medtronic telemonitoring program. Members receive a tablet with applicable peripheral (i.e BP cuff, weight scale) to assess daily chronic condition biometrics and symptoms. Member data is transmitted to a Medtronic RN for triage, assessment and follow up. If member data suggest a flare up of their chronic condition, the PCP is contacted. In addition, the member receives monthly RN phone calls with education on their chronic condition, co-morbid conditions and lifestyle management. Recent telemonitoring data is made available for member physician office visits. The telemonitoring tablet is available in English and Spanish. Members enrolled in PMAP and MNCare are eligible for the chronic condition management telemonitoring program.
Members receive equipment, such as a wrist blood pressure cuff, bathroom scale, or educational materials) based on their conditions and goals. The primary care clinic and care coordinator/case manager receive a letter of member enrollment into the program.
Disease management programs are evaluated annually using these criteria:
- Clinical impact on UCare members
- Operational components of each program
- Potential for member and provider satisfaction
- Potential return on investment
UCare’s Quality Improvement Advisory and Credentialing Committee (QIACC) provides input for individual programs.
Furthermore, UCare follows the Standards for Accreditation of Managed Care Organization established by the National Committee for Quality Assurance (NCQA). The program structure is described in UCare's Utilization Management Plan and implemented through Clinical Services policies and procedures.
UCare’s Quality Improvement activities include identifying and implementing a wide array of initiatives and projects that focus on improving the health of our members. In addition to working with our regulatory organizations, UCare collaborates with other health plans and partners with UCare providers on quality improvement projects to improve the health of our members.
The Minnesota Department of Human Services helps people meet their basic needs by providing or administering health care coverage, economic assistance, and a variety of services for children, people with disabilities and older Minnesotans.
DHS Website (external site)
DHS Bulletins (external site) Announcements, program changes, fiscal and budgetary information, and requests for information; published for counties, tribal health and human service agencies and other DHS business partners.
DHS eDocs (external site)
A searchable online collection of DHS forms and documents in multiple languages, maintained for clients, county workers, providers, employees and other stakeholders.
DHS Provider Manual for Minnesota Health Care Programs (external site)
A regularly updated reference guide for state public program coverage policies, rates and billing procedures.
Policy Quest (external site)
A public database of questions and answers on disability and aging topics, maintained for consumers, service providers and other interested persons.
UCare adopts and disseminates clinical practice guidelines to enhance member and clinical decision-making, improve health care outcomes, and meet state and federal regulatory requirements. These practices are found in the UCare Provider Manual.