Eight States Join NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy to Address Maternal Mortality
The National Academy for State Health Policy (NASHP) has announced a new, two-year policy academy kicking off in April for state health officials interested in building state capacity to address maternal mortality for Medicaid-eligible pregnant and parenting women, with the goal of improving access to quality care.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the Maternal and Child Health Bureau within the Health Resources and Services Administration, NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy will engage eight state teams (GA, ID, IL, IA, LA, PA, SD, and VA). The teams include representatives from state Medicaid agencies, public health agencies, and other state stakeholders (e.g., mental health/substance use agencies, child welfare agencies, provider groups, Medicaid managed care plans, and others.)
Through this policy academy, states will identify, develop, and implement policy changes or develop specific plans for policy changes to improve maternal health outcomes, with a specific focus on improving racial disparities in maternal mortality.
The United States has seen a steady rise in maternal mortality over the past few years and has the worst maternal mortality rate among developed nations. Additionally, there are stark racial disparities in pregnancy-related deaths. American Indian/Alaska Native and Black women are two- to three- times more likely to die from pregnancy-related causes than non-Latinx (non-Hispanic) White women. States are grappling with a number of factors in their efforts to improve access to quality care for this population and strengthen the systems serving them.
Over the course of the two-year project, NASHP will provide technical assistance to states, identify barriers, and share promising practices for improving maternal health outcomes to help states achieve their policy goals.
Recent State Actions to Address Declining Children’s Insurance Coverage Rates
Since reaching an all-time low in 2016, the rate of uninsured children has climbed from 4.7 percent in 2016 to 5.7 percent in 2019. In response, several state legislatures are considering bills designed to improve children’s coverage options and promote child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP).
Program and Enrollment Expansions
One of the most notable efforts to expand children’s coverage was included in New Jersey Gov. Phil Murphy’s fiscal year 2022 budget, which establishes the Cover All Kids initiative to provide coverage to all uninsured children. At an estimated cost of $20 million, it is forecasted to cover 88,000 children by expanding Medicaid eligibility thresholds and extending coverage to children currently ineligible due to immigration status.
The Cover All Kids program aligns with initiatives previously proposed by New Jersey advocates and legislators to ensure all children have coverage. The governor’s proposed budget also directs the Department of Human Services to eliminate premiums and the waiting list for children enrolled in CHIP and provides funds for an enhanced outreach campaign to increase Medicaid and CHIP child enrollment.
In Utah, lawmakers considered two children’s coverage bills during this session. In 2019, Utah had the third-highest increase in the rate of uninsured children and the highest rate of uninsured Latinx children in the country. In response to these troubling statistics, the Utah Legislature passed HB262, which creates the Children’s Health Care Coverage program. This program directs the Utah Department of Health, Department of Workforce Services, and the state Board of Education to develop a program to promote health insurance coverage for children when they enroll in school and when they apply for free and reduced lunch.
The Utah law also requires the state to:
- Conduct research on families who are eligible for Medicaid and CHIP to determine their awareness of coverage options;
- Analyze trends in disenrollment to identify barriers for coverage renewal; and
- Administer surveys to gather information about current enrollees’ experiences with the programs.
Findings from this research will be used to redesign the CHIP and children’s Medicaid enrollment websites and inform future outreach partnerships.
Another Utah bill, SB158, designed to address the state’s coverage crisis through the creation of a robust outreach program, focused on enrolling underserved populations, providing application assistance, and launching an advertising campaign to draw attention to coverage opportunities for children. In addition, the bill would have expanded public coverage to children whose family income fell below 200 percent of the federal poverty level (FPL). Despite senate approval, the bill did not pass.
Like Utah, Florida experienced a dramatic increase in childhood uninsured rates since 2016. The Center for Children and Families at Georgetown University’s Health Policy Institute 2020 report found that more than 55,000 Florida children had lost coverage between 2016 and 2019, representing the second-highest coverage drop in the nation during that period. Florida legislators are currently considering HB 201 and SB 1244, both of which would increase the eligibility threshold for their CHIP program from 200 percent of FPL incrementally by 20 percent each year beginning in the 2021-2022 fiscal year, until reaching 300 percent of FPL, which is expected in the 2026-2027 fiscal year.
In Maine, legislators are considering LD 372, a bill to expand access to CHIP. The bill includes provisions to:
- Expand income eligibility from 200 to 300 percent of FPL;
- Eliminate the waiting period for children whose families have lost employer-sponsored coverage;
- Extend coverage eligibility from age 19 to 20; and
- Eliminate premium payments for all enrollees.
Express-lane eligibility:
Last week, the Georgia Legislature passed HB 163, which directs the Department of Community Health to seek federal approval to establish express-lane-eligibility (ELE) for children whose families apply for the Supplemental Nutrition Assistance Program (SNAP). By implementing the ELE option, children will automatically be enrolled or renewed in Medicaid or the state’s CHIP program, PeachCare for Kids, based on the current information provided in their SNAP application. State child health advocates estimate that this could increase child enrollment in Medicaid in the state by 70,000. Currently, five states use SNAP data to determine eligibility for Medicaid and/or CHIP.
