How States Are Getting Ready to Unwind Medicaid’s Continuous Coverage Requirement
Across agencies, state health policy officials are in the midst of tremendous planning efforts to prepare for the end of the Medicaid continuous coverage requirement and the resumption of eligibility determination processes in Medicaid.
While the timing of this is uncertain because the requirement is tied to the COVID-19 public health emergency (PHE), states recognize that it is likely that the federal PHE declaration could end in the coming months. The Centers for Medicare and Medicaid Services (CMS) has issued a series of guidance documents for states related to unwinding PHE policies — most recently a state health official letter and new reporting templates released earlier this month — that have included specifics about reinstating disenrollments in Medicaid and strategies states can consider to minimize both churn and inappropriate coverage terminations.
On NASHP’s webinar earlier this month, three state officials each representing different health coverage programs — Medicaid (Colorado), CHIP (Utah), and a state-based marketplace (Massachusetts) — spoke about their programs’ current efforts to plan for the eventual end of the Medicaid continuous coverage requirement. While they shared unique perspectives from their various vantage points and state contexts, some of the common themes from the discussion are described below, along with state snapshots of their current key priorities.
State-Specific Unwinding Planning Efforts
Colorado: The state’s Medicaid agency is focusing on a range of strategies to ensure continuity of coverage once the continuous coverage requirement is no longer in effect. Their overarching priorities center on minimizing disruptions for enrollees and supporting their eligibility determination workforce, and they are focusing their efforts in the areas of system improvements and partner input to develop effective strategies. The agency is seeking to distribute their eligibility redetermination work evenly over the PHE unwinding period and is taking into consideration the needs of certain populations, such as individuals who will be covered under the American Rescue Plan Act’s (ARPA) extended postpartum coverage option that the state will be implementing and vulnerable populations such as homeless individuals. Additionally, the agency recently redesigned their renewal materials with the aim of improving communications with enrollees about actions that they will need to take to maintain coverage. State Medicaid officials also hold weekly meetings with their county-based eligibility determination sites and their state-based marketplace to review needed policy and system changes and assess communication plans.
Massachusetts: Officials from the state-based marketplace, the Health Connector, are working very closely with their Medicaid agency counterparts to strategize about policy and operational approaches, coordinate messaging efforts, and share general information. Health Connector staff are currently in the process of gaining a better understanding of the characteristics of the individuals currently enrolled in Medicaid who may become eligible for marketplace coverage when the Medicaid continuous coverage requirement ends. One advantage the state has is that their Medicaid and marketplace eligibility determination systems are integrated, which facilitates smoother transitions between coverage programs.
Utah: Officials from Utah’s CHIP agency are incorporating lessons learned from their experience last year when CMS informed the state that unlike Medicaid, the CHIP program should be conducting regular disenrollments for individuals determined ineligible during the PHE (CMS had previously approved the state’s request to implement a disenrollment freeze in CHIP). Although the CHIP program attempted to reach enrollees, because the process needed to be conducted quickly, 41 percent of the CHIP caseload was disenrolled. Reflecting on this experience to inform the upcoming changes in Medicaid, the state is strategizing on ways to better communicate with enrollees and examining their eligibility system data closely. Similar to Colorado, they are focusing on prioritizing certain populations based on a range of factors and are currently identifying Medicaid enrollees within their system who are either found to be ineligible or whose eligibility cannot be confirmed so that further action can be taken on these cases when the PHE ends. Additionally, the state plans to launch a dashboard that will be able to provide information to the public about the reasons individuals are disenrolled from Medicaid and whether they are transferred to other coverage programs, as well as information about call center volumes and other data points to provide a comprehensive picture of eligibility redetermination activity.
Key Strategies to Address Current and Anticipated Challenges
Broadly, all states are facing the challenges of uncertainty about when the PHE declaration will end, as well as the significant growth in Medicaid enrollment over the course of the pandemic which increases the volume of work that will need to be completed. There is the additional challenge that the enhanced federal Medicaid funding that states are currently receiving for complying with the Medicaid continuous coverage requirement will expire at the end of the quarter in which the PHE ends; but states’ work to unwind the requirement will take much longer.
Balancing workloads and providing training to address state workforce constraints: Although the majority of states have been conducting renewals during the PHE, there will still be a very sizeable amount of eligibility work for states to process during the unwinding period. State officials also mentioned additional concerns about the potential increased workload as people begin reapplying for coverage after being disenrolled or appeal eligibility decisions. Both Colorado and Utah cited challenges related to recruiting and training the large number of state eligibility determination workers that will be needed. In Colorado, the state oversees the Medicaid program, but it is administered at the county level. While the legislature allocated funding for the hiring of more eligibility workers, counties have reported that it has been difficult to find employees because many businesses in the private sector are offering higher wages. However, a centralized state-funded site has been added so that counties with excess eligibility determination work can redirect cases there, which state officials hope will help even out the workload. In Utah, about a third of the Medicaid and CHIP eligibility staff are new employees, and due to the continuous coverage requirement they lack experience with conducting disenrollments in Medicaid. The state is providing training to recently hired staff and seeking to ensure that the upcoming significant workload increase will be processed both efficiently and carefully, with a focus on helping Medicaid-eligible individuals remain enrolled or that those who qualify for other programs are smoothly transferred to other sources of coverage.
