Wisconsin – The National Academy for State Health Policy

States Advancing Equitable Maternal Health Policy Highlighted at #NASHPCONF22

October 27, 2022/in Health Equity, Maternal, Child, and Adolescent Health, Policy California, New Jersey, Wisconsin Blogs, Featured News Home Maternal Health and Mortality /by Allie Atkeson

Unwinding Medicaid’s Continuous Coverage Requirement: State Communication Strategies

September 8, 2022/in Health Coverage and Access, Policy Arizona, Arkansas, California, Hawaii, Illinois, Maryland, Nevada, New Hampshire, New York, Oklahoma, Utah, Wisconsin Blogs, Featured News Home COVID-19, Eligibility and Enrollment, State Insurance Marketplaces /by NASHP Staff

Opportunities for States to Improve HIV Treatment through Peer-Delivered Services

March 14, 2022/in HIV/AIDS Florida, New York, Wisconsin Featured News Home, Reports HIV/AIDS /by Eliza Mette and Jodi Manz

State Medicaid Financing of Home Visiting Services in Seven States

October 8, 2021/in Health Coverage and Access Colorado, Kentucky, Michigan, Minnesota, New York, Oregon, Wisconsin Charts, Featured News Home Health Coverage and Access /by Eddy Fernandez

Nine States Advance Prescription Drug Affordability Board Legislation

March 15, 2021/in Prescription Drug Pricing Arizona, Colorado, Minnesota, New Jersey, New Mexico, Oregon, Rhode Island, Virginia, Wisconsin Blogs, Featured News Home Model Legislation, Newly-Enacted Laws, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck and Trish Riley

More than 200 bills to lower drug prices have been filed across states during this session and nine states are proposing prescription drug affordability board (PDAB) legislation.

PDABs are somewhat analogous to public utility commissions. They investigate high-priced drugs and, when necessary, set more affordable rates for certain drugs for purchasers within a state. Establishing health care provider and hospital payment rates is a common approach states use to ensure services are affordable. State PDABs extend this strategy to a subset of very costly prescription drugs, while avoiding unlawful patent preemption because they establish drug payment rates – not prices. The National Academy for State Health Policy (NASHP) developed model legislation for this approach in 2017 and in 2019 Maryland became the first state in the nation to enact PDAB legislation.

This chart highlights nine states’ bills to create prescription drug affordability boards, including their implementation timelines, funding sources, enforcement, and purchasers impacted.

Nine states (AZ, CO, MN, NJ, NM, OR, RI, VA, and WI) are currently advancing PDAB bills in their legislatures. While a number of these bills are similar to Maryland’s approach that phases in upper payment limits by initially limiting them to public purchasers before potentially expanding them to include private purchasers, the majority of the currently proposed bills map more closely to NASHP’s original model legislation, which implements payment limits across all payers (public and private) in a state in a more expedited fashion.

The bills are generally similar in two approaches:

They use similar price thresholds to identify a drug for investigation by their PDABs, and
They apply the same factors when setting an upper payment limit for drugs found to be otherwise unaffordable – such as weighing the cost of administering the drug and delivering the drug to consumers.

Minnesota’s bill, however, includes unique language that empowers its PDAB to consider both the “the range of prices at which [a] drug is sold in the United States and the range at which pharmacies are reimbursed [for it] in Canada.” This language creates a bridge between the PDAB model and a newer approach in a recently released NASHP model law that creates payment rates for certain high-priced drugs based on Canadian pricing. This approach, reflected in NASHP’s Act to Reduce Prescription Drug Costs Using International Pricing, offers states a more streamlined approach than establishing a PDAB, which requires the complex task of determining the appropriate value of a drug in order to set an affordable payment rate. Five states (HI, ME, OK, ND, and RI) are currently considering international reference rate bills that use (or “reference”) Canadian prices to set more affordable rates.

As states consider PDABs and international reference rate approaches to achieve the goal of setting more affordable payment rates for drugs, there are several key factors to consider.

While international reference rates look to Canada’s drug prices when establishing appropriate payment rates, PDABs keep the task of identifying affordable rates within a state.
While PDABs may be conceptually preferable for this reason, the time and resources required to implement this approach may not make PDABs feasible for all states. For those states, using Canadian prices to set rates may be the most viable option.