CHIP Buy-in Programs:
Legislators in Iowa and West Virginia are considering bills to create CHIP buy-in programs, which allow families with incomes above their state’s CHIP eligibility thresholds to purchase coverage.
Iowa’s SF220 would allow families to purchase CHIP coverage for children and young adults up to age 26 whose household income exceeds the maximum income eligibility threshold of 302 percent of FPL. Iowa’s CHIP-buy in plan differs from traditional CHIP buy-in programs as it would allow families to purchase CHIP coverage for their children as an alternative to qualified health plans on the exchange or plans on the individual market — which unlike CHIP are not tailored to children’s needs.
The CHIP coverage would be sold through the marketplace, allowing families to compare their coverage options, and could be paid for with premium tax credits for eligible enrollees. If passed, the state would need federal approval to implement the plan.
West Virginia’s HB2278 would establish a buy-in program for children’s whose families earn more than 300 percent of FPL and could afford to pay the cost of CHIP coverage in full.
Despite states continuing to grapple with managing the COVID-19 pandemic, many are still seeking to improve coverage for children in Medicaid and CHIP. The National Academy for State Health Policy continues to track states’ efforts to increase enrollment in children’s coverage in Medicaid and CHIP.
Iowa’s I-Smile Program Promotes Dental Care for Children, Pregnant Women, and Adults
Through a unique partnership between the Iowa Medicaid and public health agencies, Iowa’s I-Smile program addresses the disproportionate impact of dental disease on low-income individuals. I-Smile and its related I-Smile @ School for children and I-Smile Silver for adults help promote preventive oral health services and reduce barriers to dental care across the state.
I-Smile Background
In children, dental caries is the most common chronic disease, affecting 60 percent of individuals ages 5 to 17. Additionally, studies indicate that up to 40 percent of pregnant women experience periodontal disease, and 25 percent of adults over age 65 lack their natural teeth. Additionally, significant disparities exist. In 2016, Medicaid recipients accounted for more than half of dental-related emergency room visits, and in 2019, 44 percent of low-income adults had untreated tooth decay.
Dental disease not only adversely affects oral health, but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Fortunately, preventive oral health care, including sealant and fluoride treatments, can save money and lives. While many states are expecting budget cuts in response to COVID-19-related revenue declines, increasing access to preventive dental care through programs like Iowa’s I-Smile may minimize long-term dental and overall health costs by effectively reaching underserved populations.
In May of 2005, Iowa passed the IowaCare Medicaid Reform Act, which includes the provision that every child age 12 and younger enrolled in Medicaid must have a designated dental home. In addition, the legislature sought to ensure that children are provided with the dental screenings and preventive care identified as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program’s oral health standards. I-Smile was created in response to this 2005 legislation and funded via a Memorandum of Understanding (MOU) between the Iowa Department of Human Services (IDHS) and the Iowa Department of Public Health (IDPH).* IDPH holds the majority of the responsibility under the MOU and contracts with local Title V agencies (public or private non-profit organizations), that administer I-Smile and ensure access to oral health services for children and pregnant women across the state.
Oral Health in Iowa at a Glance:
- In 2002, Medicaid reimbursement for preventive oral health services became the standard of care for dental screening centers in Iowa.
- In 2018, $22 million of a total $31 million spent on preventable dental surgeries for children ages 5 and younger was billed to Medicaid.
- In 2019, 73 percent more Medicaid-enrolled children in Iowa saw a dentist than in 2005.
- In 2018, 50 percent of Medicaid-enrolled children received a dental service, including two out of every three children ages 3 to 12. Iowa rates surpassed both the national average of 34.6 percent of low-income children receiving preventive dental care, as well as the Healthy People 2020 goal of 33.2 percent.
- In 2018, more than 30,650 children received preventive dental care in public health locations, including Women, Infants, and Children (WIC) clinics, schools, and Head Start centers. This number is almost four-times as many as in 2005.
- Medicaid costs per child (ages 0-12) per year have remained relatively steady since the start of the program in 2005. After accounting for inflation and a 1 percent rate increase in 2014, the average cost was $150.75 in 2005 and $170.74 in 2019.
- Iowa met the Healthy People 2020 goal to reduce the proportion of adults 65-74 years old that have lost all of their teeth; in 2014, 13 percent of Iowa adults ages 65-74 years were without their natural teeth, well under the goal of 21.6 percent.
*The MOU for I-Smile does not include I-Smile @ School and I-Smile Silver.
