Led by the state’s Commissioner of Securities and Insurance, Montana announced the launch of a voluntary statewide multipayer medical home initiative in March 2014. The Montana Patient-Centered Medical Home Program includes participation by Montana Medicaid and three commercial health plans: Allegiance Benefit Plan Management, Inc.; Blue Cross Blue Shield of Montana; and PacificSource Health Plans. According to the state’s website, as of December 2014, 47 practices have been qualified as PCMHs and an additional 28 have been provisionally qualified.
Chapter 363 of the Montana Session Laws of 2013 laid the foundation for the Montana PCMH Program. This law gave the Securities and Insurance Commissioner, in consultation with a 15-member Stakeholder Council, authority to set participation, reporting, and payment standards for providers and insurers. The law also provided state action immunity, allowing multiple payers and practices to participate in the design of the program without the risk of violating federal antitrust laws. Regulations governing Montana medical homes are available here.
In January 2012, Montana was selected to join the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community. As a part of this Learning Community, Montana was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Montana leveraged its participation in the IMPaCT project to promote awareness of PCMH and to help pass state medical home legislation described above.
Prior to participating in the multipayer initiative, Montana Medicaid launched several patient-centered initiatives as part of Passport to Health, a primary care case management (PCCM) program for most Medicaid enrollees. Notably, the Montana Health Improvement Program connects nurse care managers and health coaches working for one of fourteen community and tribal health centers with high risk beneficiaries identified through predictive modeling software. The care managers and health coaches work closely with beneficiaries’ primary care providers. The model is profiled in this 2011 NASHP report.
Last updated: March 2015
|Forming Partnerships||Montana Patient-Centered Medical Home Program leadership has engaged stakeholders throughout the process. Prior to the creation of the 15-member Stakeholder Council authorized by Chapter 363 of the Montana Session Laws of 2013, Montana convened a 27-member Advisory Council, which included broad payer (including Medicaid) and provider representation. The Advisory Council, which itself was preceded by a Working Group, was charged with “mak[ing] recommendations about a patient-centered medical home pilot project and provid[ing] advice about how to administer it efficiently and encourage its success and expansion.” Minutes from the Advisory Council meetings (2011 to 2013) are available here, and minutes from the Stakeholder Council meetings (2013 to present) are available here.Montana first convened stakeholders in March 2010 with support of a technical assistance grant from the National Academy for State Health Policy. Furthermore, in November 2011, the Securities and Insurance Commissioner surveyed Montana providers to “determine how the Medical Home model can be molded to fit Montana’s unique needs.”Montana also participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through this project, Montana was able to support and strengthen important partnerships, both among state agencies and with external partners including non-profits, provider associations, practices, Area Health Education Centers (AHECs) and others.|
|Defining & Recognizing a Medical Home||Definition:
In March 2010, stakeholders initially agreed on the following definition of the patient-centered medical home: “In Montana, a patient-centered medical home is health care directed by primary care providers offering family centered, culturally effective care that is coordinated, comprehensive, continuous, and, when possible, in the patient’s community and integrated across systems. Health care is characterized by enhanced access, an emphasis on prevention, and improved health outcomes and satisfaction. Primary care providers receive payment that recognizes the value of medical home services.” Chapter 363 of the Montana Session Laws of 2013, passed in April 2013, echoes this language.Regulations prohibit primary care practices from identifying themselves as a medical home unless qualified by the Montana Commissioner of Securities and Insurance.Recognition:
In order to be qualify as a medical home in Montana, practices must receive either: NCQA PCMH recognition, Accreditation Association for Ambulatory Health Care Medical Home accreditation or certification, or Joint Commission Primary Care Medical Home certification.
|Aligning Reimbursement & Purchasing||The Montana Commissioner of Securities and Insurance promulgated regulations setting the payment standards for the Montana Patient-Centered Medical Home Program.The regulations stipulate that medical home payment models are required to support enhanced primary care, and payers may select from the following approved payment methodologies:
Payers may adopt alternative payment methodologies that support the intent of the program subject to the Commissioner of Securities and Insurance’s approval.
