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Care Management Manual

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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 case management/care coordination. UCare outlines case management/care coordination 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 case management and care coordination for enrollees in the following UCare health plans:

UCare MSHO (care coordination)

UCare MSC+ (care coordination)

UCare I-SNP (care coordination)

UCare Connect + Medicare (care coordination)

UCare Connect (care coordination

UCare Prepaid Medical Assistance Plan (PMAP) (case management)

UCare Medicare Plans (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 55-county service area.

Prepaid Medical Assistance Program (PMAP) – A federally and state-funded program for people and families who meet income and other eligibility requirements, including living in UCare’s 38-county service area. This program provides medical services to Medical Assistance managed care enrollees.

Minnesota Senior Care Plus (MSC +) – A federally and state-funded program for people age 65 or older who meet income and other eligibility requirements and live in UCare’s 66-county service area. This program provides medical services to Medical Assistance managed care enrollees.

UCare Connect – A plan designed to meet the unique needs of adults with certified physical disabilities, developmental disabilities, and/or mental illness. It is for people ages 18-64 who are eligible for Medical Assistance and who live in UCare’s 67-county service area.

UCare Connect + Medicare – A plan that combines the benefits of Medicare and Medicaid. It is for people between the ages of 18-65 with a certified disability who are eligible for Medical Assistance and are enrolled in Medicare Parts A and B, and who live in UCare’s 67-county service area.

UCare’s Minnesota Senior Health Options (MSHO) – A plan that combines the benefits of Medicare and Medicaid. It is for people ages 65 and older who are eligible for Medical Assistance and are enrolled in Medicare Parts A and B, and who live in UCare’s 66-county service area.

UCare’s Institutional Special Needs Program (I-SNP) – A Special Needs Plan that serve Medicare members who qualify for a nursing home level of care. These members reside in various care institutions such as long-term care or assisted living facilities.

UCare Medicare Plans (Medicare Advantage, HMO-POS) – Affordable Medicare plans available throughout Minnesota and Wisconsin.

UCare Medicare Plans (HMO-POS) Overview

UCare Medicare Plans Care Management Resources:

Requirements, forms, letter templates and process guidelines

The UCare Provider Manual is a reference guide for direct service providers of all types who serve UCare members. Updated regularly, its guidelines are part of the contract between UCare and its provider network. 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.

View the UCare Provider Manual

Utilization review is a formal evaluation of the medical necessity, appropriateness and efficacy of the use of health care services, procedures and facilities. Reviews are completed by a person or entity other than the attending health care professional to determine the medical necessity of the service or admission.

UCare follows the standards set forth in Minnesota statue or provider contract (as applicable). Utilization review may be conducted prior to service (pre-service), concurrently or retrospectively (post-service).

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 below 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 the criteria 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. If the member does not meet criteria for MH & SUD Case Management, there is an option to consult with a MH & SUD Case Manager to discuss the member’s mental health or substance use needs via UCare’s MH & SUD Triage Phone Line.

UCare’s MH & SUD Triage Phone Line is available to all UCare member’s, providers and care coordinators. The MH & SUD Triage Line is designed to support member’s mental health or substance use need, such as:

  • Crisis Intervention
  • MH & SUD Case Management Referrals
  • MH & SUD Case Management Consultation
  • MH & SUD Provider In-Network and Specialty Search
  • Identification and Connection to Community Resources
  • Assistance with finding and scheduling appointments for MH & SUD services

UCare’s MH & SUD Triage Line is available Monday through Friday, 8 am to 5 pm with afterhours support available. You may reach the MH & SUD Triage Line at 612-676-6533 or toll-free at 1-833-276-1185.

UCare's disease management programs exist to improve the health of members through innovative approaches for asthma, CKD, COPD, diabetes, heart failure, hypertension, migraine and weight management. The programs take a holistic approach in working with members which focus on using in-house staff and vendors to support 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 2024 Department of Human Services (DHS) contract for Families and Children and the 2022 Special Needs Basic contract mandate a Population Health Management strategy. UCare provides disease management programming as part of our Population Health Management strategy.

Currently, UCare’s disease management programs are offered to members with the following chronic illnesses or medical conditions:

  • Asthma (eligible products: PMAP, MNCare, Connect, Connect+, IFP plans)
  • Chronic Obstructive Pulmonary Disease (COPD) (all products are eligible)Chronic Kidney Disease (CKD) (all products are eligible)
  • Diabetes (all products are eligible)
  • Heart failure (all products are eligible)
  • Hypertension (all products are eligible)
  • Migraine (eligible products: PMAP, MNCare, Connect, Connect+ and MSC+)
  • Weight management: Connect, Connect+ Medicare, MNCare, MSC+, MSHO, PMAP

Current Disease Management program information and referral forms are located at UCare - Disease Management.

