US Medicaid Disease Management Programs Resources in United States
US Medicaid Disease Management Programs Resources
| State | Description | Model* | Disease Coverage |
| Alabama
*** updated 7/24 |
Alabama is in the process of implementing a new care management program through the Medicaid Transformation Grant– Together For Quality Project. Asthma and Diabetes control is the core of the program. However, case management will be focused on the patient as a whole. | Asthma
Diabetes |
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| Alaska | |||
| Arizona
***updated 7/21 |
Arizona’s Healthcare Cost Containment System (AHCCS) is predominately a Medicaid managed care system, with 8 acute care managed organizations and 9 long term managed organizations. The MCOs have various programs to manage their individual Medicaid members. Some plans have internal disease management programs while others may contract with outside vendors to provide such services for certain populations. The choice of how to utilize Disease Management programs, or even utilize them at all, is at the MCO’s discretion.
List of Programs |
Varies | Varies |
| Arkansas
***updated 8/15 |
Arkansas High Risk Pregnancy Program– As of February 11, 2003 High Risk Obstetrics is a Disease Management program performed as a contract with the University of Arkansas for Medical Science (UMAS), Department of Obstetrics, Division Of Maternal Fetal Medicine. The program focuses on getting women who have high-risk pregnancies care, especially in rural areas. UMAS is the only academic medical center in Arkansas and currently has four certified Maternal-Fetal Medicine specialists (paleontologist). Through the Medicaid management contract, the program has established clinics throughout the state (mostly within hospitals). Maternal-Fetal Medicine physicians perform ultrasounds and genetic counseling is provided by our genetic counselors. The program also has a call center, to assist providers throughout the state, and allow them access to any type of Maternal Medicine education they may need. The Medical center also provides transportation from host site to center if deemed necessary.
The program serves all Medicaid pregnant women in Arkansas (approximately 20,000-22,000 births a year). |
Patient Care | High-risk pregnancy |
| California | California’s disease management programs are offered through disease management organizations (DMO’s). Law requires DMO’s to obtain physician prior authorization before providing services or dispensing medication. Prohibits DMOs from using medical information to solicit to, or to offer for sale any products or services and specifies that DMOs are subject to Confidentiality of Medical Information Act. Also creates numerous task forces on various diseases and conditions. | Patient Care
Pharmaceutical |
Asthma; Stroke; Heart Disease; Diabetes; Parkinson’s; New Mothers; others |
| Colorado
***updated 7/19 |
Colorado has three Medicaid Disease Management Programs:
Asthma- Created in 2002, the program manages both children and adults. The program is educational based, and includes over-the-phone consultation and advice. Congestive Heart Failure- Created in July 2007, this is a stand alone program that manages adults. It utilizes some biometrics to monitor clients at extremely high risk. Those patients with less severity are provided with educational resourses and over-the-phone consultation and advice. Telemedicine- Created in July 2007, this program manages few clients, though they are at the highest risk. The program utilizes biometric monitoring with information fed to a nurses station on a daily basis. The program deals with patients with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes. |
Patient Care Pharmaceutical monitoring | Asthma
Chronic Obstructive Pulmonary disease Congestive Heart Failure Diabetes Depression |
| Connecticut
***updated 7/17 |
Connecticut currently has a Request for Proposal (RFP) to procure services of Disease Management. This RFP calls for a program to report to the Department of Social Services and to train providers on the latest disease management technics. The training would include: assessment tools, disease management, etc.). All Medicaid beneficiaries would be eligible, including those enrolled in managed care and fee-for-service.