The Montana Commissioner of Securities and Insurance maintains a list of practice transformation resources for interested primary care providers, including a series of five webinars hosted by the Commissioner’s Office. The webinar content was informed in part by the results of a 2011 provider survey.
No later than March 31, 2015, participating medical home practices must submit a uniform set of health care quality and performance measures. Specifically, practices must report on three of the four following measures: hypertension, tobacco use and intervention, A1C control, and childhood immunizations. Pediatric practices are expected to report on immunizations only. Additional information is available here.
Furthermore, no later than March 31, 2015, participating payers are required to report both emergency room visit and hospitalization rates. If a payer tracks patient attribution to medical homes, they are required to submit this data for both their PCMH members and their entire member population.
Montana also participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system.
Beginning in October, 2013, states initiated their first open enrollment period for health coverage under the ACA. While state approaches varied, all states implemented new rules, system interfaces, and data reporting methods required under the ACA. What are states learning so far about what works to enroll eligible individuals and what are their top-line priorities getting ready for the next open enrollment period in November 2014? This webinar provides an opportunity to learn about promising strategies and innovations states are piloting related to enrollment and retention into insurance affordability programs, including through state-based exchanges and coordination with the federally facilitated marketplace (FFM). State panelists from Kentucky, Montana and Washington share experiences and enrollment successes. NASHP also shares new findings from research with 10 states documenting promising strategies, common challenges and trends in state enrollment experience as part of the Enrollment 2014 project.
- Anne Gauthier, Director, State Health Exchange Leadership Network, National Academy for State Health Policy (Moderator)
- Alice Weiss, Director, Enrollment 2014 Project, National Academy for State Health Policy
- Carrie Banahan, Executive Director, Office of Kentucky Health Benefit Exchange (Kynect)
- Christina Goe, General Counsel, Montana Commissioner of Insurance
- Nathan Johnson, Division Director, Health Care Policy, Washington Health Care Authority
States seeking to promote better coordination of patient care, either within Medicaid or through participation in multi-payer initiatives, will run into long-standing challenges to delivering care and promoting health in rural areas. Rural areas often experience disparities in access to care, health status, and available infrastructure relative to their urban counterparts. This brief draws from health initiatives undertaken in Alabama, Colorado, Montana, New Mexico, North Carolina, and Vermont to identify common policy considerations and action steps for coordinating care in rural areas. The brief was supported by the Robert Wood Johnson Foundation’s State Health and Value Strategies.
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- As of July 1, 2011, there were 106,493 beneficiaries enrolled in Montana’s Medicaid program. Of these, 81,085 were enrolled in the state’s primary care case management program.
- Children are required to enroll a primary care case management program, Passport to Health. Passport to Health covers a number of services, including EPSDT, inpatient and outpatient mental health, and substance use disorder treatment. Magellan Medicaid Administration provides utilization Management services to the state for mental health benefits (including for children).
- Children with a Serious Emotional Disturbance qualify for services under the state’s 1915(i) State Plan Home and Community Based Services. The state also has 1915(c) home and community-based service waivers that impact children, including:
As of 2012, 89,485 individuals were eligible for Montana Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. According to CMS data from 2012, Montana achieved an EPSDT screening ratio of 100% and a participation ratio of 59%. 35,919 children received dental services of any kind, with 31,824 receiving preventive dental services.
Last updated May 2014
Regulations in Montana define a medical necessary service as:
“ a service or item reimbursable under the Montana Medicaid program, as provided in these rules:
|Initiatives to Improve Access
Medicaid-enrolled children (as well as other children) in Montana have access to Pediatric Specialty Clinics sponsored by Children’s Special Health Services in the Montana Department of Public Health and Human Services.
|Reporting & Data Collection||
In Montana, Magellan Medicaid Administration provides utilization Management services to the state for mental health benefits (including for children). The Children’s Mental Health Services Bureau in Montana’s Department of Public Health and Human Services has produced a Provider Manual and Clinical Guidelines for Utilization Management as it pertains to mental health services provided to Medicaid-enrolled children.