Minnesota’s bill, however, points to a third option, a hybrid approach in which a PDAB would consider Canadian pricing as part of its process.

Explore this chart to compare the different state approaches and implementation timelines of the nine PDAB bills proposed as of March 9, 2021.

Six States Join NASHP and AcademyHealth’s Community of Practice to Boost Immunization Rates in Medicaid-Enrolled Pregnant Women and Children

January 11, 2021/in Policy Louisiana, Michigan, Washington, Wisconsin, Wyoming Blogs, Featured News Home Chronic Disease Prevention and Management, Health Equity, Immunization, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper, Jill Rosenthal and Ariella Levisohn

The National Academy for State Health Policy (NASHP) and AcademyHealth, with support from Immunize Colorado, are facilitating a new community of practice (CoP) comprised of state health officials from six states interested in improving their immunization rates.

Funded by a US Centers for Disease Control and Prevention (CDC) cooperative agreement, the Immunization Barriers in the United States: Targeting Medicaid Partnerships program is engaging six state Medicaid agencies (LA, MI, TX, WA, WI, WY) in collaboration with their public health and immunization information system partners. Through this CoP, states are working to improve Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. The project will build on the work and lessons learned from the previous CoP of five states, which ended in late 2020.

Despite coverage of vaccines through Medicaid, immunization rates among children and pregnant women enrolled in Medicaid remain lower than those who are privately insured and have higher incomes. Disparities in vaccine coverage exist for Black women and people living in poverty. Additionally, CDC data shows a significant reduction in routine vaccines administered to children during the COVID-19 pandemic. While vaccination rates are slowly returning to pre-pandemic rates, national experts are concerned that the missed vaccine doses may have future health implications and lead to outbreaks of vaccine-preventable diseases.

Through virtual and in-person meetings over the course of the three-year project, AcademyHealth and NASHP will provide technical assistance to states, identify barriers, and share promising practices for increasing immunization rates.

States Work to Improve Long-Term Care in the Age of COVID-19

November 23, 2020/in The RAISE Act Family Caregiver Resource and Dissemination Center Ohio, Washington, Wisconsin Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, COVID-19, Health Equity, Long-Term Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by Paige Spradlin

Nursing home residents account for at least one-third of COVID-19 deaths, and this disparity reveals numerous problems with infection control in institutional settings. As a result, many states are rethinking and restructuring their long-term services and supports (LTSS) programs.

A recent National Academy for State Health Policy (NASHP) annual conference session explored what states have learned during the current health crisis that could improve LTSS during and beyond the pandemic. State officials from Washington State, Wisconsin, and Ohio highlighted their states’ responses to the current crisis, emerging innovations, and prospects for restructuring LTSS in a post-COVID-19 era.

Maximizing the Flexibility of Home- and Community-Based Waiver Services

Washington State, home to the first nursing home to be ravaged by COVID-19 in the United States, immediately worked with federal partners to maximize the flexibility of home- and community-based waiver services following its first reported case. The state was among the first to receive approval from the Centers for Medicare & Medicaid Services (CMS) for its 1135 and 1115 Medicaid waivers, which provided enrollees with increased access to services during the COVID-19 pandemic and additional supports to LTSS workers. State officials noted that the presumptive eligibility measures incorporated into these new waivers ensured that individuals were able to access the LTSS they need without having to wait for their applications to be fully processed. This flexibility has helped minimize administrative burdens on eligibility workers as states face increased demands on their Medicaid programs.

Like Washington State, Wisconsin utilized waivers to implement much-needed flexibility within its home- and community-based services (HCBS) provided through the state’s 1915(c) Medicaid waiver. Importantly, the state expanded the ability of its HCBS agencies to provide waiver services remotely, including care coordination and day services. The state also modified service delivery for Medicaid acute primary services, allowing these to be delivered through telehealth and other technologies to comply with social distancing.

Leveraging State Resources to Prevent and Contain Outbreaks for High-Risk Individuals

To contain and prevent outbreaks, Ohio relied on the following guiding principles to support its nursing facilities throughout the pandemic:

Leverage regional and local leadership to coordinate a unified response; and
Provide resources to support nursing facilities, including additional health services and technical assistance. These efforts were supported by $314 million from the US Department of Health and Human Services (HHS), some of which was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, that was specifically dedicated to Ohio skilled nursing facilities (SNFs). Each SNF in Ohio with six or more certified beds was eligible to receive a fixed distribution of $50,000 plus an additional $2,500 per bed.