Medicaid will be providing funding to expand the ConnecticutEasy Breathing Program, to provide asthma disease management. |
Healthcare Provider Training | Cardio related conditions
Childhood Obesity Diabetes Asthma |
| Delaware
***updated 7/18 |
Delaware has three managed care options for clients. One is a state administered program (Diamond State Partners), whereas the other two are contractual organizations (Unison Health Plan of Delaware and Delaware Physicians Care of Delaware). All three organizations have disease/ or case management, or are in the process of implementing a program. Below are the descriptions of the disease management program for each managed care organization:
Diamond State Partners: As of July 2007, the state administered managed care program is currently in the process of redeveloping its disease management program. They plan to consider emergency room over usage, and possibly Chronic Heart Failure and Asthma Unison Health Plan of Delaware: This contractual managed care organization offers care case management divided into the following categories: Catastrophic Care Case Management; Adult Case Management, Pediatric Case Management, and Neonatal Care Unit Case Management. The General Case Management for Chronic Illnesses includes the following conditions: Repertory Care (Asthma, and Chronic Obstructive Pulmonary Disease); Cardiac Care (Chronic Heart Failure, Coronary Artery Disease, Hypertension); Kidney Care (End Stage Renal Disease, Chronic Kidney Failure); High-risk Pregnancy Care; Diabetes Case Management; Transplant Case Management and a Special Needs Unit which provides social work based case management for clients with special needs. Delaware Physicians Care of Delaware: This contractual managed care organization focuses on: behavioral health services, co-morbidities. Asthma, Diabetes, Chronic Obstructive Pulmonary Disease, High-risk Pregnancy and Chronic Heart Failure There is currently no disease management program for fee-for-service Medicaid population. |
Patient Care
Case management |
Will work in collaboration with existing managed care programs.
Asthma Asthma Asthma |
| Florida
***updated 7/17 |
Florida Medicaid provides three main disease management programs for Medicaid beneficiaries enrolled in the Primary Care Management Program (MediPass). There are two disease-specific programs, one being for HIV/AIDS and the other is for Hemophilia. The program for Hemophilia disease management is scheduled to begin September 1, 2007, and will be conducted through two vendors.
Healthier Florida- As of January 2007, Healthier Florida is a comprehensive disease management program, contracted with Pfizer Health Solutions (partnered with McKesson Health). The program covers seven disease states, and participants have access to a care manager who oversees their overall health issues, in addition to assistance from social workers, community health workers, pharmacists and dieticians. |
Patient Care
Pharmaceutical |
HIV/ AIDS
Hemophilia Asthma |
| Georgia
***Updated 7/17 |
Georgia Enhanced Care– As of August 2005, Georgia Medicaid entered into an agreement with two vendors (APS Healthcare and United Healthcare) to provide disease management programs for the aged, blind and disabled population of Medicaid (approximately 100,000 people). There are seven disease covered. Each vendor covers a different region of the state. | Patient Care
Case management |
Asthma
Chronic obstructive pulmonary disease Congestive Heart Failure Coronary Artery Disease Diabetes Hemophilia Schizophrenia |
| Hawaii | |||
| Idaho
***updated 8/29 |
Idaho currently has 3 providers serving the fee-for-service Medicaid diabetic population. The programs are pay-for-performance models, and will reimburse for the following six services: Identification of diabetes; establishment of a plan of care; A1C; Lipid Series; fluoroscopic exam. | Patient Care | Diabetes |
| Illinois
***updated 7/17 |
Your Healthcare Plus– A voluntary program serving three groups of people: disabled adults; adults and children with asthma; adults with frequent emergency room visits (six or more within one year). The program offers nurses and social workers to conduct counseling and provide education and information to take care of chronic health problems. | Patient Care | Asthma
Chronic obstructive pulmonary disease Coronary artery disease Diabetes Heart disease Mental illness Other health problems |
| Indiana
***updated 7/18 |
Indiana Chronic Disease Management Program was implemented by the Office of Medicaid Policy and Planning. Members for the program are identified through Medicaid claims data and stratified into two groups. Members who are identified as lower severity will receive telephonic care management through a centralized call center. Members who are identified as higher severity will be assigned to a nurse care management network. | Patient Care | Asthma
Congestive Heart Failure Diabetes Hypertension |
| Iowa
***updated 7/19 |
Iowa Medicaid Care Management (IMCM) integrates Disease Management and Complex Care Management programs to assist clients with chronic illnesses. The programs engage members in self-management strategies to improve their health. The program assesses the disease processes and its affect on life events and educates the member on disease self-management. The Asthma and Congestive Heart Failure programs were implemented in 2006. The Diabetes program was implemented in 2007.
