Colorado – Page 3 – The National Academy for State Health Policy

Ten States Selected to Attend Palliative Care Summit in Chicago

June 18, 2019/in Policy Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, Texas Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Long-Term Care, Medicaid Managed Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.

States Continue to Implement Surprise Medical Billing Protections

June 17, 2019/in Policy Colorado, Nevada, New Mexico, Texas Blogs, Charts Consumer Affordability, Health Coverage and Access, Health IT/Data, Health System Costs /by Christina Cousart

By Christina Cousart
Updated June 24, 2019
During the 2019 legislative session, states have continued to advance protections for consumers against surprise medical balance bills – charges for unexpected, out-of-network medical care. To date, four new states have enacted multi-pronged policies that prohibit balance bills, institute a process for providers and carriers to resolve billing disputes, and foster pricing transparency between providers, carriers, and consumers to avoid situations that lead to balance bills. Texas also approved legislation strengthening its existing consumer protections. Here are highlights of the new legislation.

	Colorado (HB 1174)	Nevada (AB 469)	New Mexico (SB 337)	Texas (SB 1264; HB 2041)[1]	Washington (HB 1065)
Balance billing protections
Holds consumers harmless	✓	✓	✓	✓*	✓
Prohibition in case of emergencies	✓	✓[2]	✓	✓[3]	✓
Prohibition in case of out-of-network (OON) services delivered at an in-network facility	✓[4]		✓[5]	✓[6]	✓
Applicable providers/ facilities	Person who is licensed or otherwise authorized in the state to furnish health care services including: ● Physicians ● Dentists ● Optometrists ● Anesthesiologists ● Hospitals ● X-ray ● LaboratoryExcludes ambulance providers, but charges the insurance commissioner with setting payment methods for ambulance services.	Physician or other health care practitioner who is licensed or otherwise authorized in this state to furnish any health care service; and institutions providing health care services including: ● Hospitals ● Surgical centers for ambulatory patients ● Skilled nursing facilities ● Residential facilities for groups ● LaboratoriesEmergency facilities include hospitals or independent centers for emergency medical care	Licensed health care professionals, hospitals, or other facilities licensed to furnish health care.Facilities include entities providing health care services including: ● Hospitals; ● Ambulatory surgical centers; ● Birth centers; ● Drug and alcohol treatment centers; ● Laboratory, diagnostic, and testing centers; ● Health provider’s offices or clinics ● Urgent care centers ● Freestanding emergency rooms ● Therapeutic health care settings	Individual licensed under the laws of this state to practice medicine or health care facilities.Facilities include: ● hospitals; ● Licensed ambulatory surgical centers ● Licensed chemical dependency treatment facility ● Renal dialysis facilities ● Birthing centers; ● Rural health clinics; ● Federally qualified health centers ● Freestanding imaging centers; ● Freestanding emergency medical care facilities*	Person licensed under state law to practice health or health-related services, or an employee or agent of such a person acting in the scope of their employment.Facilities include: ● Hospices ● Hospitals ● Rural health care facilities ● Psychiatric hospitals ● Nursing homes ● Community mental health center ● Kidney disease treatment centers ● Ambulatory diagnostic treatment or surgical facilities ● Drug and alcohol treatment facilities; ● Home health agencies.Carriers may not balance bill in the case of emergency services delivered by out-of-state providers.
Billing dispute and resolution procedures
Reimbursement standard	For emergency services the greater of: ● In non-Denver areas: o 105% of carrier’s median in-network rate for services provided at a similar facility in the same geographic area; or o Median in-network rate for the same service at a similar facility in the same geographic area based on all-payer claims database (APCD) data. ● In the Denver area: o Carrier’s median in-network rate for the same service in a similar facility in the same geographic area; o 250% Medicare rate for the same service in a similar facility in the same geographic area; or o Median in-network rate for the same service in a similar facility in the same geographic area based on APCD data. For OON services at an in-network facility, the greater of: ● 110% of carrier’s median in-network rate for the service in the same geographic area; or ● 60^th percentile of the in-network rate for the same service in the same geographic area based on APCD data.	For facilities: ● 108% of the previously contracted rate if the facility had been in-network within the last 12 months.● 115% of the previously contracted rate if the facility had been in-network within the last 12-24 months.● If no such contract existed, an amount the carrier determines to be fair and reasonable.For providers:If a provider had been in-network within the past 12 months: ● The previously contracted rate, if the provider terminated the contract before it was set to expire without cause; ● 108% of the previously contracted rate if the provider terminated the contract for cause; ● A fair and reasonable amount, determined by the carrier, if the carrier terminated the contract for cause; ● The previously contracted rate adjusted by the Consumer Price Index, Medical Care Component for the prior year, if neither party terminated the contract.If a provider had not been in-network in the preceding 12 months, carrier may remit whatever payment it determines.	A 60^thpercentile of the allowed commercial reimbursement rate for the service performed by a provider in a similar specialty in the same geographic area. Should not be less than 150% of 2017 Medicare rate. A stakeholder group will convene annually to review the reimbursement rate.	The usual and customary rate or an agreed-to rate, meaning the allowable amount as described by the applicable master benefit plan document or policy.*	Commercially reasonable amount based on similar services provided in a similar geographic area.
Process for arbitration	Baseball arbitration (arbiter will pick the final payment offer submitted by either the health plan or the provider/facility), if carrier and provider do not agree to initial payment. Arbiter will consider: ● Provider training, education experience, and specialization ● Previously contracted rate, if the provider had a contract with the carrier within a year of the dispute	Arbiter will either require the provider to accept the payment issued by the carrier as payment in full, or to demand that the carrier remit an additional amount requested by the provider.		Mediation may be requested through the Department of Insurance.[7] In the case of mediation of facilities, the mediator shall determine if the amount charged by provider is excessive, and if the amount paid by the insurer is unreasonably low or not the usual and customary rate. In the case of mediation for other providers, the mediator shall take into account whether there is gross disparity between the amount charged by the provider and how much the provider or similarly qualified providers receive for similar services. Other factors may include:* ● Patient characteristics and complexity of the services ● Provider training, education experience, and specialization ● 80th percentile of all billed charges for the service ● 50th percentile of rates for the service ● History of network contracts	Baseball arbitration (arbiter will pick the final payment offer submitted by either the health plan or the provider/facility), if carrier and provider do not agree to initial payment. Arbiter may consider: ● Evidence from the parties to assert the reasonableness of their offer ● Patient characteristics and complexity of the services ● Other relevant information include data from the state APCD
Data collection and reporting tools	State APCD		Benchmarking database maintained by a nonprofit organization specified by the insurance commissioner. Enables the commissioner to require carriers to report: ● The annual percentage of claims and expenditures paid to OON providers ● Changes to the percent of claims paid as emergency claims	The insurance commissioner is charged with selecting an organization to maintain a benchmarking database.	Requires state APCD to establish a dataset that provider, facilities, and carrier s may use to determine reasonable rates and to resolve payment disputes. Carriers shall provide information concerning the utilization of OON providers and cost savings yielded from the law as part of their annual rate filing.
Penalties
Provider must refund excess payments made by consumers	✓[8]		✓[9]		✓[10]
Penalty for violations	✓[11]		✓[12]	✓[13]*	✓[14]
Transparency standards
Must provide disclosure of potential repercussions of OON services	● Carriers ● Providers		● Providers[15]		● Carriers ● Providers
Requires cost estimates to consumers	✓[16]				✓[17]
Additional requirements:		On carriers: ● Must arrange for patient transfer within 24 hours of receiving notice that person is stable and can be transferred.On providers: ● Must send notice to carrier, no later than eight hours after person presents at an OON facility ● Must send notice to carrier that the beneficiary has stabilized and may be transferred to an in-network facility within 24 hours of stabilization	On carriers: ● Must make claims status information available to providers.On providers: ● Must post in a publicly accessible manner and online information about which carriers it contracts with. ● Must notify the carrier of a beneficiary’s admission within a reasonable period after stabilization. ● Any communication regarding bills, shall clearly state that the beneficiary is responsible only for in-network cost sharing amounts.	On carriers: ● Explanation of benefits must include information about balance billing protections; the total amount the provider may bill the enrollee under the enrollee’s health benefit plan; and an itemization of cost-sharing included in that total.* [18] On providers: ● Facilities must post notice that o it may charge a facility fee o it may charge rates comparable to a hospital emergency room o the facility or a physician at the facility may be OON and bill separately o Lists all the carriers it contracts with ● Facilities must provide patients with a disclosure that:* o Lists the facility fees that may result from the visit o Lists the carriers the facility is in-network with o Lists other cost information such as median facility fees and observation fees. ● Prohibits facilities from using logos or language to misrepresent that it might be in an insurers network.	On carriers: ● Must immediately arrange for an alternate plan of treatment if an agreement on post-stabilization services cannot be reached with the emergency provider. ● Must update provider directory within 30 days after the addition or termination of a provider.On providers: ● The provider must contact the carrier within 30 minutes of stabilization before rendering further services. ● Must post online information about which carriers it contracts with. ● Must provide carriers with updated lists of non-employed providers working at the facility