Montana’s Medicaid provider manual specifies that each well-child visit should include an age-appropriate developmental screen. Risk assessment screenings for “signs and symptoms of emotional disturbances” as well as risky behaviors (including substance abuse).
Montana’s 1915(i) State Plan Home and Community-Based Services are available to children with a Serious Emotional Disturbance (SED). The state has created a brochure for families of children with SED advertising the availability of:
A more detailed Policy Manual on 1915(i) services for children with SED provides more information on the services available and eligibility requirements for children and providers.
|Support to Providers and Families||
Support to Families
Montana Medicaid has produced a Member Guide that covers available services, including a description of the components of a well child visit, included immunizations, and the recommended schedule for well child visits. The state has also produced a video on well-child checkups. Fliers advertising EPSDT services are also available for families.
Support to Providers
Montana’s Passport to Health primary care case management program is intended to promote the medical home model and better coordinate care for Medicaid enrollees.
Montana also has a Health Improvement Program that provides more intense coordination and care management of high-risk, high-cost Medicaid beneficiaries. The program works with patients’ primary care providers to develop a holistic treatment plan, and it builds partnerships with a range of medical and non-medical (e.g., social service) resources to help coordinate care and manage each patient’s conditions.
Montana’s Department of Public Health and Human Services provides resources on oral health services in the state. This includes a list of providers treating Medicaid-enrolled children, a Medicaid dental fact sheet on How to Find and Keep a Dentist, and rules and fees for orthodontia services for Medicaid beneficiaries under age 21. The state also provides a list of federally funded health center dental clinics.
Montana also has several brochures on Medicaid dental services for families and children on its oral health program website, as well as resources on school-based oral health screenings.
The national IMPaCT project supported North Carolina as one of four leading states in the field of practice transformation and primary care extension. Through IMPaCT, North Carolina partnered with four other states (Idaho, Maryland, Montana, West Virginia) to disseminate its primary care practice transformation strategies. Together these states formed the North Carolina IMPaCT Learning Community, and each state received individual and group technical assistance to help implement a practice transformation initiative. North Carolina, meanwhile, is completing its own IMPaCT project with a focus on further improvements to its primary care transformation model. Participants on this webinar will hear from the states in the Learning Community. Idaho will present on how it used the technical assistance offered through the project to devise a plan for primary care transformation that would become the basis of its State Innovation Model Design award. The other three states in the Learning Community will react to Idaho’s presentation and recount how the NC IMPaCT project promoted their development in key areas of data infrastructure, stakeholder engagement, and practice support. Participants will also hear from North Carolina on its IMPaCT practice support improvements. At the end of the webinar participants will have the opportunity to ask questions of the speakers about their experiences with primary care transformation.
- Denise Chuckovich, Deputy Director, Idaho Department of Health and Welfare
- Jonathan Griffin, MD, Family Physician, St. Peter’s Medical Group
- Nancy Sullivan, Assistant to the Cabinet Secretary, West Virginia Department of Health and Human Resources
- Niharika Khanna, MD, Associate Professor, University of Maryland School of Medicine
- Darren DeWalt, MD, Associate Professor of Medicine, University of North Carolina – Chapel Hill
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By Larry Hinkle
Many states are testing primary care extension as a strategy for supporting continuous quality improvement in practice. Primary care extension is based on the model of the Agricultural Extension Service. In health care this model applies scientific research and new knowledge to practices through provider education – often led by other providers or specially trained practice facilitators.
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The effective management of patients’ complex illnesses across providers, settings, and systems places extraordinary demands on primary care providers, especially those that work in resource-limited small or rural practices. Medicaid programs in some states have adopted strategies to build practice capacity to care for high-need Medicaid beneficiaries through the development of local community health teams, with members in fields such as nursing, behavioral health, pharmacy, and social work. Using data from a 2011–2012 review of state Medicaid medical home programs, we identified community health team programs in eight states that provide an array of targeted services, from care coordination to self-management coaching.
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