To coordinate a unified state COVID-19 response, Gov. Mike DeWine and leaders from a major hospital chain created three health care zones divided among the state’s large metro areas to manage hospital capacity and maintain patient level of care during an anticipated surge in hospitalization services. State officials in the three health care zones paired nursing facilities with local hospitals to manage distribution of personal protective equipment (PPE) and to ensure that staff were well-equipped to treat patients.

Additionally, the state developed the following resources to support nursing facilities, staff, and patients throughout the pandemic:

A toolkit developed by the Ohio Department of Aging, Department of Health, Department of Developmental Disabilities, and Department of Medicaid to assist nursing facilities with assessing residents and determining their care needs during a COVID-related surge in service utilization;
Increased testing services for nursing facility staff as mandated by a Public Health Order signed by the director of the Ohio Department of Health and conducted by the Ohio National Guard over a period of two months; and
Congregate Care Unified Response Team (CCURT) Bridge Team, composed of staff from the Ohio Department of Health and Ohio Department of Medicaid, to assist nursing home staff with decision making in emergency situations and coordinating facility communication with relevant state agencies, the Emergency Operations Center, health care zones, and hospitals in the area.

Many of the steps taken by Ohio state officials track with the principal recommendations issued by the CMS-appointed Coronavirus Commission Report for Safety and Quality in Nursing Homes, including establishing a statewide strategy for testing in nursing homes, coordinating with state and local leadership, leveraging resources to support the nursing home workforce, and assembling a long-term care emergency response team to evaluate and guide emergency care coordination. With these strategies and systems in place, Ohio and other states now have the infrastructure to better manage infection control in institutional settings for future public health emergencies.

Post-COVID-19 Planning

While many of the policy changes highlighted here are temporary and in effect only during the pandemic, it is important to understand the impact of these changes on cost and quality of life to determine which, if any, should be retained after the pandemic. State officials from Washington State, Ohio, and Wisconsin reported they found the following flexibilities especially helpful:

Presumptive eligibility for LTSS, so the state can initiate home- and community-based services as quickly as possible;
Waiving plan signatures and self-attestation in favor of post-enrollment verification to ensure that enrollees receive timely supports; and
Flexibilities for respite care for family caregivers, particularly those supporting individuals with intellectual and developmental disabilities, to reduce stress and burnout.

State officials noted it would be helpful to receive support from CMS in retaining these flexibilities. State officials also suggested that broader legislative changes to Medicaid, such as streamlining Medicaid authorities that support HCBS and making HCBS mandatory state plan services on par with nursing home care, would help reduce administrative complexity and facilitate rebalancing efforts.

Wisconsin CHIP Fact Sheet

December 5, 2019/in Policy Wisconsin /by NASHP Staff

Using Data, Incentives, and Innovation, Three States Work to Improve Maternal Vaccination Rates

November 4, 2019/in Policy California, Colorado, Wisconsin Blogs, Featured News Home Chronic Disease Prevention and Management, Health Coverage and Access, Health IT/Data, Immunization, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Social Determinants of Health /by Ariella Levisohn

Despite the health benefits of immunizing pregnant women against influenza and pertussis (whooping cough) and protecting them and their infants from these life-threatening diseases, only half of pregnant women are vaccinated against both diseases and only one-third receive both the influenza and pertussis vaccines during pregnancy.

Three states are trying a number of innovative approaches to increase vaccination rates among pregnant women by providing incentives to health plans, increasing access to vaccinations through pharmacies, and using data to identify and target populations, regions, and providers with substandard influenza and Tdap (which protects against pertussis) vaccination rates.

Evidence shows pregnant women are at increased risk of developing complications from certain preventable diseases and can also risk passing those diseases on to their children. Following immunization, data shows that both mothers and infants are less likely to be hospitalized from complications. When a woman is vaccinated during pregnancy, she develops antibodies that are transmitted to her child before birth, which can then protect the infant during the first few months after birth. The US Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or planning to become pregnant get the flu vaccine and the Tdap vaccine during each pregnancy.

