Designing and Implementing Medicaid Disease and Care Management Programs

Appendix: State Overviews (continued)


Oklahoma: Care Management Program

Oklahoma expanded its care management program statewide in 2004. The program covers both the Temporary Assistance for Needy Families (TANF) and aged, blind, and disabled (ABD) populations in the primary care case management (PCCM) and fee-for-service (FFS) programs, focusing on managing complex conditions and reducing comorbidities.

In 2006, the State legislature required Oklahoma to implement a care or health management program. Oklahoma issued an RFP focusing on high-cost individuals with one or more chronic conditions. The State will provide patient education and care management services to members, with in-person care management for the highest risk members. The program will also include the development of provider collaboratives focused on holistic health management and evidence-based guidelines, and practice site improvement for selected providers. The State recently awarded the contract for this program to the Iowa Foundation for Medical Care. Oklahoma held its implementation meetings with the vendor and is preparing to launch their program in early 2008.

Program Planning

After discontinuing its full-risk Medicaid managed care program, Oklahoma significantly increased its care management program (from 8 fulltime equivalents [FTEs] to 36 FTEs) for members enrolled in the expanded statewide PCCM program.

Program Design

Oklahoma's PCCM program, SoonerCare Choice, serves through mandatory enrollment the majority of Medicaid beneficiaries. Excluded from SoonerCare Choice are members dually eligible for Medicaid and Medicare, enrolled in an managed care organization (MCO), institutionalized, or enrolled in home- and community-based waiver programs, as well as children in State or tribal custody.

Oklahoma includes members from its PCCM program in the care management program. Members under the following conditions are automatically enrolled:

  • Children receiving in-home private-duty nursing.
  • Women enrolled in the Breast and Cervical Cancer Prevention and Treatment Program (BCCPTP).
  • Tax Equity and Fiscal Responsibility Act of 1982 children.
  • Transplant candidates.
  • Referred individuals with complex and diverse conditions, such as frequent emergency room (ER) utilization, high-risk pregnancy, high-risk newborns, dual diagnoses (in coordination with the Behavioral Health Department).

Program Implementation

Clients are identified and enrolled in the care management program in the following ways:

  • Claims and encounter data.
  • Medicaid eligibility workers.
  • Second tier referrals of members with four or more ER visits per quarter.
  • Referrals from physicians, nurses, family, or friends.
  • Calls by beneficiaries to member services or the SoonerCare Helpline.

The major provider-oriented activity is care coordination for complex cases, including specialty referrals. Nurses maintain a current list of specialists who will see Medicaid patients. The nurses also help expedite particular referrals when needed or arrange for specialty care within and outside Oklahoma.

Care management nurses attempt to contact each woman enrolled in the BCCPTP to facilitate diagnostic and treatment services. This contact continues until the woman no longer needs treatment for breast or cervical cancer.

Providers helped develop the evaluation grid used to evaluate children for in-home private-duty nurse services. Oklahoma educates the provider community about care management services through outreach, including health fairs, and provider training. The care management program collaborates with large provider groups, including State university provider panels.

Program Interventions

Oklahoma's care management program continued some of the interventions implemented by the MCOs. Interventions include the following:

  • Toll-free care management telephone system.
  • Nurse exceptional needs coordinators.
  • Patient self-management.

Program Evaluation

The Emergency Room Utilization Initiative has realized positive results, with large decreases in ER visits. Oklahoma employs claims and encounter data to create provider profiles, which the State develops and distributes to the SoonerCare Choice provider network. Additional profiling efforts developed include breast and cervical cancer screening; Early Periodic Screening, Diagnosis, and Treatment; and immunizations. Oklahoma is interested in moving the program to a predictive model that is more proactive in nature.

Emergency Room Utilization Initiative

The Emergency Room Utilization Initiative was implemented to curtail improper ER utilization. The initiative includes:

  • PCCM provider profiling of assigned enrollees' ER utilization to show PCCM primary care providers their patients' ER utilization rates and how these rates compare to these providers' peers.
  • Outreach to beneficiaries with high ER utilization (four or more visits in a quarter).
  • Interventions include letters, telephone calls, primary care provider assignment, and location of specialists.
  • Follow-up on nurse call line calls that directed beneficiaries to the ER.