I-Smile in Practice
I-Smile’s mission is to connect Iowa children with “dental, medical and community resources to ensure a lifetime of health and wellness.” I-Smile primarily targets the 47 percent of Iowa children ages 0-12 who are enrolled in Medicaid in order to provide dental care and disease detection early in life and limit costly, preventable dental procedures. Additionally, given the link between mothers’ oral health and their infants’, I-Smile also serves pregnant women.
Twenty-three I-Smile coordinators are responsible for implementing I-Smile strategies within all 99 Iowa counties by serving as a point of contact with the dental network. I-Smile coordinators work with families, dentists, medical professionals, schools, businesses, and local non-profits to assess community needs, coordinate dental care, improve oral health literacy and reduce barriers to care. I-Smile uses multiple approaches to improve dental care, including:
- Partnering with WIC clinics, schools, Head Start centers, preschools, and child-care centers to provide dental screenings and fluoride application;
- Coordinating dental appointments, including scheduling, setting up transportation assistance, and helping parents find payment sources for dental care;
- Training medical professionals to administer fluoride varnish and screen for dental disease; and
- Educating community members about the importance of oral health through public events, health fairs, and online informational tools.
I-Smile @ School
I-Smile @ School is a division of I-Smile that helps children access dental care by providing dental screenings, sealants, fluoride varnish, and oral health education in elementary and middle schools during the school day. I-Smile @ School strategies include:
- Assessing oral health needs of schoolchildren;
- Developing networks with dental offices; and
- Providing oral health education, preventive dental services, and care coordination.
I-Smile @ School is administered by 19 Title V agencies across the state. Funding sources include the Title V block grant, Medicaid reimbursement, a Centers for Disease Control and Prevention grant, and the Delta Dental of Iowa Foundation. Schools must have a minimum of 40 percent of students on free or reduced lunch plans to participate in the program. In the 2018-2019 school year, 43.4 percent of children who received a dental sealant through I-Smile @ School were enrolled in Medicaid, and an additional 9.8 percent had no dental insurance.
I-Smile @ School’s goals align with the Healthy People 2020 and Healthy Iowans 2017-2021 objectives, which include increasing dental sealants and preventive dental services for children and reducing untreated dental decay. In its Strategic Plan for 2018-2023, the program identified three outcome measures:
- Increase the number of schools served from 63 to 74 percent;
- Provide sealants to 5 percent more children; and
- Increase the sealant program consent return rate from 42 to 52 percent.
The strategic plan also identified a number of focus areas, including building cross-agency partnerships, implementing a state system for data collection, creating a communication plan for disseminating oral health information, and improving I-Smile @ School’s infrastructure.
I-Smile Silver
Iowa is one of 19 states (including Washington, DC) in which Medicaid covers extensive adult dental benefits. Through Iowa’s Dental Wellness Plan, Medicaid enrollees ages 19 and older can access full benefits, provided they complete “Healthy Behaviors” annually, which include an oral health self-assessment and preventive services. Despite this, adults, and especially senior citizens, report widespread barriers to care and low utilization rates. In 2016, 38 percent of Iowa seniors had not seen a dentist in five years, and 53 percent reported they could not afford dental care.
| In Iowa, full adult dental benefits cover the following: Diagnostic and preventive dental services Exams Cleanings X-rays Fluoride Fillings for cavities Surgical and nonsurgical gum treatment Root canals Dentures and crowns Extractions |
I-Smile Silver is a pilot program implemented across 10 Iowa counties designed to help adults ages 21 and older access dental care. I-Smile Silver is administered by the Iowa Department of Public Health using funding from the Delta Dental of Iowa Foundation and a Health Resources and Services Administration grant. The pilot project began in November 2014. IDPH contracts with three county health departments (covering 10 counties) to conduct the project. Each contractor has a dental hygienist as the local I-Smile Silver coordinator who is responsible for implementing strategies that include:
- Assessing needs and assets related to oral health;
- Providing training for medical providers, direct care staff, and home care providers;
- Creating referral networks with dental and medical offices to address oral health needs;
- Working with hospitals and health systems to address oral health related to chronic disease;
- Promoting oral health through participation in community events and distribution of materials; and
- Providing care coordination and preventive dental services.
In 2017, the IDPH conducted its first screening survey of older adults’ oral health. The project will continue to grow over the next two years, with the hope that its importance will be recognized and the program will receive funding to allow for statewide expansion of the pilot.
Key Takeaways:
- Through an MOU, states can create cross-sector partnerships in order to fund oral health initiatives and create clear implementation responsibilities across agencies.
- States can effectively reach low-income children and pregnant women by partnering with local organizations to provide dental services and oral health education, including leveraging Title V agencies and schools.
- Providing strong care coordination services is a critical tool for helping individuals access preventive dental care.