Low Immunization Rates Persist

Despite the CDC’s guidelines, many women do not receive the influenza and pertussis vaccines during pregnancy. According to the CDC’s recent report, Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States, published in Morbidity and Mortality Weekly Report (MMWR), current rates of maternal immunization for influenza and Tdap are 53.7 percent and 54.9 percent, respectively. Only one-third of pregnant women received both the influenza and Tdap vaccines, and the rates are even lower for African-American pregnant women. The report noted that provider recommendations to patients can improve maternal immunization rates – when providers offered vaccinations or provided a referral to pregnant women, 65.7 and 70.5 percent received the flu and Tdap vaccine, respectively. Based on this data, the CDC recommends that providers begin discussing vaccinations with pregnant patients early and continue the conversation during each visit.

Overall, women enrolled in public insurance programs were less likely to be vaccinated during pregnancy than women with private insurance, due in part to access barriers. State Medicaid agencies, which cover 43 percent of all births across the United States and up to 60 percent of births in some states, can use innovative approaches to identify pregnant women in need of vaccinations, gather data to identify strategies and targeted approaches, and encourage providers to increase vaccination rates to improve health and save on costs.

The 2019 MMWR data are especially notable in light of the Healthy People 2020 goal to increase the number of pregnant women vaccinated against influenza to 80 percent. While most states remain far from that goal, California, Colorado, and Wisconsin are working to improve maternal vaccination rates for both their Medicaid populations and privately insured women.

California’s Medi-Cal Strategies

In California, pregnant women covered by Medi-Cal, the state’s Medicaid plan, see providers who are less likely to stock or recommend the Tdap vaccine. Women on Medi-Cal receive prenatal Tdap immunizations at much lower rates than privately insured women, and infants born to mothers with Medi-Cal coverage are twice as likely to contract pertussis compared to privately insured infants. California is using a number of strategies to improve maternal immunization rates for women on Medi-Cal, including setting expectations for contracted health plans, monitoring and providing incentives, and addressing barriers at the clinician and patient level:

Medi-Cal managed care contracts require health plans to ensure the timely provision of all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations for members, and report data to the California Immunization Registry (CAIR). Medi-Cal managed care contracts also require that contracted health plans monitor their primary care provider sites for the provision of preventive services, including all ACIP-recommended immunizations for adults and children.

California’s 2019-2020 budget includes funding for incentive payments in the managed care delivery system for timely prenatal care as well as for prenatal providers who administer the Tdap vaccine to pregnant members. Some of California’s Medi-Cal managed care health plans are also trying to lower the financial barriers to providing vaccines by allowing providers to directly bill the health plan outside of capitation rates, providing free Tdap starter doses to clinics, and encouraging group purchasing of vaccines.

Medi-Cal encourages its health plans to follow up on potential quality of care issues when cases of pertussis in infants born to unvaccinated mothers are identified through public health department notification.

California pharmacists are authorized to provide immunizations without a physician’s order. Most major chain pharmacies in California offer Tdap immunizations as part of their vaccine portfolio. All routinely recommended adult vaccines are covered by Medicaid without prior authorization (in both fee-for-service and managed care plans) when given in a provider’s office or in a pharmacy. Recent state regulations require pharmacists to notify providers of immunizations administered and to enter all doses into the California Immunization Registry, making it possible for providers to know whether vaccine referrals to pharmacies are successful.

Colorado and Wisconsin’s Use of Data

One of the challenges to improving maternal immunization rates is obtaining and monitoring data, especially as many states do not require providers to report immunizations to their Immunization Information Systems (IIS). Quality data, though, is needed by states working to tailor their strategies for improving immunization uptake to the areas of highest need and to monitor trends. Specifically, the Centers for Medicare & Medicaid Services identifies data linking of Medicaid eligibity and claims data with vital statistics data as a critical mechanism for surveillance, programmatic monitoring, and evaluation of maternal immunization.

Colorado is using data matching to determine the rates of maternal immunization in each county. Colorado has successfully matched 96 percent of patient medical record numbers with Colorado Immunization Information System (CIIS) records. The CIIS data matching has allowed the state to map immunization rates by provider and region and identify gaps in maternal immunization uptake. Colorado is now using this data to determine the areas of highest need in the state to inform and guide outreach programs. Currently, Colorado is also piloting text and email reminders to encourage patients to get vaccinated.