*Indicates changes made by the new Texas law.
[1] Texas’ 2019 law amends and enhances already existing protections in the state. Changes made by the new law are noted by asterisk.
[2] Does not apply when: 1) Services are received at a critical access hospital; 2) A person is covered by insurance sold outside of the state; 3) Services provided more than 24 hours after notification has been provided and a person has been stabilized.
[3] In the case of a beneficiary who cannot reasonably access a preferred provider, the protections extend to 1) medical screening and examinations require to determine if a medical emergency exists; 2) necessary emergency services to treat and stabilize; 3) services originating in an emergency facility following stabilization; and 4) supplies related to the services rendered by that facility.
[4] Does not apply if the consumer affirmatively consented to receive OON services.
[5] Only applies when; 1) A participating provider is unavailable; 2) Medically necessary care is unavailable in the beneficiary’s network (determined by the provider in conjunction with the health plan); or 3) the patient did not consent to receive services from the OON provider.
[6] Does not apply in the case of a beneficiary that elects, in writing and in advance, to receive services from the out-of-network provider, or in the case that the provider does provide the enrollee with a written disclosure that they are out-of-network and provides an estimate of the projected amount the enrollee will be responsible for. Explicitly includes protections for OON services delivered by diagnostic imaging or labs.
[7] Prior law allowed mediation requests only in the case of claims over $500 and that were for either emergency services, or services rendered by a provider or supplier at an in-network facility.
[8] Refund must be issued within 60 days, or interest will accrue.
[9] Refund must be issued within 45 days, or interest will accrue.
[10] Refund must be issued within 30 days, or interest will accrue.
[11] Punished by a fine of not more than one thousand dollars, or by imprisonment in the county jail for not more than one year, or both.
[12] Insurance superintendent may impose a fine on any provider that offers an unlawful rebate or inducement to entice a person to seek OON services
[13] The Attorney General may bring civil action against entities that exhibit a pattern of repeatedly violating billing protections. Authorizes applicable agencies to take action against providers or facilities who violate billing protections. The Secretary of State may suspend or revoke a license, or bring civil action against entities who violate the disclosure requirements outlined under Texas law. The Department of Health may impose penalties up to $1,000 for certain violations.
[14] Authorizes the Department of Health or an appropriate authority to levy fines against providers or facilities who violate these policies. Commissioner may levy a fine against carriers who violate these policies. Repeated violation may constitute unprofessional conduct and risk licensure of a provider or facility.
[15] If an OON provider has advanced notice that the beneficiary is OON, they must notice the beneficiary of their OON status and recommend the beneficiary contact their carrier to discuss options.
[16] A provider must issue a cost estimate within three days if requested by a patient.
[17] Carrier must provide an estimate of out-of-pocket costs for OON services upon request.
[18] Applicable to Health Maintenance Organizations.