Additional Information 

Oklahoma Medicaid Web site:

Return to Appendix Contents


Pennsylvania: ACCESS PLUS

Pennsylvania implemented ACCESS Plus, its enhanced primary care case management (EPCCM) and disease management program in 2005. ACCESS Plus covers both the TANF and ABD populations with a disease management focus on asthma, diabetes, congestive heart failure (CHF), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and high-risk obstetrics.

Pennsylvania's Pay-for-Participation Program

Pay-for-participation payments are made in addition to Medicaid fees paid for covered professional services. Physicians receive payments for:

  • Reviewing and partnering in the ACCESS Plus program.
  • Contacting newly eligible high-risk patients to encourage them to enroll in the program.
  • Furnishing contact information for selected patients.
  • Completing the Chronic Care Feedback Form that care coordination nurses use to help them monitor and coach high-risk patients more effectively.
  • Implementing clinical interventions for year one, based on self-reported data by high-risk patients.
  • Implementing clinical interventions for year two, based on claims data for both high-risk and low-risk patients.
  • Implementing clinical interventions for year three (measures yet to be selected).
  • In November 2007, Pennsylvania transitioned its program to reward providers for improvements in clinical outcomes.

Program Planning

Prior to implementing ACCESS Plus, the State was having difficulty expanding mandatory managed care into additional counties, which were more rural, had low managed care penetration, and had little provider interest. To mitigate these issues, Pennsylvania decided to pursue an EPCCM and disease management program.

To begin planning ACCESS Plus, Pennsylvania used lessons learned from its mandatory Medicaid managed care program. The State formed an interdepartmental workgroup, included various stakeholders, and consulted with other State programs. During the procurement process, Pennsylvania worked closely with the Centers for Medicare and Medicaid Services (CMS) to develop an RFP and corresponding waiver. Pennsylvania also collaborated with potential vendors through the pre-RFP and proposal process. To review bids, the State used both a technical committee and a cost committee.

Program Design

The EPCCM and disease management program is operated through a vendor contract and medical home model. With the exception of managed long-term care enrollees, nursing home residents, institutionalized persons, and dual eligibles over age 21, all newly eligible Medicaid beneficiaries in the additional counties are automatically enrolled in ACCESS Plus. Members who choose to participate in voluntary managed care are disenrolled from ACCESS Plus. An independent enrollment assistance vendor educates Medicaid beneficiaries on their choices, helps them with primary care provider selection, and processes all enrollments.

Program Implementation

The State assembled Regional Advisory Committees comprised of physicians and program members who meet regularly to offer feedback on disease management activities. The vendor also created a monthly steering committee and an advisory committee that included providers and health plan representatives. Each of these entities renders constant feedback to the vendor and the State.

Pennsylvania also launched a pay-for-participation program designed to offer incentives for providers in three critical areas: help enrolling eligible patients in the program, collaboration in members' disease management, and delivery of key clinical interventions that help improve quality of care and clinical outcomes. The program strives to minimize workflow impact for offices by providing flexibility as to who completes the Chronic Care Feedback Forms to meet requirements.

Program Interventions

Three care management units operate for the ACCESS Plus population: Primary Care Case Management, Disease Management, and Intensive Case Management. All three units work together to refer patients to respective units that can better meet their needs:

  • Primary Care Case Management. This unit, operated by Pennsylvania's vendor, provides care or services beyond what is typically offered to PCCM members. Services might include prevention, care coordination, and support for high-risk pregnancies.
  • Disease Management. Operated by Pennsylvania's vendor, this unit includes a field staff of community-based nurses and workers. The community-based nurses help deliver disease management services to program members. Interventions can be telephonic or in-person if staff are unable to reach the member by telephone. Nurses encourage members to visit their primary care provider, teach members to recognize signs of disease process, increase members' self-management skills, coordinate with the provider's plan of care, and promote a healthy lifestyle. Community-based workers locate the member, explain services and benefits, and help locate basic community resources. Pennsylvania's vendor employs a proprietary risk stratification methodology with three tiers:
    1. Level One. Educational mailings, nurse call line, audio health libraries. (The patient receives a call from a nurse care manager at weeks six and 26.)
    2. Level Two. All Level One services plus more frequent calls from a nurse care manager. (The patient might be referred to PCCM, whereby the patient's provider is notified that he or she is receiving disease management.)
    3. Level Three. All Level One and Level Two interventions plus in-person visits and a more intensive call schedule.
  • Intensive Case Management. Operated by State staff, this unit provides services to high-risk members with a range of conditions. The majority of case management is telephonic; in-home visits are conducted on a case-by-case basis.