Wisconsin is also using data matching to obtain baseline immunization rates. Wisconsin matched 96 percent of women who gave birth in 2018, as recorded by the Vital Records Office, with data from the Wisconsin Immunization Registry. Like Colorado, Wisconsin used this data to create data maps to identify influenza and Tdap vaccination levels in each region of the state. Wisconsin was also able to track vaccination rates by age, race, type of insurance, and quality of prenatal care. Next steps for the state include monitoring these trends, identifying areas of highest need, and using the data to improve maternal immunization rates.

In addition to partnering with state public health departments and their immunization programs, state Medicaid agencies can partner with providers to ensure vaccines are stocked and to promote vaccine recommendations for pregnant women so they become routine. For example, the American College of Obstetricians and Gynecologists has released a number of resources designed to support health care providers in increasing maternal vaccination rates, including the Maternal Immunization Tool Kit, strategies for immunization implementation, and a guide to starting an office-based immunization program. The American Academy of Pediatrics also offers recommendations on cost-saving measures for the purchase and administration of immunizations. Finally, the CDC has compiled a toolkit for prenatal care providers that includes resources for provider and patient vaccination education.

In addition to these resources, other states can learn from the work California, Colorado, and Wisconsin have done to identify gaps and improve vaccination rates among pregnant women covered by state Medicaid programs.

Acknowledgements:
The National Academy for State Health Policy (NASHP) would like to thank Abby Klemp at the Wisconsin Department of Health Services, Sarah Royce at the California Department of Public Health, and Karen Mark at the California Department of Health Care Services for their time and insight. NASHP would also like to thank the US Centers for Disease Control and Prevention for their assistance with this blog and for funding this project.

How States Use the National Standards for CYSHCN to Strengthen Medicaid Managed Care for Children with Special Health Care Needs

November 30, 2018/in Policy Arizona, District Of Columbia, Florida, Georgia, Texas, Virginia, Wisconsin Reports Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Integrated Care for Children, Long-Term Care, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement /by Hannah Eichner and Kate Honsberger

About this Fact Sheet

The various state examples outlined here resulted from a 12-month learning collaborative facilitated by NASHP, in partnership with the Association of Maternal & Child Health Programs (AMCHP), with support from the Lucile Packard Foundation for Children’s Health (LPFCH). NASHP and AMCHP convened the learning collaborative academy both virtually and in-person, providing targeted technical assistance, peer-to-peer learning opportunities, and individual assistance to state teams from October 2017 to September 2018. The learning collaborative states included Delaware, Georgia Massachusetts, New Mexico, Rhode Island, and West Virginia. Each team was comprised of representatives from the state’s Medicaid and Title V agencies, a provider who serves CYSHCN, a representative from a Medicaid managed care organization and a family member of a CYSHCN.