Challenges and Next Steps
While Iowa continues to make strides in increasing access to dental and oral health care, particularly among Medicaid-eligible children, some challenges remain. Compared to 60 percent of children ages 3-12, only one in five Medicaid-enrolled children under age 2 saw a dentist in 2019. To increase these numbers, I-Smile started the Cavity Free Iowa campaign to train pediatricians to provide preventive oral health care, including fluoride varnish applications, and education on the importance of oral health.
Additionally, though the number of children on Medicaid is increasing, Iowa is experiencing a decline in dentists who accept Medicaid. Providers note that Medicaid has lower reimbursement rates than private insurance, and often comes with additional administrative burdens.
Finally, as the COVID-19 public health emergency continues to unfold and dental offices address the pandemic’s effects, the long-term impact on oral health care remains unknown. Especially for children who receive dental services through school-based programs such as I-Smile @ School, the pandemic raises concerns about children’s ability to continue to be screened and treated should schools remain closed in the fall. Moreover, older citizens, who are at increased risk for COVID-19, may not feel comfortable leaving their houses to go to the dentist.
To address some of these concerns, Iowa is working to increase the use of silver diamine fluoride, a preventive treatment that can arrest dental decay. The state anticipates there will be fewer dentists accepting new Medicaid patients in the future, and is therefore emphasizing the importance of preventive oral health now to limit future complications requiring care. Iowa is also looking at new points of contact to reach children and adults. As a result of COVID-19, IDPH is preparing to play a bigger role in the dental delivery system by screening for disease, triaging who needs to be seen within a dental office and collecting diagnostics to send electronically to dentists to complete a telehealth exam. While the pandemic may require I-Smile @ School and I-Smile Silver to revise some of their strategies, in the months and years to come programs like I-Smile will undoubtedly play a crucial role in helping Medicaid-eligible children, pregnant women and adults obtain necessary dental services.
Acknowledgements: The author wishes to thank the state officials in Iowa who graciously shared their experiences and reviewed a draft of this publication. Trish Riley, Neva Kaye, and Carrie Hanlon of NASHP provided helpful guidance and assistance. Finally, thank you to the Health Resources and Services Administration officials who provided thoughtful input.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
Six States’ Strategies to Providing Home Health Services to Children Enrolled in Medicaid
To improve the quality of services for children and youth with special health care needs (CYSHCN) and reduce health care costs, states are implementing strategies to improve access to home health services. Of particular importance as states confront COVID-19-related budget challenges, home health services can help to avoid costly emergency department use, hospitalizations, and institutional care.
The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit mandates coverage of all medically necessary services for children under age 21 who are enrolled in Medicaid. However, states vary in their definitions of medical necessity, prior authorization processes, and approaches to home health service delivery.
Prior to National Academy for State Health Policy’s (NASHP) analysis, there was limited information available on home health services for CYSHCN, and few studies had analyzed states’ approaches to delivering these services.
In its new report, State Approaches to Providing Home Health Services to Children with Medical Complexity Enrolled in Medicaid, NASHP examines six states’ (WA, OH, IA, MD, DL, CT) strategies to support access to home health services for CYSHCN. These include addressing provider capacity, advancing the person-centered medical home model, streamlining prior authorization processes, collaborating with Title V Maternal and Child Health Services Block Grant Programs for CYSHCN, and promoting stakeholder collaboration.
Through analysis of these states’ home health service delivery systems, NASHP identified several key insights that other state health policymakers can leverage in their own systems to improve service delivery and reduce costs. A shortage of home health providers was the primary challenge that states faced in delivering these services to CYSHCN, which states have addressed through training programs and by increasing or modifying reimbursement policies.
Partnerships across agencies and families were recognized as key to developing informed strategies to improve home health services for CYSHCN. States have leveraged these partnerships, as well as implemented technologies and streamlined processes, to deliver more coordinated, cost-effective home health services.
- Prioritize efforts to address provider shortages. To address the lack of home health provider capacity, several states have focused on developing, enhancing, and raising awareness of training programs to increase the supply of home health agency staff. States have also modified their reimbursement policies, including increasing their reimbursement rates for home health providers, and proposing a structured fee schedule to streamline the reimbursement process for home health agencies. Ohio, for example, allows for reimbursement of family caregivers for providing services for children enrolled in its Medicaid waivers in an effort to increase home health service provider capacity.
- Leverage the benefits of cross-sector and stakeholder collaboration. Partnering with a variety of state agencies, including Title V CYSHCN programs, provider groups, families, and other key stakeholders helps build the infrastructure necessary to deliver comprehensive home health services to CYSHCN. Stakeholder groups in Ohio, Maryland, and Delaware were crucial to developing strategies to improve access to home health services for CYSHCN. Two of these states also referenced the importance of family engagement to inform the work of the stakeholder group. In Ohio and Iowa, Medicaid agencies, providers, and Title V CYSHCN programs have formed collaborations to improve care coordination and access to home health services for CYSHCN.