Program Evaluation

Pennsylvania conducted a chart review of modified HEDIS measures using six medical technicians (approximately 1.5 FTEs for two months) who pulled samples for each HEDIS parameter and programmed claims data to run modified HEDIS measures.

Additional Information

Pennsylvania Medicaid Web site: 

Pennsylvania ACCESS Plus Program Web site:

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Rhode Island: Connect CARRE (Coordinated Assessment Referral Re-Assessment Evaluation)

Rhode Island began serving adult FFS members through a chronic care program, Connect CARRE, in 2002. The program is not disease specific, but instead identifies high-risk and high-cost members to assist through care management. Rhode Island has a provider contract with a State MCO to provide nurse care managers for the program.

Rhode Island's Lessons Learned: Self-Management

  • Be prepared for a significant time and financial commitment.
  • Partner with other State entities to "share the wealth."
  • Explain the program clearly to partnering entities and new trainers.

Program Planning

Rhode Island created its managed care program in response to a legislative mandate and State concerns about the cost and quality of care for adults with chronic conditions. Approximately 45,000 adults are enrolled in the FFS program, and 15,000 are not dual eligibles and are living in the community. Of the 15,000, 620 have been served through Connect CARRE. Program goals include the following:

  • Improve the wellness of chronically ill members by engaging, empowering, and educating them to manage their conditions.
  • Promote primary and preventive care through the medical home.
  • Reduce acute care costs by shifting care appropriately to community and ambulatory care settings.
  • Improve disease-specific care and monitoring.

Program Design

Rhode Island partnered with Medicaid's Neighborhood Health Plan of Rhode Island (NHPRI) to build its care management program. NHPRI provides nurse care management to the program through a provider agreement. Targeting adults with three or more chronic conditions living in the community, Connect CARRE focuses on teaching self-management techniques, managing comorbidities and social issues, and providing care guidelines for people with specific diseases.

Program Implementation

Rhode Island uses predictive modeling to identify high-risk adults for the program. Initially, identified patients were invited to join the program, but enrollment was low. Rhode Island switched to an opt-out strategy, which increased enrollment. Due to incorrect address data and limited consumer response, however, enrollment was still too low to keep the program viable. Rhode Island then placed a nurse care manager at its largest hospital and began training hospital discharge planners to refer patients to Connect CARRE. This method has proven the program's most successful recruiting strategy.

Program Interventions

NHPRI has four nurse care managers, dedicated fulltime to this project, making in-person visits and providing telephonic care. The nurse care managers lead a care team that can include the patient's primary care provider, social worker, and pharmacist to coordinate care. Given the severity of their conditions, patients typically do not graduate from the program.

In addition to nurse care management, Rhode Island has brought the Stanford Chronic Disease Self-Management Program (CDSMP) to the State. CDSMP offers group self-management training through a 6 week course. Rhode Island has trained 17 CDSMP master trainers who will be able to train additional trainers and conduct self-management courses. In January 2007, Rhode Island held its first 6 week self-management course.

Program Evaluation

Rhode Island performs all program monitoring and evaluation in-house. Every year the State compares utilization data for all Connect CARRE members in all settings (including behavioral health, nursing facilities, emergency room, and pharmacy) to the utilization data for Medicaid beneficiaries who chose not to enroll in Connect CARRE. Rhode Island also collects clinical outcomes measures, including influenza vaccination rate, smoking cessation, daily weighing, foot exam, eye exam, and HbA1c testing. All measures except for smoking cessation are collected through claims data; nurse care managers report on smoking cessation. Rhode Island also conducts patient and physician satisfaction surveys.