A New State Tool to Manage Drug Costs: Experts Share Insights into Outcome-Based Contracts for Medicaid Pharmacy Claims

May 27, 2019/in Policy Colorado, Michigan, Oklahoma Blogs Administrative Actions, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Quality and Measurement, Value-Based Purchasing /by Jennifer Reck

Colorado and Michigan have joined Oklahoma to become the nation’s pioneering states with approved State Plan Amendments (SPAs) that enable Medicaid alternative payment models (APMs) for prescription drugs in the form of outcome-based contracts with pharmaceutical manufacturers.
In early May, state experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their APMs during a NASHP webinar. A recording of the webinar is available here.

Experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their outcome-based Medicaid alternative payment models during a recent NASHP webinar. Listen to the webinar here.

The SPAs enable states to negotiate contracts based on agreed-upon outcome measures tailored for specific drugs. Outcomes measures vary but may include measures such as patient adherence or reduced hospitalizations. If the drug’s performance fails to meet agreed-upon outcomes and triggers the need for additional manufacturer payments to the state, those payments are made in the form of supplemental rebates. The contract template was developed with the support of the State Medicaid Alternative Reimbursement and Purchasing Test for High-cost Drugs (SMART-D).
Though these outcomes-based APMs are valuable tools for states to manage escalating drug costs, APMs are best understood as “one more tool in our toolbox,” which are most effective when used in tandem with other strategies rather than in isolation, explained Cathy Traugott, pharmacy office director of the Colorado Department of Health Care Policy and Financing. Though these APMs may help states manage payment for high-cost drugs, the high-list prices themselves remain a problem that states are also attempting to address head on. During this year’s state legislative session alone, 47 states have filed 254 drug-cost-related bills (as of May 22, 2019).
Executing and implementing outcome-based contracting can be a time-consuming endeavor for states because of the necessity for state officials to engage with multiple manufacturers in exploratory discussions to identify drug candidates, followed by the data analysis necessary to design, and then track the outcome-based measures.
Oklahoma, whose work NASHP supported through a subgrant from the Laura and John Arnold Foundation, found that the process took longer than anticipated. Terry Cothran, director of the University of Oklahoma’s College of Pharmacy, advised states that pursue outcomes-based contracting to consider dedicating a project coordinator to execute the work most effectively.
To date, these contracts are with state Medicaid agencies only, and have not included inter-agency efforts. Rita Subhedar, state assistant administrator for Michigan’s Department of Health and Human Services, stressed the importance of broad engagement within a Medicaid department to effectively implement these APMs, including pharmacy, medical, and behavioral health staff. A separate, subscription-based payment approach, known as the “Netflix” model, utilizes a cross-agency approach engaging both Medicaid and a state corrections department. This approach was explored in another NASHP webinar, How States Pay for Hep C Drugs Using a “Netflix-style” Subscription Model.
The first results from outcome-based contracting will come from Oklahoma, whose first, one-year contract is scheduled to end July 2019, with three other contracts concluding soon after. Colorado and Michigan have not yet executed contracts.

Webinar: Medicaid Alternative Payment Models for Prescription Drugs – A Look at Three States

May 9, 2019/in Policy Colorado, Michigan, Oklahoma Webinars Administrative Actions, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health System Costs, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Value-Based Purchasing /by NASHP Staff

Thursday, May 9, 2019
1 p.m. (ET)

View Webinar

As states struggle with the increasing cost of prescription drugs, they are testing various alternative payment models (APMs) to curb costs. The Oklahoma Health Care Authority is a national leader with four APMs through direct contracts with pharmaceutical manufacturers. These contracts are each based on a specific drug, agreed upon outcomes, and approaches to measurement. Since Oklahoma began implementation, Michigan and Colorado had State Plan Amendments approved to advance similar APMs. Join this NASHP webinar to learn more about these states and their experiences engaging in APMs.
The moderator is NASHP Executive Director Trish Riley. Speakers include:

Terry Cothran, Director, University of Oklahoma College of Pharmacy, Pharmacy Management Consultants
Cathy Traugott, Pharmacy Manager, Colorado Department of Health Care Policy & Financing
Trish Bouck, Pharmacy Management Division Director, Michigan Department of Health & Human Services
Rita Subhedar, State Assistant Administrator, Michigan Department of Health & Human Services

Listen to the Dec. 12, 2019 webinar Medicaid Alternative Payment Models for Prescription Drugs: Do They Add Value for States? here.
Listen to the May 9, 2019, webinar Medicaid Alternative Payment Models for Prescription
Drugs: A Look at Three States here.

New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD

April 29, 2019/in Policy Alabama, Colorado, Kentucky, Mississippi, New Jersey, South Carolina, Texas, Virginia Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Erin Bonzon

Substance use disorders (SUD) and mental health conditions are prevalent among pregnant and parenting women in the United States, and they have far-reaching consequences for the health and well-being of women and their children. Integrated care models that support pregnant and parenting women’s physical and behavioral health and social service needs can improve outcomes for women and children and reduce health care costs.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau of the Health Resources and Services Administration (MCHB, HRSA), the National Academy for State Health Policy (NASHP) is working with states to support and advance innovative policy initiatives that improve access to quality health care for pregnant and parenting women.
As part of the MCH PIP initiative, NASHP is convening a two-year policy academy including eight state teams made up of representatives from state Medicaid agencies, public health agencies, mental health/substance use agencies, and other state stakeholders. States selected to participate in the first cohort of the NASHP policy academy include:

Alabama
Colorado
Kentucky
Mississippi
New Jersey
South Carolina
Texas
Virginia

Over the next two years, these states will identify, promote, and advance innovative, state-level policy initiatives to improve access to care for Medicaid-eligible pregnant and parenting women with or at risk of SUD and/or mental health conditions. NASHP will work with the states to identify high-priority policy issues, challenges, and opportunities through targeted technical assistance, peer-to-peer learning, analyses of policy issues, and development of policy briefs and other resources that will be disseminated nationally.
While many states have identified pregnant and parenting women as a priority population for their SUD and behavioral health efforts, challenges and opportunities persist. NASHP recently published two Issue Hubs that provide valuable resources, including information on the Centers for Medicare & Medicaid Services’ Maternal Opioid Misuse (MOM) Model. They are available at:

Resources to Help States Improve Integrated Care for Pregnant and Parenting Women: This Issue Hub provides valuable resources for states interested in using the Maternal Opioid Misuse (MOM) model and others to improve access to comprehensive and coordinated care and implement innovative payment and care delivery models for pregnant and parenting women eligible for Medicaid.
Resources to Help States Improve Integrated Care for Children: This Issue Hub provides valuable resources for states interested in the Integrated Care for Kids (InCK) Model and others working to implement payment, coverage, and cross-agency strategies to improve for integrated care coordination of behavioral, physical and health-related social needs for children eligible for Medicaid or the Children’s Health Insurance Program (CHIP).

Governing Accountable Health Entities: Examples from 12 States

March 29, 2019/in Policy California, Colorado, Connecticut, Delaware, Massachusetts, Michigan, Minnesota, New York, Oregon, Rhode Island, Vermont, Washington Charts Accountable Health, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Housing and Health, Population Health, Social Determinants of Health /by NASHP Staff

More than a dozen states are developing accountable health models to improve population health and control costs by addressing community needs, such as transportation, recreation, and housing. These entities’ mission — to build healthy communities through cross-sector partnerships — is supported by innovative and evolving governance structures. This NASHP chart and a companion blog highlight how states are structuring these entities to keep them accountable and reflective of their communities.
Print this chart.

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
California Accountable Communities for Health Initiative (CACHI)	“An accountable communities for health (ACH) must establish a sound governance structure that ensures effective decision-making; accountability to the community; representation of stakeholders’ interests; proper fiduciary, fiscal, and social responsibilities; and control over funding and staff.” (ACH Legal & Practical Recommendations, p. 4) An ACH should have a set of rules (bylaws or agreement) to hold stakeholders accountable to their obligations, defined fiduciary duties for the Governing Body, established controls over activities and finances, and a conflict of interest policy and procedure.” (p. 4)	The ACH collaborative must include: “-Health plans, hospitals, private providers or medical groups and community clinics serving the geographic area. -Government health and human services agency/public health department -Grassroots, community and social services organizations that include authentic and diverse representation of residents, particularly from underserved communities.” “It is desirable that every ACH include broad representation of several of the following types of entities: -County and/or city government leadership, including elected officials -Behavioral health providers – Housing agencies -Food systems -Employers and other business representatives -Labor organizations -Faith-based organizations -Schools and educational institutions -Parks and recreational organizations and agencies -Transportation and land use planning agencies -Dental providers -Local advocacy, grassroots organizations or policy-focused organizations.”(RFP, p. 7)	CACHI’s Year 1 request for proposals awarded points for, “Meaningful resident engagement and a process for ongoing engagement throughout the funding period.” (RFP, p. 14)	Recommended key milestone: “By the end of Year 1: Develop a governance plan that includes the following: -A list of community sectors to be represented on the Governing Body of the Wellness Fund. -An outline of key components of bylaws to establish the number of directors, meetings, voting procedures, a community investment committee, and conflict of interest and anti-nepotism policies. -A document outlining how accountability to the community will be achieved and maintained (e.g., by reserving board and committee slots for community residents and providing annual reports on activities and spending).” (ACH Legal & Practical Recommendations, p. 35-36)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Colorado Regional Accountable Entities	“The contractor shall have a governing body responsible for oversight of the Contractor’s activities in relation to this Contract.” (RFP 5.3.5)	“The contractor shall select members of the governing body in such a way as to minimize any potential or perceived conflicts of interest.” (5.3.5.1)	“The regional accountable entities (RAE) will develop mechanisms to engage community partners within the RAE’s region for population health and nonmedical community services.” (3.3.10) The RAE will “promote physical and behavioral health ….[and] the population’s health and functioning, coordinate care across disparate providers, interface with long-term services and supports providers, and collaborate with social, educational, justice, recreational and housing agencies to foster healthy communities ….” (3.3.3)	The contractor shall publicly list information, including, but not limited to, the names of the members of the governing body and their affiliations, on the contractor’s governing body on the contractor’s website.” (RFP, 5.3.6)	“The program will focus on greater coordination with the Colorado Departments of Human Services, Public Health and Environment, Education, and Corrections, as well as initiatives such as Comprehensive Primary Care Plus (CPC+), State Innovation Model (SIM), Hospital Transformation Program, and the Colorado Opportunity Project. The RAE will play key regional roles in these initiatives as they are well aligned with the Accountable Care Collaborative’s goals.” (3.3.11)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Connecticut Health Enhancement Communities (HECs)	“Health Enhancement Communities (HEC) will have a defined structure, with a formal governance structure and community organizing groups. The formal governance structure will have clearly defined decision-making roles, authorities, and processes. The community organizing groups will have ownership and decision-making authority over the things that matter most to them and will lead the identification and implementation of interventions in their communities.” HEC Design Principles (See p. 52-54 of HEC model design draft proposal, Oct. 22, 2018, for chart of other governance requirements.)	“-In addition to community organizing groups, HECs will need to identify multiple methods for gaining meaningful involvement, including in decision-making, as HECs form and operate -HECs will need to include multiple community organizations that directly address root causes of poor health in their communities.” (HEC model design draft proposal p. 52)	“Given their unique and essential perspectives and insights about their communities, HECs’ success depends on the ongoing involvement of community members and community members making decisions about things that matter most to them. In addition to community members being involved in HEC formation and operation, the HEC structure should also support community organizers and locally owned and directed community organizing groups within communities….” (HEC model design draft proposal p. 9-10)	Minimum governance structure elements required by the state and determined by HECs: “-Partnership agreements -Bylaws -Backbone organization -Formal contracts for services.” (HEC model design draft proposal p. 52-53)	State Innovation Model