- Adjust service delivery models to increase capacity. The medical home is a primary care service delivery model that emphasizes coordinated care through a team-based approach. Connecticut and Delaware, have looked to this model to encourage providers to improve care coordination for CYSHCN, including home health services. States have also looked to streamline their prior authorization processes to reduce administrative challenges for CYSHCN to access home health services. Delaware and Iowa are implementing changes to simplify this process through a “flag” in their data system and by developing a standardized prior authorization form for all managed care plans, respectively.
Other key insights from this analysis include seeking regular feedback from families, strengthening oversight, and customizing fee-for-services and managed care approaches. States interested in improving children’s access to home health services through Medicaid may benefit from the approaches implemented by the six states highlighted in this issue brief. For a list of NASHP’s reports, blogs, and other resources related to improving care for CYSHCN, please click here.
State Strategies for Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs
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Care coordination is an essential component of care for children and youth with special health care needs (CYSHCN). When successfully implemented, it can improve care, reduce costs, avoid fragmented and duplicative care, and improve family functioning and satisfaction. As states work to provide quality care coordination, many are adopting shared plans of care (SPoC) to enhance patient- and family-centered care delivery, and support improved outcomes and care quality. This issue brief, developed by the National Academy for State Health Policy with support from the Health Resources and Services Administration’s Maternal and Child Health Bureau, identifies approaches and strategies states can use to promote the use of SPoCs as part of care coordination. It also features case studies showcasing how Iowa, Oregon, Utah, and West Virginia are implementing SPoCs for CYSHCN.
Read or download: State Strategies for Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs
Blog: Why Shared Plans of Care Are Critical to Coordinated Care and How States Are Implementing Them
Why Shared Plans of Care Are Critical to Coordinated Care and How States Are Implementing Them
Children and youth with special health care needs (CYSHCN) can require significant care coordination across a continuum of health and social services. Improved care coordination for CYSHCN can lead to better outcomes for CYSHCN, as well as cost savings for states. To achieve those goals, state Medicaid agencies and Title V CYSHCN programs are increasingly using individual, comprehensive plans of care, called shared plans of care (SPoCs), to strengthen care coordination for CYSHCN.
States play a significant role in coordinating care for CYSHCN and in implementing SPoCs. Nationally, state Medicaid agencies and Children’s Health Insurance Program (CHIP) provide health insurance to 48 percent of all CYSHCN, and their Title V programs are an essential resource for care coordination for CYSHCN and can play a central role in supporting and implementing SPoCs.
Health care delivery transformation and other federal and state reforms present key opportunities for states to promote the use of SPoCs. For example, states are now integrating SPoCs into patient-centered medical home (PCMH) initiatives, health home models, Medicaid managed care arrangements, and state accountable care organizations. To implement SPoCs, states are:
- Creating a standardized SPoC document for use or adaptation by Title V CYSHCN program staff, health care providers, health plans, and others that serve CYSHCN;
- Contractually requiring Medicaid managed care organizations to use SPoCs as part of their care coordination services; and
- Working within programs or with outside entities to modify existing care planning processes to accommodate SPoCs and ensure they meet shared care planning standards.
In a new issue brief, State Strategies for Using Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs, the National Academy for State Health Policy (NASHP) outlines state strategies to effectively launch and implement SPoC. The report also features four state case studies that explore how Iowa, Oregon, Utah, and West Virginia are implementing and advancing their SPoC initiatives. Highlights include:
- Iowa’s Title V CYSHCN program developed an electronic SPoC using ACT.md, a web-based platform that serves as the central hub for SPoCs. Iowa uses the SPoCs to support care coordination for a subset CYSHCN who receive services through the state’s Pediatric Integrated Health Home Program or Child Health Specialty Clinics (the state’s community-based public health agencies).
- Oregon is implementing SPoCs for a select group of CYSHCN through its local public health agencies (LPHAs), which it contracts with to provide care coordination services. SPoCs are developed during meetings with all of the child’s providers, which helps ensure that everyone involved in the child’s care receives the same information. To enable LPHAs to better provide cross-sector care coordination and support integration of care in the community, Oregon maintains a resource-rich SPoC website that includes its SPoC Implementation Guide.
- Utah’s SPoC initiative targets CYSHCN living in rural areas who receive direct clinical services from the state’s Title V CYSHCN program, with the Title V care coordinators leading the development and oversight of SPoCs. SPoCs are housed in the state’s electronic medical record system (Cadurx). Families can access their children’s SPoCs through a patient portal and they also receive a printed copy. Training, tools, and information on care coordination and SPoCs are available to providers and care coordinators through the Utah Children’s Care Coordination Network.