Additional Information

Rhode Island Medicaid Web site: 

Rhode Island Connect CARRE Web site:

Return to Appendix Contents


Texas: Disease Management Program

Texas began its disease management program in 2004, serving TANF and supplemental security income (SSI) adults and children in PCCM and FFS Medicaid, who reside in non-urban areas. To be eligible, patients must be diagnosed with one or more of five diseases: asthma, diabetes, CHF, CAD, or COPD.

Program Planning

Texas launched its disease management program in response to a legislative mandate. The State legislature mandated $8.5 million in savings for the program. Because of staffing limitations, the Texas Medicaid agency decided to contract with an outside vendor.

Program Design

Texas sends its vendor a presumptive eligibility file of approximately 1.1 million potential members. Through an algorithm, the vendor identifies eligible members and determines who the program will actively manage through the call centers. All eligible members are enrolled but can opt-out of the program. Of the 48,000 eligible individuals identified, approximately 11,000 are actively receiving disease management services.

Program Implementation

Texas' vendor conducts provider outreach activities on behalf of the State. Before program implementation, the vendor met with major provider groups, such as the Texas Medical Association, to promote the program. Texas' vendor initiated a variety of strategies to engage providers:

  • Distributing clinical guidelines to Medicaid providers.
  • Creating the Physician Advisory Board, a statewide coalition of providers who meet quarterly to provide program feedback.
  • Establishing a disease management advisory group comprising various stakeholders.
  • Sending alerts to providers when a patient requires follow-up care.
  • Hosting continuing medical education classes, offering decision support software, and providing physician practice improvement.
  • Offering Chronic Care Patient Registry Reports to providers.

The disease management program manages provider relations using local medical advisors, who meet with providers in their areas, meet quarterly with the equivalent of an advisory committee to network with other providers, and respond to other issues as they arise.

Chronic Care Patient Registry Report

The Chronic Care Patient Registry Report, distributed by the vendor semiannually, profiles physicians with four or more disease management members and includes information on:

  • Summary statistics across the network.
  • Individual physician performance on condition guideline and utilization measures.
  • Disease-specific measures.

Program Interventions

Program interventions are mostly telephonic with community-based nurses paying some in-person visits and communicating with providers if urgent action is required. Interventions include a health assessment, patient education materials, telephonic contact, home visits, a 24/7 nurse call line, patient self-management, and provider education. Texas' vendor operates the call center, which allows incoming and outgoing calls.

Program Evaluation

Texas staff visited their vendor headquarters to meet with program staff and to learn about the call center. Their major goals for the site visit were ensuring that activities specified in the contract were being accomplished and understanding the vendor's call center operations. To prepare for the site visit, Texas developed an onsite monitoring tool that lists items for evaluation. To follow up on specific questions from regular reporting on the call center operations, Texas staff listened in on calls and offered recommendations to redesign the call center scripts. State staff also reviewed call center staff's methods for recording information from calls. Texas expects to repeat a site visit to the vendor headquarters annually. In addition to an onsite review of the call center, Texas staff plan to conduct a more comprehensive review of operations by interviewing focus groups and evaluating home visits by nurse care managers. Finally, the State plans to complete an independent assessment of the State's 1915(b) waiver.

Additional Information 

Texas Medicaid Web site:

Return to Appendix Contents


Virginia: Disease State Management Program

In January 2006, Virginia Medicaid began operating a disease management program for its FFS and PCCM populations. Virginia contracts with a vendor to provide disease management services for recipients with asthma, diabetes, CAD, and CHF.

Virginia's Lessons Learned: Enrolling Members in HCBS Waivers

  • Work with mental retardation/developmentally disabled (MR/DD) Directors Disease management is not a redundant service for the MR/DD population.
  • People with MR/DD can participate actively in managing their disease.

Program Planning

Virginia has a long history of providing disease management services to Medicaid beneficiaries. Beginning in 1993, the State's first program, Virginia Health Outcomes Partnership, provided disease management to members with asthma and diabetes. In 1997, Heritage/ACS operated an expanded statewide disease management program, which changed to a provider-centric model focused on pharmacological management and increased the number of diseases covered. This program ended in 2000.