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Delaware Healthy Neighborhoods	Neighborhood task forces: “Create and propose data driven, evidence-based initiatives, request funds…measure outcomes… engage in quality improvement. Local councils “serve as a ‘board’ of the Healthy Neighborhood (e.g. decision making about resource allocation)… [and] approve Task Forces’ requests for resources.” (HMA, Healthy Neighborhoods Model, Dec. 2017, p. 7) The role of the fiscal agent is to: -“Distribute funding to entities implementing Task Force Initiatives (once ‘readiness process’ has been completed) -Collect data/outcomes from each Task Force related to funded initiatives and utilize this practice of continuous analysis as a tool for ongoing learning -Focus on sustainability of the SIM Grant funding (e.g., establishing and managing a community trust) -Serve as a ‘Backbone Organization’ across all Local Councils.”(HMA, p. 4)	Local neighborhood task forces contain: “-Local community stakeholders and leaders that are focused on a priority area -Two co-chairs.” Local councils are made up of: “-At least one representative from each task force -Local leaders with expertise in priority areas -Cross-sector entities and organizations recruited via the Social Network Analysis to ensure representation of all critical entities -Delivery systems as well as community-based organizations -Community advocates from neighborhoods -Community stakeholders.” (HMA, p. 7) “Voting procedures are established in the bylaws of the Local Council.” (HMA p. 18)Local councils are advised by a statewide consortium with: “-Local council co-chairs -Statewide leaders focused on user-friendly community-level data -Statewide leaders focused on sustainability of healthy neighborhoods -Statewide leaders focused on policy -Advocacy organizations from neighborhoods -The statewide fiscal agent.” (HMA p. 8)		“Readiness assessment will assess: -Did the task force use data about community needs to develop the initiative? -Did the task force include representatives from diverse entities who weighed in on the creation of the plan? -Similarly, do you have community buy-in?” (p. HMA 15-16)	State Innovation Model

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Massachusetts Accountable Care Organizations (ACOs)	Massachusetts Health Policy Commission (HPC)’s ACO Certification Program assessment criteria includes a “Patient-centered, accountable governance structure.” (ACO Policy Brief, April 2018, p. 3)	“The ACO provides for meaningful participation in the composition and control of the Governing Body for its participants or their representatives.” ACOs must attest that “ACO Participants have at least 75% control of the Governing Body (Proposed 2019 ACO Certification Standards, p. 7). – [ACOs must have] “at least one patient or consumer advocate within the governance structure.” (Proposed 2019 ACO Certification Standards, p. 7-8)	“The ACO governance structure is designed to serve the needs of its patient population, including by having … a patient and family advisory committee.” (Proposed 2019 ACO Certification Standards, p. 7-8)	The HPC requires ACOs to submit an “Organizational chart(s) of the Governance Structure(s) of the Applicant (and Component ACOs as applicable), including Governing Body, executive committees, and executive management, and indicating the location of a patient or consumer representative role within each Governance Structure.” (Proposed 2019 ACO Certification Standards, p. 5-6) ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (p. 14)	MassHealth Medicaid Section 1115 Demonstration
Massachusetts Accountable Care Organizations (ACOs)	“The ACO Governing Body regularly assesses the access to and quality of care provided by the ACO, in measure domains of access, efficiency, process, outcomes, patient safety, and patient experiences of care, for the ACO overall and for key subpopulations (i.e. medically or socially high needs individuals, vulnerable populations), including measuring any racial or ethnic disparities in care.” (Proposed 2019 ACO Certification Standards, p. 8)			ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (DSRIP protocol, p. 14)	MassHealth Medicaid Section 1115 Demonstration

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Michigan Community Health Innovation Regions (CHIRs)	“Each of the five regions is supported by a backbone organization that serves as a fiduciary and acts as a neutral convener for the CHIR’s governing body.” “CHIR partners are organized by a neutral backbone organization that [serves as a fiduciary and] facilitates the development and implementation of key strategies, creating the necessary capacity to sustain progress on stated objectives. CHIR steering committees provide a clear leadership structure and promote shared accountability among partners for aligning their resources to address priority community health needs.” (SIM, “About CHIRS”)		“CHIR governance facilitates effective collaboration of providers, health plans, community based organizations and individuals to pursue community‐centered solutions to upstream factors of poor health outcomes and health disparities.” (NASHP slides, Aug. 2018)		State Innovation Model