There is also a Medicaid Pharmaceutical Care Managementprogram in Iowa. It is for specific chronic diseases and criteria regarding pharmaceuticals. It is a service provided by physicians and pharmacists working together to closely manage the total medication regimens of their most complex patients. |
Patient Care
Pharmaceuticals |
Asthma
Congestive Heart Failure Diabetes |
| Kansas | |||
| Kentucky | |||
| Louisiana | The Women’s Health Program in the Department of Health and Hospitals provides a statewide Breast Cancer Control initiative. The program is funded by the Health Excellence Fund which supports comprehensive chronic disease management services.
Another program requires tobacco settlement proceeds be used for certain activities, such as comprehensive chronic disease management |
Patient Care | Cancer, other |
| Maryland
***updated 7/24 |
Disease management activities are provided by the seven Managed Care Organizations participating in HealthChoice (the statewide mandatory managed care program), at the MCO’s discretion. | Patient Care | Asthma
Cardiac Services Diabetes High-risk pregnancy Other |
| Maine
***updated 7/20 |
MainCare Care Management Program– As of July 2007, Maine is in the process of implementing a new chronic disease management program following the completion of a pilot program (August 2006- July 2007). The pilot program contracted with an outside vendor with 300 people involved. MainCare plans on extending the program to all of its members and treating those at the highest risk (top 10% of adults, and top 5% of children). The program manages all diseases of its members, with the most common being: Asthma, Cardiovascular diseases, Diabetes, Depression, and Lower Back Pain. | Follows Ed Wagner’s Chronic Care Model | Asthma
Cardiovascular diseases Diabetes Depression Lower Back Pain Other |
| Massachusetts | |||
| Minnesota | Minn. Stat. § 62E.10
Minn. Stat. § 62J.68 2003 Minn. ALS 14; 2003 Minn. Chapter Law 14; 2003 Minn. H.F. No. 6 |
Patient Care
Pharmaceutical |
Diabetes |
| Mississippi
***updated 7/23 |
Mississippi currently has a Request for Proposal (RFP) to procure a new disease management contractor. Issued February 2007, the RFP calls for disease management services that include: care management and education of enrollees to improve self-management of their disease(s)/condition(s) and overall health; training enrollees with appropriate usage of telephonic or other electronic devices so they can readily communicate vital signs, health indicators, and health information to physicians or the contractor; review of enrollee medication list, education on medication and side effects, review of mediation for appropriate drug utilization; and enrollee and provider access to RN through nurse call center (toll-free line). | Patient Care
Pharmaceutical |
Asthma
Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Diabetes High-Risk Hypertension Sickle Cell Disease |
| Missouri
***updated 7/20 |
Missouri Medicaid Pharmacy Program– The disease management program entails a physician / pharmacist team develops plan of care and completes a follow-up (Program ends June 2008)
Chronic Care Improvement Program– Integrates disease management, case management and electronic care in order to improve the quality of care for chronically ill clients enrolled in Missouri Medicaid. The program provides education, health management support services and improved coordination of healthcare services for enrollees, as well as incorporates an internet-based plan of care. The program is contracted through APS healthcare. |
Patient Care Pharmaceutical | Asthma; Congestive Heart Failure; Diabetes; Other Asthma Cardiovascular disease Chronic Obstructive Pulmonary disease (COPD) Diabetes Gastroesophageal Reflux disease |
| Montana | Mont. Code Ann. § 17-6-606 appropriates a portion of tobacco settlement proceeds to fund a statewide comprehensive tobacco disease prevention program. | Patient Care | general disease management |
| Nebraska
***updated 7/23 |
As of July 2007, Nebraska is working toward an Enhanced Care Coordination program for the fee-for-service population as part of its Medicaid reform initiative. Still in the planning phase, its is projected that the program will be based upon high-cost, potentially high-cost, or complicated medical cases that could benefit from coordinated care. | ||
| Nevada | |||
| New Hampshire
***updated 7/23 |
New Hampshire Medicaid Health Management Program— The program currently serves a large Medicaid population, members of the program are chosen based upon condition eligibility. The program is educationally based and focuses on self management. | Patient Care | Asthma
Coronary Artery Disease Chronic Kidney Disease Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Diabetes End Stage Renal Disease |
| New Jersey | Disease management services are offered for the clients of the Division of Developmental Disability who are enrolled in managed care. DM programs that MCO’s have in place are available to all enrolled Medicaid beneficiaries.