In 2004, Anthem, one of Virginia's Medicaid MCOs, approached the State with a proposal to provide a pilot disease management program at no cost to the State. Virginia agreed to the pilot, and Anthem's subsidiary, Health Management Corporation, implemented Healthy Returns, which ran from June 2004 through June 2005. During Healthy Returns' pilot year, the State legislature passed legislation requiring Virginia to implement a disease management or chronic condition care management program. Healthy Returns continued to run until the new program was operational.

Program Design

Issuing a RFP for its program in May 2005, Virginia awarded the contract to Health Management Corporation (HMC), to implement its pilot program. The State chose to cover asthma, diabetes, CAD, and CHF and to include individuals receiving mental retardation/developmentally disabled (MR/DD) home- and community-based waiver services (HCBS) in the disease management program.

Initially, stakeholders resisted inclusion of the MR/DD population in the program because they felt disease management services would be redundant and potentially contradictory to the care coordination that members in the MR/DD waiver receive. The State worked closely with the MR/DD advocacy community, MR/DD Directors, and group home providers to develop protocols for working with the MR/DD population. Virginia now has actively engaged MR/DD waiver clients and has received no complaints.

Another important feature of Virginia's disease management program is the State's ability to benchmark condition-specific outcome measures from the FFS disease management program to identical outcomes measures from the Medicaid MCO disease management programs. Virginia worked with HMC to develop "HEDIS-like" measures for this process. Benchmarking across the FFS program and the MCO programs has enabled Virginia Medicaid to improve care and access for all disease management members. All MCOs offer disease management for at least four conditions, and Virginia can identify and build on successes identified through this process.

Virginia's Lessons Learned: Coordination of FFS and MCO Disease Management Programs

  • Select identical conditions for all MCOs and FFS programs to cover.
  • Establish similar condition-specific benchmarks.
  • Evaluate and build on successes.

Program Implementation

HMC assumes responsibility for the majority of program implementation tasks. The vendor identifies and enrolls Medicaid beneficiaries in the disease management program based on claims and eligibility data. The program requires members to opt-in to enroll. Initially, Virginia worked with CMS to develop a 1915(b) waiver program to automatically enroll all eligible members, while giving members the ability to opt-out. Virginia, however, changed this strategy, and CMS approved an Alternative Benchmark State Plan Amendment for Virginia to operate an opt-in disease management program.

Program Interventions

Virginia's disease management interventions include:

  • Case management.
  • 24/7 nurse advice line.
  • Health status assessment.
  • Disease education.
  • Self-management monitoring.

Providers have access to a toll-free line for questions about the disease management program, and they receive treatment protocols and evidence-based guidelines.

Program Evaluation

Virginia's program evaluation and monitoring includes vendor reports. HMC measures cost savings by developing a predictive model of expected expenditures and comparing projected expenditures to actual expenditures, less program costs. The vendor is required to submit regular reports on disease management, outreach and participation, nurse call line activity, satisfaction surveys, and clinical outcomes. HMC also measures utilization including the number of hospital admissions and readmissions, number of emergency room and ambulatory care visits, and physician office visits. In addition, the vendor reports the degree of participation in self-management (a self-reported measure).

Virginia also has contracted with an External Quality Review Organization, Michigan Peer Review Organization (MPRO), to monitor its contract with HMC. MPRO ensures HMC is meeting contract requirements and will evaluate program cost effectiveness. Finally, Virginia plans to conduct an internal review of the program.

Additional Information 

Disease State Management Program Web site:

Return to Appendix Contents


Washington: Chronic Care Management

Implementing a disease management program for Medicaid fee-for-service members in April 2002, Washington contracted with two vendors, focusing on asthma, diabetes, CHF, chronic COPD, end stage renal disease (ESRD), and chronic kidney disease. The program ran for 4 years, ending June 2006.

Building on experience from the original program and successes in other States, Washington created a new program with both a statewide vendor and local vendor. In January 2007, the State piloted a new chronic care management program. Washington contracts with AmeriChoice to provide care management services and a predictive modeling mechanism statewide. At the same time, Washington contracts with a local organization, Seattle Aging and Disability Services (Seattle ADS), to coordinate medical home and care management services for King County residents. The pilot is testing the effectiveness of predictive modeling and the ability of local care management organizations to deliver services.