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Minnesota Accountable Communities for Health (ACHs)	“The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community. ACH projects are exploring and testing a variety of governance approaches such as charters, formal business agreements between partners and use of technical subcommittees …. ACH leadership team structure and makeup differs across ACHs. Some ACHs created an entirely new governance structure while others use existing committees, task forces, or advisory bodies (such as Statewide Health Improvement Program – SHIP – committees) to organize their work.” (ACH: Perspectives on Grant Projects and Future Considerations, Oct. 2016, p. 12). “Besides leadership and governance, the ACH must have a ‘backbone’ or lead organization to serve as convener and integrator.” (p. 35)	“Each ACH has a lead organization (e.g., private foundation, non-profit social service agency, local public health agency or health care system) that serves as fiscal agent and resources manager. The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 12) “All health plans and systems serving the population should participate in the ACH. Local public health must be an active partner, and local political leaders, government officials and other leaders should be invited to participate. Most importantly, the governing body should ensure that persons experiencing health disparities are represented in ACH partnerships, mission and vision.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 35)	“Each ACH grant project features … community-led leadership.” (Minnesota Accountable Communities for Health)	Required components of each ACH grant project are: “-Community-led leadership -Care coordination between multi-sectoral partners -Population-based prevention -Measurement and evaluation -Partnership with an Accountable Care Organization -Participation in an ACH learning community -Sustainability planning -Health equity focus.” (Minnesota Accountable Communities for Health)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
New York Performing Provider Systems (PPSs)	“The Performing Provider System will need to demonstrate that it has a governance strategy that ensures that participating providers work together as a “system” and not as a series of loosely aligned providers nominally committed to the same goal.” (DSRIP Program Funding and Mechanics Protocol, p. 14)	“Please explain how the selected members provide sufficient representation with respect to all of the providers and community organizations included within the PPS network. Please outline where coalition partners have been included in the organizational structure, and the PPS strategy to contract with community based organizations.” (DSRIP PPS Organizational Application, p. 35)	“Describe how the PPS governing body will engage stakeholders on key and critical topics pertaining to the PPS over the life of the DSRIP program.” (DSRIP PPS Organizational Application, p. 34-36)		Medicaid Section 1115 Demonstration Delivery System Reform Incentive Payment program
	“Describe the decision making/voting process that will be implemented and adhered to by the governing team. Explain how conflicts and/or issues will be resolved by the governing team.” (DSRIP PPS Organizational Application, p. 35.)				State Health Innovation Plan (through the State Innovation Model)
					State Health Improvement Plan (the Prevention Agenda).

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Oregon Coordinated Care Organizations (CCOs)	“Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two.” (2017 ORS 414.625) “Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.” (ORS 414.625)	“Each coordinated care organization has a governing body of which a majority of the members are persons that share in the financial risk of the organization and that includes: (a) A representative of a dental care organization selected by the coordinated care organization; (b) The major components of the health care delivery system; (c) At least two health care providers in active practice, including: (i) A physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and (ii) A mental health or chemical dependency treatment provider; (d) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and (e) At least one member of the community advisory council.” (2017 ORS 414.625)	Required to serve on the governing body are: “At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and At least one member of the community advisory council.” (2017 ORS 414.625)Community advisory councils: “A coordinated care organization must have a community advisory council to ensure that the health care needs of the consumers and the community are being addressed. The council must: (a) Include representatives of the community and of each county government served by the coordinated care organization, but consumer representatives must constitute a majority of the membership; and (b) Have its membership selected by a committee composed of equal numbers of county representatives from each county served by the coordinated care organization and members of the governing body of the coordinated care organization.” (2017 ORS 414.627)		Medicaid Section 1115 Demonstration

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Rhode Island Accountable Entities (AEs)	“The intent of these requirements include: 1) To ensure multi-disciplinary providers are actively engaged in a shared enterprise and have a stake in both financial opportunities and decision-making of the organization; (2) to ensure that assets and resources intended to support RI Medicaid are appropriately allocated, protected, and retained in Rhode Island; (3) to ensure that the mission and goals of the new entity align with the goals of EOHHS and the needs of the Medicaid population; (4) to ensure a structured means of accountability to the population served.” (AE Certification Standards, 2017, p. 16)	“There shall be an established means for shared governance that provides all AE Partner Providers with an appropriate, meaningful proportionate control over the AE’s decision-making process.” (AE Roadmap, April 2017, p. 42) “Board or Governing Committee Membership. The majority of voting members of the Board or the Governing Committee shall be provider representatives from participating Partner or Affiliate provider organizations, provided that at least three members shall be LTSS providers and one member shall be a behavioral health provider. Minimal representation requirements for each population certified to serve -Children: pediatric representative member of Consumer Advisory Committee, community-based organization (CBO) provider of age-appropriate supports -Adults: representative member of Consumer Advisory Committee, CBO provider of age-appropriate social supports (AE Certification Standards, 2017, p. 45)	Draft certification standards include a requirement for AEs to have a “Community Advisory Committee consisting of at least ten persons who are attributed Medicaid beneficiaries who are representative of the populations served by the AE.” (AE Roadmap, 2.1.8)		Medicaid Section 1115 Demonstration
					State Innovation Model (SIM)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Vermont Accountable Communities for Health (ACHs)	“An accountable community for health is managed through a governance structure that articulates the process for decision-making and outlines the roles and responsibilities of the integrator organization, the steering committee (or other decision-making body), and other collaborative structures or partners.” From Vermont Accountable Communities for Health Peer Learning Lab Report, March 2017	“The governance structure should include a diverse representation of stakeholders, including decision-makers, experts, community members, and leaders from the variety of community organizations that impact health in the region.” (Vermont ACH Peer Learning Lab Report, p. 18).	“The ACH Peer Learning Lab sought to build on this framework and test model implementation while increasing community capacity and readiness across the nine Core Elements of the ACH model.” (Vermont ACH Peer Learning Lab Report, p. 6 )	Governance is one of the nine core elements of the ACH model. (Vermont ACH Peer Learning Lab Report, p. 18)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Washington Accountable Communities of Health (ACHs)	Accountable communities of health must: -Maintain a governance structure that includes balanced cross-sector collaboration and decision-making, including the necessary documented procedures and agreements, e.g. bylaws and a memorandum of understanding. -Ensure that no one sector or organization can control decision-making. -Revisit the process at least annually to determine effectiveness considering the regional landscape and specific governance structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, P. 5)“Minimum expectation: ACHs must develop and maintain a communications framework to keep partners informed and involved in between meetings and events.”(State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8).	“Washington’s tribes and urban Indian health organizations (UIHOs) are among the partners ACHs should reach out to for participation in ACH activities, including governance and decision making… Tribal governments are not stakeholders. The state maintains relations with the tribes on a government-to-government basis.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 7)	“ACHs require governance structures tailored by community leaders to most effectively implement the goals of Healthier Washington at the local level.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 5). “Because of the unique regional demographics, existing resources, and potential initiatives already under way, the specific community engagement strategies will not be prescribed by the state.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8).	“Minimum expectation: ACHs must implement a cascading engagement approach tailored to the local environment that brings the voice of consumers and individual community members to ACH development and decision making, in addition to the balanced multi-sector decision making structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8) “ACHs are strongly encouraged, under the SIM contract, to maintain open public governing body meetings.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8)	State Innovation Model

