Primary Care Case Management

Acronym: PCCM

In Primary Care Case Management programs, which are a form of Medicaid managed care, state Medicaid agencies contract with primary care providers to provide, locate, coordinate, and/or monitor the care of Medicaid beneficiaries who select them or are assigned to them. The provider, in effect, serves as a beneficiary’s medical home for primary and preventive care. States generally set requirements for the participating primary care providers, such as minimum hours of operation at each location, specific credentials or training, and responsibility for referral to specialists. State staff carry out, or sometimes contract out, administrative functions related to PCCM (e.g., network development and credentialing) and generally assume full financial risk. States pay primary care providers a small monthly fee for case management, in addition to regular fee-for-service payments; some states include a pay-for-performance element within their payment approaches. The PCCM payment structure stands in contrast to capitation-based payments to managed care organizations, another form of Medicaid managed care. Enhanced Primary Care Case Management refers to PCCM programs that include additional services and responsibilities to strengthen coordination of care. Relevant Federal Legislation or Regulation: Primary Care Case Management, Social Security Act §1905(t). Defines the content of a PCCM contract between a state and a primary care provider who is responsible for locating, coordinating, and monitoring covered primary care services and for providing for reasonable hours of operation, including 24-hour availability of information, referrals, and treatment for medical emergencies. PCCM: Primary Care Case Management (PCCM) is a managed care arrangement in which primary care providers contract with the state to provide a core set of case management services to the enrollees assigned to them and to serve as the enrollees’ home for medical care, in exchange for a small administrative fee. All other services are reimbursed on a FFS basis. Primary Care Providers (PCPs) can include primary care physicians, clinics, group practices and nurse practitioners, among others. PCCM enrollment also includes enrollment in a PCCM entity, which provides enhanced functions and services, such as operation of a nurse triage advice line, provision of payments for FFS providers on behalf of the state, operation of a customer service call center, implementation of qualify improvement activities, and coordination with behavioral health and long-term services and supports providers.