Leveraging partnerships to reduce enrollee communication barriers: All three state officials commented on the significant challenge of finding effective ways to communicate with enrollees about the impending changes, especially because many enrollees have not ever had to take action to maintain coverage and may be unfamiliar with the redetermination process. In Colorado, in addition to their revamped renewal packet, the agency is promoting their newly modernized online portal that state officials are working to ensure is user-friendly. They are also using text messaging and other communication tools to engage enrollees and collect updated contact information. Massachusetts is aiming to use best practices in communication with enrollees and is currently conducting focus group testing of messaging that can be used across agencies so that they are in sync and are using the same “song sheet.” Additionally, for individuals who no longer qualify for Medicaid but are eligible for qualified health plans, Massachusetts Health Connector staff are thinking through ways to inform individuals about how marketplace coverage differs from Medicaid in terms of factors such as cost, provider networks, and income change reporting requirements. In Utah’s CHIP program, premiums have been suspended during the pandemic and state officials are working to develop effective strategies to inform enrollees about the reinstatement of these charges once the PHE ends.
One essential element in improving enrollee communication methods and gathering updated enrollee contact information cited by all three states is the engagement of a range of partners, such as community-based organizations with well-established ties to underserved and vulnerable populations. In Massachusetts, the state legislature allocated $5 million in ARPA funding to Health Care for All (HCFA)—a grassroots organization with strong connections to many marginalized communities—to support outreach efforts to Medicaid enrollees, and the state’s health insurance marketplace and Medicaid agency are working in tandem with HCFA on these initiatives. In Utah, advocates are helping to ensure that notices are written in plain and clear language, and the state is also actively reaching out to tribal nations for their input on communication strategies. In Colorado, community-based partners are directly assisting with updating enrollee contact information and the state has frequent communication with advocacy organizations. All three states are also coordinating closely with health insurance carriers that may have more frequent communication with members enrolled in their plans to both collect updated enrollee contact information and communicate about the upcoming changes. For example, in Utah, managed care plans are conducting outreach calls to individuals, and the state will soon be able to share more detailed information about enrollees’ eligibility determinations with the plans.
Putting the Medicaid Continuous Coverage Requirement Unwinding in Context
State officials also emphasized that it is important for all stakeholders to keep in mind that the work of unwinding PHE policies and resuming normal eligibility determination operations in Medicaid will be occurring within the context of many other substantial changes, overlapping timelines, and unique state challenges. For example, in Utah, the state is making significant changes to their eligibility determination system, recently launched a new Medicaid Management Information System, and is in the process of merging their health and human services agencies. From the perspective of the state-based marketplaces, if the PHE ends in July 2022, that coincides with their efforts to prepare for the fall open enrollment season, which involves considerable system changes and could create outreach and communication challenges. A further complication is that if the enhanced marketplace subsidies currently available via ARPA are not extended by Congress, individuals transferring to the marketplace will face considerably higher costs. Additionally, each state’s unique characteristics, such as their Medicaid and marketplace coordination arrangements and eligibility system structures, will affect the resumption of regular Medicaid eligibility operations and the overall PHE unwinding process.
States appreciate CMS’ ongoing support, but also hope that the administration will provide them with ample notice about when the PHE will end as well as offer some flexibility on certain rules to facilitate the overall process for both individuals and programs. While the many impending policy and operational issues are daunting for states, they are continuing to actively prepare and are hopeful that with a common goal across state agencies, partners, and the federal government of ensuring that eligible individuals remain enrolled, efforts will be coordinated and coverage disruptions will be minimized.
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.
Recent State Action on Medicaid Expansion, Work Requirements, and Block Grants
This year, many states have continued to pursue federal approval for a range of proposals affecting Medicaid coverage, such as seeking modifications to the Affordable Care Act’s (ACA) Medicaid expansion or adding Medicaid work requirements.
Currently, nine states have implemented expansion through Section 1115 waivers to impose conditions such as monthly premiums, lock-out provisions for non-payment, and work requirements on certain Medicaid enrollees. While some Medicaid waivers approved by the federal government that include work requirements have faced legal challenges, other states — including those that have not implemented Medicaid expansion — are continuing to seek federal approval to condition Medicaid eligibility on work, with nine additional proposals currently pending.