- West Virginia’s Title V program developed its SPoC initiative when it redesigned its care coordination program for CYSHCN. The care coordinators within the state’s Title V CYSHCN program lead the development of SPoCs and collaborate with the Medicaid managed care organizations’ (MCOs) medical case managers, foster care services agencies, and primary care physicians to provide care coordination. The strong partnership between the state Medicaid agency and state Title V program helped the Title V program established memos of understanding (MOUs) with the four state Medicaid MCOs. Through the MOU, MCOs and the Title V program are required to coordinate the care planning process for CYSHCN, including the use of SPoCs.
Toolkit: State Strategies to Improve Health Outcomes for People Living with HIV
Collaboration between state health department HIV programs and Medicaid is integral to providing quality, comprehensive care to people living with HIV (PLWH). With consistent, well-coordinated care and access to antiretroviral therapy (ART) many PLWH can achieve virologic suppression. Those who achieve sustained virologic suppression tend to have better health outcomes and a reduced risk of transmitting HIV to others. Collaboration and partnership can be challenging in many states, particularly when the Medicaid and state health departments are housed in separate agencies. There are, however, numerous strategies states can implement to improve collaboration and partnership between Medicaid and state health departments to implement policy and program changes to achieve this goal.
In 2017, NASHP completed work with 19 states to support them in identifying and implementing policy and program changes to improve rates of sustained virologic suppression among Medicaid and CHIP beneficiaries living with HIV. While working with these states, NASHP identified that state officials needed additional resources on a variety of topics, such as data sharing and use and quality improvement.
This toolkit, supported through a cooperative agreement with the Health Resources and Services Administration, is intended provide state officials with tools and resources, including issue briefs, webinars, and presentations, they need to improve rates of sustained virologic suppression. New items will be added to the toolkit on a regular basis, providing state officials with up-to-date information and timely policy resources.
Tools and Resources
Publications
One-Page Summary: HIV Health Improvement Affinity Group Evaluation Report
March 2019
This two-page summary 2019 highlights state action plans designed to increase viral suppressions and improve health outcomes for people living with HIV enrolled in Medicaid.
HIV Health Improvement Affinity Group Evaluation Report
March 2019
This full report explores the state action plans that 19 states and Medicaid agency staff developed to increase viral suppression and improve the health of people living with HIV. Federal agency partners and NASHP supported this one-year, peer-to-peer learning initiative.
States play critical roles in ensuring that people living with HIV (PLWH) have access to quality care through their Medicaid and Ryan White HIV/AIDS programs. PLWH can be among the most medically complex individuals covered by state health programs, and their care can cost five-times the average Medicaid beneficiary. Given limited resources, state policymakers are working to develop policies and strategies that are accessible, well-coordinated, and effective. This three-part series explores policy levers and strategies that states are using to focus limited resources and provide comprehensive and accessible care to PLWH.
This mini-brief highlights promising strategies for HIV Health Improvement Affinity Group states to successfully engage managed care organizations, health systems, and providers in quality improvement efforts aimed at increasing rates of virologic suppression. Louisiana, Michigan, New York, and Wisconsin are featured. This mini-brief was written as part of the HIV Health Improvement Affinity Group project.
How States Use Medicaid and State Health Department Data to Improve Health Outcomes of People Living with HIV
December 2017
This issue brief discusses key considerations and promising state strategies to share and then analyze Medicaid claims and HIV surveillance and Ryan White HIV/AIDS Program data. Analyses of these interagency data sets can help inform state and local policy and program changes aimed at increasing rates of virologic suppression for Medicaid and CHIP beneficiaries living with HIV. The brief also provides an overview of select data sets that states may be interested in sharing. This issue brief was written as part of the HIV Health Improvement Affinity Group project.
This mini-brief highlights promising strategies for HIV Health Improvement Affinity Group states to successfully engage managed care organizations, health systems, and providers in quality improvement efforts aimed at increasing rates of virologic suppression. Louisiana, Michigan, New York, and Wisconsin are featured. This mini-brief was written as part of the HIV Health Improvement Affinity Group project.
States Share Data to Improve the Health of People Living with HIV
December 2017
This blog presents lessons learned from three HIV Health Improvement Affinity Group states—Alaska, Louisiana, and Maryland—that are working toward sharing and analyzing Medicaid and state health department data to ultimately increase rates of virologic suppression among people living with HIV. This blog was written as part of the HIV Health Improvement Affinity Group project.
Better Together: How Cross-Agency Data Sharing Can Improve the Care Continuum for People Living with HIV/AIDS
October 2017
The state of Georgia leveraged a data sharing agreement between its public health and Medicaid departments in order to assess care quality for Medicaid beneficiaries living with HIV. Data use agreements are critical for agencies interested in sharing data. This blog was written as part of the HIV Health Improvement Affinity Group project.