Historically, most children and youth with special health care needs (CYSHCN) were not enrolled in Medicaid managed care (MMC) programs because of their medical complexity and the number of specialty services they required. These services, including community-based supports such as in-home and respite care, care coordination, and long-term services and supports, were deemed by state health policymakers as best delivered by a fee-for-service system. As states become more adept at designing and implementing managed care programs for adult Medicaid beneficiaries, they have begun enrolling populations with complex needs into managed care to better coordinate care, control costs, and improve health care quality and outcomes.
As of June 2017, 47 states and Washington, DC, used some form of managed care to provide services to all or some children and adults enrolled in Medicaid.[1] Of states with managed care delivery systems, all enrolled at least some or all of the CYSHCN population into some type of MMC. Contracting with risk-based managed care organizations (MCO) is the most common managed care delivery system used to serve Medicaid beneficiaries, including CYSHCN.
Nearly 20 percent of US children ages birth to 18 years (14.6 million children) have a chronic and/or complex health care need (e.g., asthma, diabetes, spina bifida, autism) requiring physical and behavioral health care services and supports beyond what children require normally.[2] CYSHCN are costlier to care for than children without special health care needs. Within Medicaid, for example, annual per enrollee spending is over 12-times higher for children who use long-term care services ($37,084) as compared to those who do not ($2,863).[3] MMC gives states a unique opportunity to strengthen the structure and delivery of health care, improve quality, and control costs, particularly for beneficiaries with chronic and complex health care needs.
The National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN) is a resource to guide and support states working to improve systems of care for CYSHCN, including Medicaid managed care. The National Standards for CYSHCN highlight the core components of the structure and process of an effective system of care for CYSHCN. The standards were developed with guidance from a national work group whose members include families of CYSHCN, state Medicaid agencies, public health, researchers, children’s hospitals, health plans, provider groups, and other stakeholders. Since its release in 2014, Medicaid and Children’s Health Insurance Program (CHIP) agencies, state Title V CYSHCN programs, health care systems, consumers, and others have used these standards as guideposts to improve systems of care for CYSHCN in an ever-changing health care landscape.
In 2018, the National Academy for State Health Policy (NASHP), in partnership with the Association of Maternal and Child Health Programs (AMCHP), led a national learning collaborative to help several states use the National Standards as a guide as they worked to improve MMC for CYSHCN. The following lessons learned highlight how these states effectively used the National Standards to strengthen their managed care systems for CYSHCN.
Analyzing and Enhancing Specialized Managed Care Plans
States can enroll special populations into health plans that are designed to uniquely serve enrollees with special needs (e.g., a specialized managed care program). Six states (Arizona, Florida, Georgia, Texas, Virginia, and Wisconsin) and Washington, DC have developed specialized MMC programs that exclusively serve all or some CYSHCN populations.[4] These plans target health care benefits and services to meet the specific needs of Medicaid beneficiaries served by these programs. Georgia used the National Standards as a resource to strengthen collaboration across agencies to improve the state’s specialized MMC program — Georgia Families 360 — for children in foster care and the juvenile justice system. Learning collaborative participants from Georgia Medicaid, the Title V CYSHCN program, and the Department of Behavioral Health reviewed the National Standards for CYSHCN and selected the domains of Access to Care, Transitions of Care, and Care Coordination for their analysis. The state team created a crosswalk elements from three National Standards domains and elements their Georgia 360 contract as an internal evaluation tool. As a result of this review, the state updated its Medicaid policy manual with elements from the National Standards. Future work is planned to increase collaboration between the Georgia Families 360 MCO and the Title V agency to improve the provision of high-quality care coordination for the foster care population.
Providing a Framework to Design and Strengthen Care Delivery Systems
As a result of a state budget legislative mandate, in 2017 Delaware’s Medicaid agency developed a comprehensive plan to manage the health care needs of Delaware’s children with medical complexity (CMC). The agency formed a state steering committee and various work groups to develop the plan, working closely with MCOs and other stakeholders. The Models of Care Workgroup used the National Standards for CYSHCN to develop a framework on which to build a model of care for CMC. The framework was outlined in the final report to illustrate what an ideal system of care for CMC would look like. The Delaware Plan for Managing the Health Care Needs of Children with Medical Complexity was published in May 2018 and includes a comprehensive set of recommendations that the Delaware team plans to work implement in the future.
Strengthening Contract Language to Address the Needs of CYSHCN
New Mexico has coordinated across agencies and stakeholders to provide input into the state’s 1115 Medicaid waiver renewal and contract language development pertaining to CYSHCN. As part of this work, New Mexico Medicaid and state Title V CYSHCN officials developed a definition of CYSHCN,[5] which enables the state to better identify CYSHCN and target services to this population within its managed care program. The definition is scheduled to be included in the next round of Medicaid contracts with MCOs. This work aligns with the first standard in the National Standards’ Identification, Screening, Assessment, and Referral domain that\ states, “the state system should have a definition of CYSHCN.” Additionally, the New Mexico Learning Collaborative team used the National Standards for CYSHCN Medicaid Managed Care Contract Language Tool to inform development of the definition.