The following is an overview of some of the current state Medicaid coverage waiver activity and other state actions affecting health coverage, including Tennessee’s recent block grant proposal.
State Changes to Medicaid Expansion Passed by Ballot Initiatives
Earlier this year, Idaho’s governor signed into law a number of changes to the Medicaid expansion ballot measure approved by voters in November 2018. One component of the law required the state to seek a 1332 waiver to enroll individuals eligible for expanded Medicaid who had income between 100 to 138 percent of the federal poverty level (FPL) in subsidized exchange coverage, although these individuals could opt for Medicaid coverage instead. However, in late August the Centers for Medicare & Medicaid Services (CMS) rejected the state’s waiver request, citing that it did not meet the deficit neutrality guardrails required of 1332 waivers. State officials have indicated that they will resubmit the application with additional information, although CMS noted in its letter that even a revised application would likely still not demonstrate compliance with those guardrails. Another aspect of Idaho’s law modifying the voter-approved Medicaid expansion directs the state to seek a waiver to implement Medicaid work requirements for most expansion enrollees, and the state recently submitted this 1115 waiver request for federal approval. If the waivers are not approved by Jan. 1, 2020, the state law requires implementation of traditional Medicaid expansion.
Similar to Idaho, voters in Utah passed a measure last November to implement Medicaid expansion, and in February state legislators enacted a law that significantly alters the voter-approved expansion in a number of ways. The law requires the state to seek a series of waivers, outlined in the state’s implementation toolkit, through a potentially four-step process, depending on what CMS approves. In March, CMS approved the state’s first request — the Bridge Plan — to expand Medicaid to only those earning 100 percent of FPL at the state’s regular federal medical assistance percentage (FMAP) rate, include an enrollment cap if projected costs exceed state appropriations, require individuals with access to employer-sponsored insurance (ESI) to enroll in that coverage with Medicaid premium assistance, and add work requirements in 2020. In May, the state submitted the second waiver proposal for the enhanced FMAP that the ACA provides for the expansion population while keeping the expansion eligibility level at 100 percent FPL, but CMS indicated that it would not provide the enhanced FMAP for a partial expansion. This second proposal also maintains the enrollment cap, work requirements, and ESI premium assistance from the initial waiver, adds in 12-month continuous eligibility and lock-out provisions for non-compliance with certain activities, and notably requests to implement a per capita cap model for receiving federal Medicaid funds for the new eligibility group. Although CMS did not approve the enhanced FMAP for the partial Medicaid expansion, the governor issued a statement that the state would move forward with requesting approval of the other proposal components, and the state submitted the waiver request in late July. If CMS does not approve this per capita cap proposal, the state plans to request permission to implement a “fallback” plan — the third step in the state’s implementation plan — that expands Medicaid to the ACA’s 138 percent of FPL eligibility threshold and provides the state with the enhanced expansion FMAP, and includes work requirements, an enrollment cap, and lock-out provisions. The final option – if this third plan is not approved – is implementing traditional Medicaid expansion through a state plan amendment, as was passed by the voters.
Nebraska was the third state in 2018 to pass Medicaid expansion through a ballot initiative, and while state legislators there did not follow the same route as Idaho and Utah, expansion in Nebraska has not yet occurred because the state intends to seek modifications to the expansion. State officials submitted a state plan amendment for expansion this past April, indicating the state would seek a waiver to modify its existing managed care program to include the expansion population and provide different benefit packages based on whether enrollees complete certain wellness requirements. Expansion will occur no later than Oct. 1, 2020, and the plan eventually will also incorporate work requirements for eligible individuals wishing to remain in the “prime” coverage option, which offers more robust benefits such as dental and vision services.
Activity in Medicaid Expansion States
Montana originally implemented Medicaid expansion through a waiver because the state requires certain individuals to pay premiums. The expansion was scheduled to sunset in July of this year, but in April the legislature passed a bill, signed by the governor in May, to continue expansion that added work requirements for most enrollees. The state’s waiver amendment also seeks to maintain the original waiver’s implementation of 12-month continuous eligibility and modify the monthly premium structure to be based on the amount of time an individual is enrolled. The federal comment period for the waiver amendment recently closed.
In Virginia, Democratic Gov. Ralph Northam and Republican state legislators negotiated a compromise to expand Medicaid with work requirements in 2018. Coverage became effective in January of this year, but the work requirements were not implemented as the state needed to seek federal permission through a waiver. The state is now negotiating to receive federal funding for employment supports, as Northam’s administration has indicated that the state cannot afford to implement the work requirements without these federal dollars. Some Republican state legislators are characterizing the request for this federal funding as an effort to backtrack on the compromise struck last year between them and the governor.
