Care Management
Chapters
Care coordination and case management supports UCare’s mission statement, which is “to improve the health of our members through innovative services and partnerships across communities.”
UCare follows community best practices as well as the requirements set forth by regulators to determine the practice standards and expectations for care coordination/case management. UCare outlines care coordination/case management practice standards and expectations in the requirement documents within the manual. 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:
Care Coordination Alerts (email)
Care Coordination Newsletter (monthly)
Quarterly training for care systems and county partners
UCare and/or delegated entities provide care coordination and case management for enrollees in the following UCare health plans:
UCare MSC+ (care coordination)
UCare Connect (care coordination
UCare Prepaid Medical Assistance Plan (PMAP) (case management)
Care coordination and case management are collaborative processes that involve assessment, support planning, facilitation, and advocacy for options and services to meet an individual’s health needs, through communication and available resources.
Care coordination and case management goals are to:
- Improve access to the appropriate care
- Promote high-quality and cost-effective outcomes
- Improve the coordination of care by:
- Ensuring optimal health status or decreasing the rate of health decline
- Reducing or preventing unnecessary rehospitalization
- Promoting a safe environment
- Reducing or eliminating the impact of behavioral health issues
- Encouraging self-reliance
- Providing social or community support systems
UCare's practices must be consistent with relevant Minnesota Department of Human Services (DHS) contract provisions regarding care coordination/case management services.
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 33-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 +) – A federally and state-funded program for people age 65 or older who meet income and other eligibility requirements and live in UCare’s 33-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 67-county service area.
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. UCare adopts and disseminates clinical practice guidelines to enhance member and clinical decision-making, improve healthcare outcomes, and meet state and federal regulatory requirements. The UCare Provider Manual lays out policies and procedures as well as tools and guidelines to assist providers in working with UCare and our members.
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).
Authorizations are required for select services. Services requiring authorization or notification are listed in the 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.
Authorization and Notification Requirements grids. The provider must inform UCare prior to providing those services to a member.
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.
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.
Delegation Oversight
Delegation oversight has four main components.
1. 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.
2. 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.
3. 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.
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.
4. Ongoing Oversight. UCare conducts 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 web-ex meetings, e-mails, phone conversations, audit report reviews and follow-up, and ongoing compliance education for delegates.
Quality Review
The Quality Review is complementary to annual DHS compliance audits. Quality Reviews are conducted annually and geared towards improving member experience and highlighting strengths of the care coordination process. It is designed to review and provide feedback on current care coordination requirements and practices in real-time. The outcomes do not result in corrective action plans but rather provide the delegate with an opportunity to provide training and education to care coordinators and improve processes in preparation for the compliance audit.
Clinical Liaisons
The Care Coordination and Long-Term Services and Supports (CCL) 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 Care Coordination Manual and training materials.
- Producing the monthly Care Coordination Newsletter.
- Issuing Care Coordination Alerts as needed.
The goal for Mental Health and Substance Use (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 members on all UCare products.
Members must meet one or more of the following criteria to qualify for Mental Health and Substance Use Disorder Case Management:
- Member has a mental health condition or substance use disorder and a need for more support is identified
- Member has a diagnosis of Autism or a related condition
Please note: MH & SUD Case Managers will provide consultation regarding members other than those listed above and may open these members for case management based on member need.
If you would like to refer a member to MH & SUD Case Management, please complete the MH & SUD Case Management referral form. Members in need of locating an in-network MH & SUD provider can call UCare Customer Service for assistance.
UCare's disease management programs exist to improve the health of members through innovative approaches for asthma, diabetes and heart failure. The programs take a holistic approach in working with members which focus on supporting members in improving or maintaining their health.
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 participating members 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 to set short- and long-term health goals.
- Emphasizing the prevention of exacerbations and complications, using cost-effective and evidence-based practices, and using patient empowerment strategies.
- 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 2025 Department of Human Services (DHS) contract for Families and Children mandates a Population Health Management strategy. UCare provides disease management programming as part of our Population Health Management strategy.
Currently, UCare’s disease management programs are offered to members with the following chronic illnesses or medical conditions:
- Asthma (eligible products: PMAP, MNCare, Connect, Connect+, IFP plans)
- Diabetes (all products are eligible)
- Heart failure (all products are eligible)
Current Disease Management program information and referral forms are located at UCare - Disease Management.
Asthma
- Asthma Health Coaching: Our asthma program's pediatric and adult members (under 65) receive regularly scheduled health coaching calls with a UCare health coach. Our coaches partner with members to discover their barriers and vision for the future, establish short and long-term behavior change goals and empower members to achieve them. Health coaches use active listening, motivational interviewing and behavior change techniques. This program helps members and families manage their asthma to lead a healthy lifestyle.
- Members enrolled in PMAP, MNCare, Connect and IFP plans are eligible for the asthma program.
Diabetes
- Adult members in our diabetes program receive regularly scheduled health coaching calls with a UCare health coach. Our coaches partner with members to discover their barriers and vision for the future, establish short and long-term behavior change goals and empower members to achieve them. Health coaches use active listening, motivational interviewing and behavior change techniques.
Heart Failure
- Adult members in our Healthy Hearts heart failure program receive regularly scheduled health coaching calls with a UCare health coach. Our coaches partner with members to discover their barriers and vision for the future, establish short and long-term behavior change goals and empower members to achieve them. Health coaches use active listening, motivational interviewing, and behavior change techniques.
The effectiveness of UCare’s disease management programs is evaluated based on improved HEDIS rates, as applicable, decreased utilization such as hospital admissions, emergency department visits and hospital readmissions and meeting or exceeding benchmark goals. UCare recognizes the diverse population of the membership and addresses the specific needs of all members.
UCare’s Quality Improvement Advisory and Credentialing Committee (QIACC) provides input for individual programs.
Furthermore, UCare follows the Standards for Accreditation of Managed Care Organizations established by the National Committee for Quality Assurance (NCQA). The program structure is described in UCare's Utilization Management Plan and implemented through Quality Management policies and procedures.