New Jersey contracts with 5 HMOs that provide access to services that already include a variety of disease management programs. |
Patient Care | Diabetes; Asthma; Congestive Heart Failure; Other |
| New Mexico | Patient Care | ||
| New York
***updated 7/24 |
The Office of Health Insurance Programs (OHIP) is conducting six regional disease management demonstrations, as required by state public health law, passed in 2004. The intent of the demonstrations are to test new and innovative approaches to providing disease and care management services to address the complex health care needs of Medicaid recipients with, or at risk of, chronic illness and diseases. The demonstrations will be conducted for a two year period (March 2006 – February 2008); including a four month implementation period and twenty month operational period with phase down occurring in the last two months of operations.
The demonstration programs range in services, including: telephonic care by registered nurses, 24-hour nurse call centers, face-to-face visits, and/ or educational mailings. Participation in these regional demonstration programs by eligible Medicaid fee-for-service (FFS) recipients is voluntary. Each program will be evaluated by the Department of Health (DOH) to determine if providing disease and care management services is cost effective while improving health outcomes for those patients enrolled in these programs, compared to a control group of recipients who did not receive services. At the conclusion of the demonstrations a report will be sent to the Governor and Legislature with DOH findings and recommendations for continuation, modification or termination of each CMD. |
Patient Care
Pharmaceutical |
Asthma
Bipolar Disorder Chronic Kidney Disease Chronic Mental Health Illness Congestive Heart Failure Coronary Artery Disease Chronic Obstructive Pulmonary disease (COPD) Depression Schizophrenia Schizoaffective Disorder Sickle Cell Anemia End Stage Renal Disease *** Above is a comprehensive list of all diseases covered within all of the 6 demonstrations. |
| North Carolina
***updated 7/26 |
HIV Case Management Program— As of July, 2007, the state is in the process of finalizing policies for the program. It is a targeted case management program for Medicaid recipients with HIV. Case managers assist recipients in gaining access to needed medical assistance and services not offered by Medicaid. | Patient Care | HIV |
| North Dakota
***updated 7/23 |
Experience Health North Dakota— As of July 2007, the program is in the process of being implemented. The program will consist of registered nurses conducting case management for each client. Enrollees identified as lower severity will typically be served by monthly telephonic follow-up, whereas those with higher severity may have more face-to-face visits from nurses, provided with more education about their disease(s), and have more frequent phone call follow-ups. | Patient Care | Asthma
Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Diabetes |
| Ohio | |||
| Oklahoma
***updated 7/26 |
As of July 2007, Oklahoma is in the process of choosing vendors for the SoonerCare Health Management Program. The current implementation date projected for the program is October, 2007. The program will take a holistic approach and plans to serve 1,000 tier 1 highest risk clients, and up to 4,000 tier 2 (less severe) clients. The program will use predicative modeling and claims information to identify participants. It will include eight (8) practice felicitators, Division collaborative, Regional periodic collaborative, a call center (primarily for the tier 2 clients), and face-to-face monthly visits for the highest risk clients. Physicians who it is determined that they are caring for the most Medicaid patients, will be paired for a month, with a Proactive Facilitator who will assist the physician and clinic in improving disease management practices. | Patient Care
Pharmaceutical |
High risk/ High cost patients |
| Oregon
***updated 8/16 |
The state contracts with McKesson Health Solutions CareEnhance to provide disease management and case management for the fee-for-service population of Oregon Medicaid.