Asthma

  • Interactive Voice Response (IVR)/Texting Program: Pediatric and adult members in our IVR/texting program receive scheduled asthma education phone calls providing education and condition-related questions to respond to. Responses are triaged for follow up provided by an asthma educator where the call is triaged for further education, referral to PCP or enrollment in the Asthma Education Program.
  • Asthma Education Program (UCare asthma educators): Pediatric and adult members (under 65) in our asthma education program receive scheduled asthma education phone calls. This program helps members and families manage their asthma to lead a healthy lifestyle. Asthma management tools, such as pillowcase covers, medication chambers and education materials are provided to participating members.
  • Asthma Virtual Support Program (Cecelia Health): The asthma support program offers guidance, education, support, and resources to help members understand how their asthma related medications work; understand triggers and allergens; learn how to create and use an asthma action plan; recognize the importance of regular doctor visits; and understand how sleep, stress and emotional barriers impact their breathing.
  • All members with an asthma diagnosis receive asthma education newsletters and an Asthma Action Plan annual reminder.
  • Members enrolled in PMAP, MNCare, Connect, Connect+, IFP plans are eligible for the asthma programs.

Chronic Kidney Disease (CKD)

  • CKD Virtual Support Program: A registered dietician (RD) offers members guidance, education, and support via telephone. Members set actional behavior change goals while learning to make health food choices to help prevent the progression of kidney disease; understand their labs related to CKD; recognize the importance of regular doctor visits; and understand how a kidney-friendly diet can fit into their daily life.

Chronic Obstructive Pulmonary Disease (COPD)

  • COPD Virtual Support Program | Cecelia Health: A RRT offers members guidance, education, support and resources via telephone. Members set actionable behavior change goals while learning to use a COPD management plan; understanding how their COPD related medications work; understanding triggers and allergens to watch out for; recognize the importance of doctor visits; and understand how sleep, stress and emotional barriers can impact their breathing.

Diabetes

  • Interactive Voice Response (IVR)/Texting Program: Adult members in our IVR/texting program receive scheduled education phone calls providing diabetes education and condition-related questions to respond to. Responses are triaged for follow up support provided by a health coach where the call is triaged for further education, referral to PCP or enrollment in the health coaching program.
  • Health Coaching (UCare Health Coaching): Adult members in our diabetes program receive scheduled health coaching calls with a health coach who partners with members to discover their barriers and vision for the future, establish short- and long-term behavior change goals, and empower members to achieve their goals. Health coaches use active listening, motivational interviewing and behavior change techniques.
  • Health Coaching (Diabetes Virtual Support Program | Cecelia Health): A certified diabetes care and education specialist (CDCES) supports members through health coaching and education via telephone. The member sets actionable behavior change goals while the health coach provides ongoing support and resources to assist members in reaching their goals toward self-management of their condition. The diabetes support program helps members monitor their blood sugar; lower their A1c; adjust their diabetes device to make sure they are using it optimally; and achieve healthy eating and exercise goals.
  • Virta Health: Eligible members with type 2 diabetes are eligible for Virta’s type 2 diabetes reversal program. Virta is a virtual nutrition therapy clinic helping members lower blood sugar, lose weight and rely less on prescription drugs.
  • All members with a diabetes diagnosis receive diabetes education newsletters.

Heart Failure

  • Healthy Hearts: Adult members in our Healthy Hearts heart failure program receive scheduled health coaching calls with a UCare health coach who partners with members to discover their barriers and vision for the future, establish short- and long-term behavior change goals, and empower members to achieve their goals. Health coaches use active listening, motivational interviewing and behavior change techniques. Heart failure management tools, such as our Health Journey education book, bathroom scale, and wrist blood pressure cuff are provided to participating members.

Migraine Management Program

  • Adult members in our migraine management program receive scheduled health coaching calls with a UCare health coach. Our team of coaches partner with members to discover their barriers and vision for the future, establishes short- and long-term behavior change goals, and empowers members to achieve their goals. Health coaches use active listening, motivational interviewing and behavior change techniques. Migraine management tools including a headache management book and migraine action plan are provided to participating members. Members enrolled in PMAP, MNCare, Connect, Connect+ and MSC+ are eligible for the migraine management program.

Weight Management (Coming soon in Q3 2024)

  • UCare has partnered with Cecelia Health to help members better manage their health through the weight management program. An RD provides support to help members develop a plan to achieve and maintain their health weight. The weight management program offers one-on-one support and education to help members manage weight loss, with or without medication; design a personalized nutrition plan; get real time feedback and chat with their clinical team through a secure app; and set goals and track progress.
  • We also send a newsletter with weight management education to members with weight management related diagnosis.

Brook Health App

  • All UCare members are eligible to access the Brook Health app. Brook is a personal health service app that helps app users find healthy zones in the flow of their everyday life. Brook empowers members to get into their healthy zone via regular insights and feedback from the Brook Experts and coach bot. Members can share a snapshot of their data with their care team via email and can chat with a Brook Expert for 24/7 in app support. Brook is geared towards those living with chronic conditions, with relevant programming, easy logging and Bluetooth device syncing capabilities. Brook is available in the phone app store.

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 Organization 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.

UCare’s Quality Improvement activities include identifying and implementing a wide array of initiatives and projects that focus on improving the health of our members. In addition to working with our regulatory organizations, UCare collaborates with other health plans and partners with UCare providers on quality improvement projects to improve the health of our members.