Communicating with Providers: Benefits of a Disease Management Program

  • Will enhance, rather than replace, primary care provider services.
  • Will not result in reductions of provider payments.
  • Will not create significant paperwork for providers.

Program Planning

In 2001, Washington's legislature mandated the creation of a Medicaid disease management program to cover three to five conditions, with an intended cost savings of $600,000 within the biennium. The State reached out to providers for support and input during the planning process, primarily through professional associations (e.g., State medical association, pharmacy association) and several provider meetings across the State. In partnership with the State health department, Washington coordinated provider-focused collaboratives on chronic diseases. The State also sought consumer input through its Title 19 (Medicaid) Advisory Committee.

Program Design

As part of the 2001 legislative mandate, the legislature commissioned a planning study from the Washington State Institute for Public Policy at Evergreen State University. The study estimated the per-member per-month (PMPM) cost of the program and made recommendations about diseases that should be covered. Based on the results of this report and its experience, the Medicaid agency decided to adopt a disease-specific approach; moreover, the short timeline to achieve savings dictated by the legislation compelled the State to adopt a vendor model rather than create an in-house disease management program.

When the State issued a request for information and a RFP, bidders were asked to recommend diseases. The winning bidder, McKesson, proposed covering asthma, diabetes, and CHF. Washington contracted with a second vendor, Renaissance, to provide disease management services for ESRD. COPD and chronic kidney disease were added a year later.

For the new Chronic Care Management program, an RFP was issued to select vendors for predictive modeling using Medicaid claims data as well as for care management for members with chronic conditions. AmeriChoice was awarded the statewide contract for predictive modeling and care management services outside King County, and Seattle ADS was awarded the care management contract for King County. Washington also solicited models that supported the local medical home infrastructure, and Seattle ADS is providing that service with several King County clinics.

Program Implementation

Based on claims data provided by the State, McKesson's algorithm identified members who might have had diseases covered by the program. The algorithm sorted members into disease categories according to a hierarchy of conditions; the remaining members remained enrolled to be able to access the nurse call line. Care managers were required to make multiple attempts (at least seven telephone calls) to contact hard-to-reach members. In the contract's fourth year, the State assigned payment differentially according to high-risk and low-risk status by condition and assigned a basic payment to members with none of the four conditions. After 90 days, if a member was still unreachable, he or she was automatically assigned to the low-risk category.

Approximately 20 providers were involved in the program through an advisory committee with provider representation. Providers initially participated in disease-specific subgroups to allow McKesson and the State to receive valuable feedback on the disease management program.

Program Interventions

Washington's program with McKesson included member interventions such as assessment, a toll-free telephone system, a nurse call line, nurse care managers, and member education. For providers, McKesson offered evidence-based guidelines and protocols. Providers received individual faxed reports or queries on members and enrollment data on the number of their members enrolled in the disease management program.

Program Evaluation

Washington contracted with Milliman, an actuarial consultant, and the University of Washington to conduct program evaluations. The University of Washington analyzed outcomes data to determine the efficacy of the disease management program's first year. The study compared members actively enrolled in the program (i.e., receiving disease management) to a control group of patients who were not actively enrolled. The control group members and their providers received education and support materials by mail. To evaluate the program, the University of Washington used several data sources, including claims data, chart data, and vendor-provided administrative data. Findings from the University of Washington evaluation include the following:

  • Asthma. Disease management patients were more than twice as likely to have written care plans. Length of stay decreased for high-risk patients who were hospitalized.
  • Diabetes. Disease management patients were more than twice as likely to receive an HbA1c test and one and one-half times as likely to have a retinal exam.
  • CHF. No significant outcomes were found.
  • ESRD. A high degree of patient contact was associated with improved lab values. Emergency room visits, hospitalizations, and length of stay decreased for patients with ESRD.

The Milliman study found that the disease management program improved overall use of medical services (e.g., fewer days in the hospital for children with asthma and members with ESRD). It also found that the asthma, diabetes, and CHF program realized no net savings in its first year; however, ESRD did realize net savings ($29.58 PMPM beyond the guaranteed savings).