While New Mexico originally implemented the ACA’s traditional Medicaid expansion, the state sought and received approval in December 2018 to add premium and copayment requirements and waive retroactive eligibility for certain expansion enrollees. However, under Gov. Lujan Grisham, the state is now requesting to amend the waiver and remove the copayments, premiums, and waiver of retroactive eligibility.
Activity in Non-Medicaid Expansion States
Like last year, voters in some nonexpansion states will have the chance to consider expansion in 2020. Groups in Oklahoma indicated that they have gathered enough signatures to put expansion before voters in 2020. Medicaid expansion proponents in other states — specifically Missouri and South Dakota — are also attempting to place the issue before voters in 2020. Additionally, in Mississippi’s upcoming gubernatorial election in November, voters will decide between a Republican who opposes expansion and a Democratic who supports it.
North Carolina’s Democratic Gov. Roy Cooper vetoed the state budget in June in part because it did not include Medicaid expansion. However, in mid-September state legislators in the House voted to override the governor’s veto. While the Senate still needs to hold a vote on the veto override, a bill to expand Medicaid with work requirements and premiums has been added back to the legislative calendar.
Georgia is currently drafting two waiver proposals as part of a law signed by the governor in March. The state is expected to submit an 1115 waiver proposal to expand Medicaid to only those earning 100 percent of FPL, as well as seek federal approval through a 1332 waiver to implement a reinsurance program.
Beyond continuing efforts to expand Medicaid or modify laws to do so, block grants have surfaced again. Tennessee has developed a draft proposal to shift federal funding for most of the state’s Medicaid program into a version of a block grant, which would be a significant change and is based on a state law passed earlier this year. Under the plan, the state would receive a capped amount of federal Medicaid funding for low-income parents, children, and individuals with disabilities. Unlike a traditional block grant — which the state acknowledges its plan differs from — the state is requesting additional funding if enrollment rises above a certain threshold, but the funding amount would not be reduced if enrollment declined. Additionally, the funding cap does not include state spending on individuals dually eligible for Medicaid and Medicare, disproportionate share hospital (DSH) payments, outpatient prescription drug expenses, or administrative costs, and any savings achieved from the financing model would be divided evenly between the state and the federal government (the state’s current federal match rate is 65 percent). The state is also requesting additional flexibilities, such as modifying the amount, duration, and scope of benefits without federal approval or public comment and implementing a closed formulary for prescription drugs. The waiver request also proposes to exempt the state from federal regulations for managed care plans. Some policy analysts have identified that federal law does not allow Medicaid’s financing model to be restructured through the 1115 waiver authority, and if CMS does approve the waiver it is expected to face legal challenges. Tennessee also submitted a separate waiver request in December 2018 seeking to implement Medicaid work requirements for low-income parents and caretakers, which is still awaiting federal approval.
Legal Challenges to Medicaid Work Requirements
Medicaid waivers containing work requirements approved by CMS have been halted by court rulings earlier this year in Arkansas, Kentucky, and New Hampshire, and a legal challenge was recently filed against Indiana’s approved work requirements. Earlier this month, a three-judge panel heard oral arguments on the federal government’s appeal of the Arkansas and Kentucky rulings, and the judges noted that the administration had not considered the coverage losses resulting from work requirements. The ruling by this federal appeals court will have significant implications for Medicaid work requirements overall, and while they did not provide specific information about timing for the decision, it is expected before the end of the year. The court challenges are already beginning to have some implications — on Oct. 17, 2019, Arizona informed CMS that it would postpone implementation of the state’s approved Medicaid work requirements due to the litigation in other states. Additionally, a recent study conducted by the Government Accountability Office (GAO) recommended that CMS should improve its oversight of the administrative costs associated with work requirement waivers, which GAO found can be significant, ranging from under $10 million to over $250 million.
In addition to the next round of court decisions on Medicaid work requirements, states are waiting to see if federal guidance on Medicaid block granting will be issued soon — which is currently under review at the Office of Management and Budget. Similar to how states are seeking to implement Medicaid work requirements despite legal challenges, if CMS provides guidance and approves Tennessee’s block grant proposal, other states may also pursue this financing model, even if the block grant is challenged in court. Also, whether CMS and states that have been hesitant to expand will be able to find a middle ground on Medicaid expansion remains a question, and how decisions play out in Idaho and Utah in particular, will be significant for future actions. Similar to this past year, in 2020 states are expected to continue to seek new ways to test the boundaries of Medicaid coverage waivers and manage their Medicaid programs.
For more information about each state’s Medicaid expansion activity, explore NASHP’s map, and for up-to-date information about states’ Medicaid work requirement proposals, review this NASHP chart.
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.
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. 