Colorado Develops New Payment Method for Physician-Administered Drugs – with the Potential to Save Millions

March 18, 2019/in Policy Colorado Blogs Administrative Actions, Cost, Payment, and Delivery Reform, Health System Costs, Medicaid Managed Care, Prescription Drug Pricing, Quality and Measurement /by Johanna Butler and Jennifer Reck

The National Academy for State Health Policy (NASHP) provided a grant to the Colorado Department of Health Care Policy and Financing to develop a new payment methodology for physician-administered drugs (PADs). PADs are drugs delivered by intravenous infusion or injection in clinical settings. The category includes costly drugs, such as chemotherapy and other specialty medications.
Developing an appropriate payment methodology is a challenge for states due to a lack of information about how much providers actually pay to acquire these drugs. Colorado’s current methodology reimburses providers based on an average sales price (ASP) plus 2.5 percent – however, it is unknown how closely these prices reflect what providers actually pay. One recent analysis suggested that hospital markups for a variety of brand name drugs ranged from three- to seven-times more than the average sales price. Hospital markups for generic drugs were even higher.
To determine what providers actually pay for PADs, Colorado contracted with Myers & Stauffer to survey Medicaid providers from July to August 2018 to establish their actual acquisition costs. Using the aggregated acquisition cost data, Myers & Stauffer developed an average acquisition cost-based payment rate model and compared them to existing payment rates in Colorado.
They found that current Colorado payment rates were 12 percent higher overall than the average acquisition cost-based rates, meaning this new methodology could produce significant savings for the state.
The new model for payment rates based on the average acquisition cost survey is similar to the average acquisition model that many states currently use to pay for pharmacy-dispensed prescription drugs – called the National Average Drug Acquisition Cost (NADAC).
For more information about Colorado’s trailblazing work and research findings on the impact of NADAC on state drug spending, register for the upcoming NASHP webinar State Tools to Lower Medicaid Prescription Drug Costs: Exploring Payment Methodologies for Retail and Physician-Administered Drugs, from 2 to 3 p.m. (EST) Friday, March 29, 2019.

Hospital Price Transparency: The Next Frontier

March 4, 2019/in Policy Colorado, Maine, Massachusetts, New Hampshire, Washington Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs, Medicaid Managed Care, Value-Based Purchasing /by Josephine Porter

The Centers for Medicare & Medicaid Services (CMS) took an important first step toward increasing the transparency of hospital finances when it required hospitals to post their charge information, effective January 2019. But, these charges are not prices paid — they are typically the starting point against which commercial payers negotiate discounts.
States with all-payer claims databases (APCDs) have an important tool that allows them to go a step further – they can analyze the differential between “charges” and “prices paid.” This is an increasingly important distinction, particularly as 90 percent of hospital marketplaces are highly concentrated. Research shows that such concentration diminishes the capacity of health plans to negotiate rates and has increased hospital costs from 20 to 40 percent without gaining improvements in efficiency or quality .
New Hampshire Comprehensive Health Care Information System’s APCD releases data that allows the comparison of the difference between what is charged by hospitals and what health plans and consumers pay. The statewide report of charges and allowed amounts for common hospital services in New Hampshire, available at the NH HealthCost website, shows how charges compare to allowed amounts. Analysis of this data, shown in the table, illustrates that the actual amount paid for a service can vary greatly from what is charged, sometimes by more than 100 percent.

Service Category	Median Price Charged	Median Price Allowed or Paid	Percentage Difference between Median Price Charged and Amount Paid
Biopsy skin lesion	$ 189.00	$ 69.12	-173%
Total hip arthroplasty	$ 37,195.00	$ 20,193.17	– 84%
Total knee arthroplasty	$ 14,543.50	$ 5,824.55	-150%
Nasal endoscopy dx	$ 1,119.16	$ 437.85	-156%
Diagnostic colonoscopy	$ 2,553.00	$ 1,800.61	-42%
Fetal non-stress test	$ 369.00	$ 261.34	-41%
Low back disk surgery	$ 10,615.75	$ 6,559.99	-62%
CT head/brain w/o dye	$ 2,030.56	$ 685.86	-196%
Chest x-ray	$ 366.00	$ 146.95	-149%
X-ray exam of knee 3	$ 399.00	$ 189.53	-111%
MRI joint of lower extremity	$ 2,598.00	$ 1,392.21	-87%
Comprehensive metabolic panel	$ 86.92	$ 56.15	-55%
Lipid panel	$ 106.00	$ 68.44	-55%
Glucose blood test	$ 43.00	$ 12.44	-246%
Eye exam new patient	$ 264.65	$ 140.25	-89%
Speech/hearing therapy	$ 313.45	$ 157.70	-99%
Comprehensive hearing test	$ 235.00	$ 188.85	-24%
Cardiovascular stress test	$ 1,154.00	$ 662.88	-74%
Office/outpatient visit new	$ 288.50	$ 188.27	-53%
Emergency dept. visit	$ 2,300.00	$ 1,374.67	-67%

Importantly, the charges and prices paid vary by procedure, hospital, and payer and the data that shows these price differences is available through APCDs. NH HealthCost and similar websites in Maine, Colorado, Massachusetts, and Washington all are valuable resources to enhance transparency by identifying the price for services and the variation of those prices within each state.
Working together, CMS and state APCDs can provide important data to fuel conversations about hospital charges and payments, and the policy issues that the data raises.
Notes
The Affordable Care Act’s amendment to section 2718(e) of the Public Health Service Act requires each hospital operating within the United States to make public a list of standard charges for items and service provided by the hospital including for diagnostic-related groups. CMS published proposed rules for FY 2015 reminding hospitals of their obligation to comply, and again for FY 2019, ultimately finalizing the rules to improve the public accessibility of charge information in a machine-readable format effective January 2019. https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-16766.pdf.