The state is in the process of developing a new Request for Proposal (RFP) to solicit for a new Disease Management program which is scheduled to be released fall 2007. |
Patient Care
Pharmaceutical |
Asthma
Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Coronary Artery Disease Diabetes |
| Pennsylvania | |||
| Rhode Island
***updated 7/23 |
Connect CARRE– The program is a voluntary, comprehensive care management and wellness program implemented in 2002. Designed for clients with declining health and frequent illnesses, it serves the fee-for-service population of Medicaid. The program is not disease specific, rather it serves clients with any chronic diseases, and clients typically have one or two diseases. Connect CARRE serves to link consumers to a medical home with a team of providers and care coordinators including a Lead Physician, usually the Primary Care Physician, and a Nurse Care Manager (NCM). They assist clients in developing self management goals, provide educational programs, and identify and coordinate services and care in the community setting to assist clients in maintaining wellness and reducing recurrent illness.
As of July 2007, the state is in the process of implementing another program, Connect CARRE Choice. |
Patient Care | Asthma
Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Depression Diabetes Sickle Cell Anemia |
| South Carolina
***updated 8/29 |
The state is currently conducting small pilot programs for disease management. | ||
| Tennessee
***updated 8/28 |
TennCare Required Disease Management Programs— Each of the 8 Managed Care Organizations is required to develop their own “opt out” disease management programs. Though each MCO’s program varies, each are required to include methods for member identification, and attention to the program content of condition monitoring, patient adherence to the program’s treatment plan, consideration of other health issues and lifestyle issue. Also, the programs must included methods for informing and educating members and providers, interventions based on stratification, integration of member information and evaluation including both measuring for effectiveness and members satisfaction with DM. In general, all programs include non-clinical staff, nurses, 24/7 help lines, education, care coordination and referral to case management when appropriate. The stratifications level dictates the staff engaged and the interventions executed. | Primary Care | All MCO’s cover:
Asthma Congestive Heart Failure Diabetes Maternity Care Management Obesity Two MCO’s also include: |
| Texas
***updated 7/30 |
Texas Medicaid Enhanced Care–this program started in November 2004 and serves the disabled and Temporary Assistance for Needy Families (TANF) clients of the Texas Medicaid Fee-for-Service population. Contracted through McKesson Health Services, clients in the program are automatically enrolled via a Health and Human Services Commission presumptive eligibility file, but are allowed to disenroll by contacting the service provider. The program begins with an initial letter with Disease Management materials, and a 1-800 nurse line sent to enrollees, followed by an initial assessment by program registered nurses. Nurses also do follow-up monitoring and coaching calls/visits as needed. The nurses do special needs coordination and provide clinical alerts to provider offices for any symptom decomposition. Educational materials are issued to the client in the mail and are reinforced during nurse out-bound calls. Additionally, Texas has 2 Provider Outreach Coordinators (POCs) and 1FT/1PT Local Medical Advisors (LMTs) to visit educate and engage providers & clinics.