West Virginia officials, led by the state’s Title V CYSHCN program director, wanted to take advantage of the changes required by the federal Medicaid Managed Care Final Rule and use the National Standards for CYSHCN to make improvements in how the Medicaid Managed Care system served CYSHCN. After meeting as an interagency workgroup, West Virginia officials identified the need for closer coordination between the Title V program and the individual Medicaid MCOs to improve care coordination and the services that CYSHCN received. To improve coordination, the team developed a memorandum of understanding (MOU) and an associated data-sharing agreement between Medicaid MCOs and the state Title V program. To assist with implementation of the updated MOU, West Virginia referred to Strengthening the Title V-Medicaid Partnership: Strategies to Support the Development of Robust Interagency Agreements between Title V and Medicaid. To ensure this MOU is enforced and coordination continues, state Title V program staff plan to meet monthly with MCO staff on an ongoing basis. Future work will focus on implementing standards for shared plans of care in cases where MCOs and Title V are both providing services to the same enrollees. The National Standards will be used to guide this work.
Improving Care Coordination and Transition to Adult Care
Rhode Island Medicaid and Title V agencies have worked to better understand the care coordination system in their state and specifically identify providers of care coordination for CYSHCN. Care coordination is a key component of a high-quality system of care and a crucial National Standards element. After reviewing the care coordination standards to learn what an ideal system of care coordination should offer, Rhode Island officials assembled key stakeholders and held monthly meetings to review the current status of care coordination services, identify available resources, and share experiences. The team also conducted an analysis of a specific group of CYSHCN enrolled in Medicaid managed care — the state’s Patient-Centered Medical Home program (PCMH-Kids) – who receive care in a community specialty care center. The children enrolled in this program require care coordination due to the complex array of services they receive. The state identified numerous barriers to providing care coordination, including limited communication between care coordinators, a lack of official designation for some care coordinators by Medicaid which prevents reimbursement, and an inability for care coordinators to authorize services, which caused delays in care. Now that it understands the barriers and complexity of care coordination for CYSHCN, Rhode Island plans to explore opportunities for policy changes, such as designating a lead care coordinator and linking a specialty care plan to the child’s medical home.
Massachusetts has similarly focused on improving integration and coordination of care with the state’s recently launched Accountable Care Organization (ACO) managed care structure. Accountable Care Organization (ACO) managed care structure. The Massachusetts’ team focused its work on the feasibility of using the new ACO model to support transition of youth with special health care needs (YSHCN) from pediatric to adult health care settings using transition policies aligned with National Standards. The Massachusetts’ team analyzed some existing transition activities in the state. These include a hybrid transition model that is being piloted at Boston Children’s Hospital between pediatrics, pediatric neurology/developmental pediatrics and adult care. The Massachusetts Department of Public Health also surveyed Title V funded care coordinators and families of CYSHCN to learn about the barriers to transition. State officials learned about integrated care strategies used by other states and organizations for transition such as Got Transition and identified value based purchasing strategies that could be used to incentivize quality transition. Massachusetts is now planning to develop guidance around strategies to implement transition policies within the ACO structure.
Conclusion
As states expand the use of Medicaid managed care to serve CYSHCN, the National Standards for CYSHCN and recent state approaches to their implementation can provide valuable resources. For more information on the National Standards and tools and resources for their implementation, visit the National Standards Toolkit.

Notes
[1] National Academy for State Health Policy. State Medicaid Managed Care Enrollment and Design for Children and Youth with Special Health Care Needs: A 50-state Review of Medicaid Managed Care Contracts. Washington, DC: National Academy for State Health Policy, October 2017.
[2] Health Resources and Services Administration, “Children with Special Health Care Needs,” December 2016, https://mchb.hrsa.gov/maternalchild-health-topics/children-and-youth-special-health-needs.
[3] The Henry J. Kaiser Family Foundation. Medicaid Restructuring Under the American Health Care Act and Children with Special Health Care Needs. Washington, DC: The Henry J. Kaiser Family Foundation, June 2017.
[4] National Academy for State Health Policy. State Medicaid Managed Care Enrollment and Design for Children and Youth with Special Health Care Needs: A 50-state Review of Medicaid Managed Care Contracts. Washington, DC: National Academy for State Health Policy, October 2017.
[5] Children and Youth with special health care needs (CYSHCN) is defined as an individual younger than 21 years old, regardless of marital status experiencing a moderate to severe medical and/or behavioral condition.

a) With significant potential or actual impact on long term health and ability to function
b) Which requires specialized health care services and/or a variety of services from multiple diverse systems.