As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates an integrated care model they call “one-stop shopping.” This issue brief showcases the CORE Center’s model and how it is partnering with the Illinois Department of Health to improve care for people living with HIV. The accompanying webinar can be accessed here. The webinar and issue brief were developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Advancing HIV Prevention Through Health Departments: Health Homes for People Living with HIV/AIDS
June 2016
This case study highlights Wisconsin’s health home program for Medicaid beneficiaries living with HIV, which is the first and only health home program exclusively for this population. Wisconsin’s experience may assist other states considering the health home state plan option as a strategy to support integrated care for Medicaid beneficiaries living with HIV. This case study was developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Advancing HIV Prevention Through Health Departments: HIV-Specific Quality Metrics for Managed Care
June 2016
This case study highlights New York’s use of HIV-related performance metrics to incentivize its Medicaid managed care plans to improve care for their members living with HIV. Their experience may assist other states considering how to incentivize quality improvement in their managed care program. This issue brief was developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Strategies for Coordination Between Medicaid and Ryan White HIV/AIDS Programs
November 2013
This policy brief discusses the importance of coordination between a state’s Medicaid agency and the Ryan White HIV/AIDS Program (RWHAP) to ensure that people living with HIV have access to comprehensive, high-quality care. NASHP interviewed Medicaid and RWHAP officials in 14 states about successful coordination efforts. This brief highlights those examples, along with additional promising practices for coordination that facilitate delivery improvements for people living with HIV. An accompanying webinar can be accessed here. The Health Resources and Services Administration (HRSA) provided support for this issue brief and webinar.
Webinars and Presentations
Overview of state and federal HIV programs
State Health Department HIV Programs: An In-Depth Look
February 23, 2017
View the webinar | Download the slides
The purpose of this webinar was to provide Medicaid and other state officials with information about the structure and components of state health department HIV programs and resources, as well as opportunities for collaboration between these programs and Medicaid. The Centers for Disease Control and Prevention discussed state HIV surveillance and prevention programs and the Health Resources and Services Administration discussed the Ryan White HIV/AIDS Program. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Housing Opportunities for Persons with AIDS: Presentation for HIV Health Improvement Affinity Group
December 7, 2016
Download the slides
This presentation described the Housing Opportunities for Persons with AIDS (HOPWA), a federal program dedicated to assisting with the housing needs of people living with HIV, and work in Alabama focused on improving health outcomes for people living with HIV/AIDS through greater access to housing. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Health Resources and Services Administration and HIV/AIDS Bureau Update
December 6, 2016
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Laura Cheever, Associate Administrator for the HIV/AIDS Bureau within the Health Resources and Services Administration presented an overview of the Bureau’s priority areas and a preview of 2015 Ryan White HIV/AIDS Program Services Report data. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
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This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Overview of state Medicaid programs
The Medicaid Program: An In-Depth Look
February 16, 2017
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While Medicaid programs vary greatly across states, the purpose of this webinar was to provide state health department and other officials with information about the structure and components of this program, as well as opportunities for collaboration between Medicaid and state health departments. The Centers for Medicare & Medicaid Services and NASHP presented about Medicaid structure, eligibility, benefits, financing, payment and delivery, as well as waivers and state plan amendments. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Interagency collaboration
Rhode Island Lessons Learned: Relocating Ryan White
December 7, 2016
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Rhode Island presented on how Medicaid and its Ryan White HIV/AIDS Program are partnering on quality improvement projects and the implementation of Medicaid benefits, such as a targeted case management program. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination
August 29, 2013
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This webinar highlighted strategies that California, Massachusetts, Tennessee, and Washington have used to improve interagency coordination, as well as implement policy changes to improve health outcomes for people living with HIV. An accompanying issue brief is available here. The Health Resources and Services Administration (HRSA) provided support for this webinar and issue brief.
Opportunities for state policy improvement
Webinar: Increasing Rates of Virologic Suppression: Promising Practices from HIV Health Improvement Affinity Group States
Wednesday, Dec. 6, 2017
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Increasing rates of virologic suppression among people living with HIV is critically important to improving their quality of life and decreasing the risk of further HIV transmission. For the last 12 months, the HIV Health Improvement Affinity Group has worked with state health departments and Medicaid agencies from 19 states to develop and implement performance improvement projects aimed at improving rates of sustained virologic suppression among Medicaid beneficiaries living with HIV. This webinar featured leaders from the Office of HIV/AIDS and Infectious Disease Policy in the US Department of Health & Human Services, the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Centers for Disease Control and Prevention. It also featured Affinity Group states, Alaska and North Carolina, that shared lessons learned and best practices from their performance improvement projects.