Each HMO has Disease Management programs for the Managed Care population. Such programs are administered at the discretion of the HMO; however each program covers the same five diseases. |
Patient Care | Asthma
Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Coronary Artery Disease Diabetes |
| Utah
***updated 8/1 |
Utah Pharmacotherapy Risk Management System— The program uses a computerized surveillance and trigger tools to support medication therapy and risk management. It employs the service of targeted clinical reviews which impacts nearly 4,800 patients with high-risk medication therapies. As many as 600 of the high risk patients receives the Medication Therapy Management services (MTMs) consultation. About 2,500 prescribers receive feedback and recommendation for appropriately prescribing medications, with approximately 100 also receiving Academic Detailing visits. The team will conduct statewide surveillance and mailing/telephone interventions. | Pharmaceutical | Anticoagulation/Antiplatelet drugs
Antipsychotic therapy Asthma Diabetes therapy Hypertension Pain Management (opioid narcotics and anticonvulsants) |
| Vermont
***updated 7/31 |
Chronic Care Management Program– As of July, 2007, The Office of Vermont Health Access (OVHA) has contracted with APS Healthcare, Inc. to conduct Health Risk Assessments and Intervention Services for 25,000 of the 150,000 state Medicaid beneficiaries. The Center for Health Policy and Research at the University of Massachusetts Medical School has also been contracted to provide population selection and program monitoring services. The program consists of registered nurses and medical social workers providing telephonic interventions and patient education via a call center. A Health Risk Assessment (the SF-8) is conducted by a health coach prior to the establishing a plan of care with the RNs and MSWs in the Intervention Services. The program is designed to take a more holistic approach by taking into consideration all physical conditions and socioeconomic issues when developing a plan of care. All enrollees have at least one of the 11 chronic illnesses identified. | Patient Care | Asthma
Arthritis Chronic Renal Failure Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Depression Diabetes Hyperlipidemia Hypertension Ischemic Heart Disease Low Back Pain |
| Virginia
***updated 7/24 |
Healthy Returns Disease State Management (DSM) Program– Effective January 2006, Healthy Returns is a disease state management program designed to help patients better understand and manage their disease through prevention, education, lifestyle changes, and adherence to prescribed plans of care (POCs). The program provides care management services for Disease State Management eligible persons including outreach and education, initial assessments, counseling, regularly scheduled follow-up assessments, and a 24-hour toll-free nurse call line. In addition, the program will monitor clinical health outcome measures and track changes in Virginia’s Medicaid and FAMIS expenditures. The Department of Medical Assistance Services has contracted with Health Management Corporation (HMC) to administer the program. | Patient Care | Asthma
Congestive Heart Failure Coronary Artery Disease Diabetes |
| Washington
***updated 7/25 |
As of January 2007, Washington state has contracted with two vendors to provide Chronic Care Management services to Washington Medicaid beneficiaries.
AmeriChoice– This Personal Care Model program will serve the entire state of Washington except for King County. The program uses predictive modeling software to create risk scores for clients from claims data. Clients identified at the highest 20% of risk are invited to enroll in the program for care management. Nurses and social workers then work as a team to address the member’s medical, psychosocial, and environmental needs in an integrated, comprehensive care model incorporating both primary and specialty care and services. King County Health Partners— A local program serving King County works with a small group of clinics (mostly community clinics). The program works to improve clinic’s existing disease management programs by sending registered nurses to the clinics to work with staff with traditional care management. The nurses also work one-on-one with clients identified as highest risk. |
Patient Care | High-Risk Patients |
| West Virginia | Patient Care | Diabetes | |
| Wisconsin
***updated 8/29 |
Most of Wisconsin’s Medicaid clients are enrolled in one of its 13 Health Management Organizations (HMOs). As of December 2006, Each organization operated its own disease management program. The programs vary in respect to disease states, and program design with each HMO, and delivery of disease management is at the discretion of the organization.
The department of Health and Family Services assist in identifying clients with chronic conditions through and assessment tool that is administered by the enrollment broker called the New Enrollee Health Needs Assessment (NEHNA) survey. Information obtained from the survey is then passed on to the client’s HMO in order to facilitate early outreach and linkage to the HMO’s disease management program case managers and provider network. |
Asthma
Coronary Artery Disease Chronic Obstructive Pulmonary disease (COPD) Congestive Heart Failure Diabetes High Risk Obstetrics Renal failure ***Above is a comprehensive list of all diseases states covered within all 13 HMOs |
|
| Wyoming
***updated 7/24 |
Healthy Together– As of 2004, Wyoming Medicaid (EqualityCare) contracts with vendor ACS Healthcare for the state Health Management Program. The Healthy Together program is a total population health management program aimed at improving health outcomes and reducing costs for clients of EqualityCare with chronic illnesses. At minimum, all clients receive education and educational materials to encourage self management, then depending upon the severity of the illness, clients receive one-on-one support from a health coach or case manager. | Patient Care
Pharmaceutical |
Total Population |