Josephine Porter is director of the University of New Hampshire’s Institute for Health Policy and Price and co-chairs the All-Payer Claims Database Council (APCD Council).
Trish Riley is executive director of the National Academy for State Health Policy.

How States Promote Recovery for Pregnant and Parenting Women with Substance Use Disorder

October 30, 2018/in Policy Colorado, Pennsylvania, Texas Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by Hannah Eichner, Becky Normile and Carrie Hanlon

Substance use disorder (SUD), including opioid use disorder (OUD), is prevalent among pregnant and parenting women, and these women have unique and often un-met treatment needs. Despite significant efforts, states report that access to treatment continues to lag for this population. In 2014, half of pregnant women with OUD who were enrolled in publicly-funded treatment programs received medication-assisted treatment (MAT) – considered the standard of care for people with OUD. New mothers are also at increased risk of relapse and overdose during the postpartum period.

The number of women with opioid use disorder during pregnancy has increased dramatically, affecting 6.5 of every 1,000 women at delivery in 2014.

Recognizing the needs of this population, Congress recently passed the SUPPORT for Patients and Communities Act, which orders a Government Accountability Office study into the coverage gaps that persist for pregnant and postpartum women with SUD who were eligible for Medicaid during pregnancy. And last week, the federal Center for Medicare & Medicaid Innovation announced the Maternal Opioid Misuse Model, which will offer cooperative agreements to up to 12 states to transform their delivery systems for pregnant and postpartum women with OUD and reduce fragmentation in delivery of care.
As SUD impacts mothers, it also affects their children. Between 2000 and 2012, rates of neonatal abstinence syndrome (NAS), caused by opioid exposure during pregnancy, rose five-fold, accounting for $462 million in Medicaid hospital costs in 2014. Exposure to other substances, such as alcohol, can also affect child development and parental substance use is linked to increased risk of child welfare involvement and childhood trauma.
A new National Academy for State Health Policy (NASHP) report, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder, supported by the Health Resources and Services Administration Office of Women’s Health, identifies promising strategies from Colorado, Pennsylvania, and Texas to support pregnant and parenting women with SUD. These states:

Support access and coverage through early identification of substance misuse by expanding postpartum coverage for SUD treatment, and by facilitating transitions between care settings. In Texas, a state that has not expanded Medicaid, women may become ineligible for Medicaid coverage 60 days after giving birth. As a result, they face challenges continuing SUD treatment beyond 60 days postpartum. To address this issue, Texas expanded state-funded SUD treatment slots for postpartum women. Under this initiative, when a woman’s Medicaid coverage ends after giving birth, she can seamlessly transition to a treatment slot funded by state general revenue without being on a waiting list, and experience no change or disruption in her providers or services.
Implement innovative care delivery models that consider the unique needs of women and families, such as integrating reproductive health care and SUD treatment, family-centered care models, and supports for social determinants of health. For example, Pennsylvania offers a Centers of Excellence (COE) program, funded by Medicaid and state general revenue, which provides coordinated and team-based care to individuals with OUD. Six COEs focus on meeting the unique needs of pregnant and postpartum women. These COEs coordinate services including SUD treatment, obstetric and postpartum care, and services that address social determinants of health, such as housing and transportation.
Promote cross-system financing and collaboration to develop alignment across policies and programs and to leverage multiple federal and state funding streams. For example, Colorado’s Special Connections program offers comprehensive and coordinated SUD treatment services for Medicaid enrollees who are pregnant and the services continue up to 12 months postpartum. The program is administered through a partnership between the state’s Department of Health Care Policy and Financing and Office of Behavioral Health. The program weaves together funding from Medicaid (authorized under the Medicaid state plan and a 1915(b) waiver), the federal Substance Abuse Prevention and Treatment Block Grant, and state general funds.

To learn more:

Read NASHP’s new issue brief, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.
Listen to a recording from an Oct. 24, 2018 webinar that explores how Colorado supports pregnant and parenting women with SUD.
Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.

State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

October 30, 2018/in Policy Colorado, Pennsylvania, Texas Reports Behavioral/Mental Health and SUD, Care Coordination, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Hannah Eichner, Becky Normile and Carrie Hanlon

The opioid epidemic has heightened states’ efforts to prevent and treat of substance use disorder (SUD) in pregnant and parenting women. The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration, interviewed Colorado, Pennsylvania, and Texas officials about the unique interagency approaches they are using to promote recovery for this population. This new report explores:

State coverage, care delivery, and financing strategies to support pregnant and parenting women with SUD;
Available state and federal funding sources for these initiatives; and
Key considerations for states working to promote recovery.

Read or download: State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

Download webinar slides and listen to the webinar that explored how Colorado supports pregnant and parenting women with SUD. The speakers were:
- Amy Cooper, Women’s Services Coordinator, Office of Behavioral Health, Colorado Department of Human Services;
- Susanna Snyder, Maternal Child Health Policy Specialist, Health Programs Office, Colorado Department of Health Care Policy and Financing; and
- Dr. Kaylin Klie, Physician, Denver Health; Assistant Professor, University of Colorado Department of Family Medicine

Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.