Improving Quality of Care for Medicaid Beneficiaries Living with HIV: Strategies to Engage Managed Care Plans and Providers
August 17, 2017
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It is important for states to engage key partners, such as managed care plans and providers, in order to improve the quality of care provided to Medicaid beneficiaries living with HIV. This webinar showcased New York state’s work to incentivize managed care plans to improve rates of virologic suppression for their members living with HIV. The New England AIDS Education and Training Center also shared resources and promising strategies to engage HIV providers in quality improvement. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group: Policy and System Change
December 7, 2016
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This presentation highlighted the role that Medicaid plays in ensuring many people living with HIV have access to comprehensive, high quality care. It also showcased policy changes that states could implement to improve access to and quality of care for beneficiaries living with HIV, including increased access to HIV testing, benefit design changes, and network adequacy standards. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Rhode Island Lessons Learned: Relocating Ryan White
December 7, 2016
Download the slides
Rhode Island presented on how Medicaid and its Ryan White HIV/AIDS Program are partnering on quality improvement projects and the implementation of Medicaid benefits, such as a targeted case management program. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Recent HIV Data to Care (D2C) Experiences in Maryland
December 6, 2016
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Maryland presented on how it is using analyses of HIV surveillance and Medicaid claims data to identify people living with HIV who are not engaged in regular HIV care, and then developing policy and program changes to address these gaps in care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination
August 29, 2013
Download the slides
This webinar highlighted strategies that California, Massachusetts, Tennessee, and Washington have used to improve interagency coordination, as well as implement policy changes to improve health outcomes for people living with HIV. An accompanying issue brief is available here. The Health Resources and Services Administration (HRSA) provided support for this webinar and issue brief.
Data sharing and use
Data Sharing and Use: Creating Platforms for Exchange, Insight, and Action
May 24, 2017
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This webinar highlighted the importance of building technological infrastructure to link and use data sets across state agencies, programs, and provider groups, as well as provided details about available 90/10 match funding to support infrastructure development. Louisiana and the District of Columbia both shared their experiences with developing information technology infrastructure to share data among agencies and programs. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Data Transfer and Use: Navigating Federal and State Laws and Regulations
March 28, 2017
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This webinar discussed various data sharing regulations at the state and federal level, such as HIPAA and 42 CFR Part 2, and how these regulations may impact the sharing and use of HIV-related data across state agencies. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
North Carolina’s Engagement in Care Database for HIV Outreach (NC Echo): A Collaborative Effort
December 7, 2016
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North Carolina presented on its Engagement in Care Database, which analyzes data from Medicaid claims and health department surveillance and Ryan White HIV/AIDS Program to identify people living with HIV that are not engaged in HIV care. State program staff then use this information to target outreach to these individuals to get them re-engaged in HIV care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Public Health Innovation: Emerging Opportunities for Leveraging Health Systems Data
December 6, 2016
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This presentation explained why data sharing between Medicaid and state health departments is critical to better understanding utilization patterns and health outcomes for people living with HIV. It also identified key considerations for states interested in advancing this work. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Data analysis and presentation
How Data Visualization Efforts Impact Care and Decision Making
July 20, 2017
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The way in which data is presented is important when trying to increase stakeholder understanding and engagement on a particular issue. This webinar discussed strategies states can use to tailor their communication of data to specific audiences. The Massachusetts Department of Public Health shared how it designed a new website about the impact of the state’s opioid epidemic to be a rich, user-friendly resource for policymakers and community members. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Recent HIV Data to Care (D2C) Experiences in Maryland
December 6, 2016
Download the slides
Maryland presented on how it is using analyses of HIV surveillance and Medicaid claims data to identify people living with HIV who are not engaged in regular HIV care, and then developing policy and program changes to address these gaps in care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Provider- and system-level quality improvement
Improving Quality of Care for Medicaid Beneficiaries Living with HIV: Strategies to Engage Managed Care Plans and Providers
August 17, 2017
View the webinar | Download the slides
It is important for states to engage key partners, such as managed care plans and providers, in order to improve the quality of care provided to Medicaid beneficiaries living with HIV. This webinar showcased New York state’s work to incentivize managed care plans to improve rates of virologic suppression for their members living with HIV. The New England AIDS Education and Training Center also shared resources and promising strategies to engage HIV providers in quality improvement. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Data, Delivery, and Decisions as Levers for Enhancing Whole-Person Care for People Living with HIV: Lessons from the Ruth M. Rothstein CORE Center
January 26, 2017
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As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates an integrated care model it calls “one-stop shopping.” This webinar featured speakers from the CORE Center and the Illinois Department of Health who shared lessons learned from their partnership to improve care for PLWH. The accompanying issue brief can be accessed here. The webinar and issue brief were developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Process Improvement Methods and Tools
November 18, 2016
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Dr. Kevin Larsen from the Centers for Medicare & Medicaid Services shared methods and tools that states can use to design quality improvement initiatives. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Addressing social determinants of health
Housing Opportunities for Persons with AIDS: Presentation for HIV Health Improvement Affinity Group
December 7, 2016
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This presentation described the Housing Opportunities for Persons with AIDS (HOPWA), a federal program dedicated to assisting with the housing needs of people living with HIV, and work in Alabama focused on improving health outcomes for people living with HIV/AIDS through greater access to housing. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