Additional Information

Washington State Medicaid Web site: 

Media release for the conclusion of Washington's pilot disease management program:

Return to Appendix Contents


Wyoming: Health Management Program

Wyoming's Health Management Program offers care management to all Wyoming Medicaid beneficiaries. Implemented in 2004, the program targets approximately 76,000 members and addresses all chronic conditions.

Health Buddy

Wyoming's Health Management Program offers some members the Health Buddy, a telemedicine device that collects symptomatic and behavior information vital signs and tests members' knowledge base. This information is transmitted through a telephone line to the member's health coach. High-risk members who are enthusiastic about using the Health Buddy receive the device after three conversations with a care manager.

The Health Buddy requires members to respond to five to eight questions daily, entering information such as blood sugar level and weight gain. Nurse care managers call all Health Buddy users once a month, but they call immediately if a member's daily responses indicate his or her health might be in danger.

Program Planning

With a strong background in care and utilization management, Wyoming Medicaid staff already knew about their benefits and, consequently, decided to include all populations in wellness and prevention activities. They did not consider operating the program in-house because of program staffing limitations. While drafting a RFP, the State contracted with a consultant to develop a specific return-on-investment (ROI) methodology, to which Wyoming's vendor agreed before finalizing the contract. The consultant remains on retainer to assist Wyoming with future ROI needs.

Program Design

All Medicaid beneficiaries are eligible to receive wellness and preventative services. Members with coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, asthma, and depression as well as high-risk maternity cases may participate in the care management program. Complex case management is reserved for members with catastrophic conditions. Members may disenroll from the program. Wyoming was not required to submit a waiver to the CMS; the program is funded using an administrative match.

Program Implementation

To identify patients, Wyoming supplied its vendor with two years of claims data at the start of the contract. Because Wyoming's care management vendor is also its utilization management vendor, it has access to claims data feed daily. The vendor uses claims history to identify members for care management services, stratifies them by risk, and conducts outreach accordingly. If a member requires complex case management, the vendor refers him or her to Wyoming staff for the case management component.

Program Interventions

The Health Management Program comprises three components: disease management, complex case management for specific conditions, and prevention and education.

  • Disease Management. Health coaches or case managers—registered nurses with specific experience in a clinical area and at least three years of acute care management experience—provide the majority of member support and education telephonically. For some diseases, such as mental health disorders, health coaches and care managers are licensed professionals or social workers certified to deal with mental health issues. The goals of health coaching are to empower members to better understand their illness and self-manage their condition as well as to coordinate care between providers, the member, and the community. Wyoming's vendor operates a 24/7 call center for all Health Management Program members. Registered nurses operate the call center, which is located in Montana. Few calls come into the center, likely because once a health coach or care manager contacts a member, the member begins contacting the health coach or care manager directly. To minimize after-hours calls, members also receive instruction in how to handle emergencies.
  • Complex Case Management. Case Management is a method of managing the provision of health care to members with high-cost medical conditions. Health Management Program members are identified proactively via triage of pre-certification requests, analysis of claims and pharmacy data, or both. Types of cases appropriate for complex case management include trauma, genetic disorders, hemophilia, and cancer.
  • Prevention and Education. Wyoming's vendor distributes a Healthwise Handbook, which is a self-care guide covering topics from ear infections to diabetes with clear, easy-to-understand information and illustrations.

Program Evaluation

Limited staffing prevents Wyoming from performing in-house measurement or evaluation. Instead, the State contracts with a vendor to monitor the program, conducting member and provider satisfaction surveys. In addition to monthly and quarterly reports, the vendor submits an annual report containing results of the quality and clinical outcomes measures, an executive summary of program educational events, and outreach and enrollment strategies.

As part of the contract, Wyoming contracts with an actuarial consultant to conduct an external ROI evaluation. The consultant collects data to calculate trends and ROI. Eighty percent of the ROI is based on financial outcomes, while 20 percent depends on performance measures outcomes. The baseline, calculated by using data from the aged, blind, and disabled population from five surrounding States with no care management program, was combined with trends from the Wyoming TANF population. The PMPM cost was compared to the Health Management Program's PMPM cost.

Additional Information

Wyoming Medicaid Web site:

Wyoming Health Management Program Web site:

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Page last reviewed October 2014
Page originally created March 2008
Internet Citation: Appendix: State Overviews (continued). Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.