Children/Youth with Special Health Care Needs – Page 4 – The National Academy for State Health Policy

Oklahoma Promotes Healthy Child Development through Increased Well-Child Visits and Screenings Using Innovative Funding

New Medicaid Funding Could Help States Better Integrate Care for Children with Medical Complexity

April 15, 2019/in Policy Blogs Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care /by Hannah Eichner and Kate Honsberger

Earlier this month, the Senate passed the Medicaid Services Investment and Accountability Act of 2019 (H.R. 1839), which contains funding mechanisms and reforms that allow states to improve care coordination for children enrolled in Medicaid. As of early this week, the bill was on the President’s desk awaiting his signature.
This legislation significantly gives states the option to establish health homes for children with medical complexity (CMC) to promote better care coordination. The concept of giving states this option was originally proposed in the Advancing Care for Exceptional (ACE) Kids Act and was debated in Congress for several years before it was passed as part of H.R. 1839.
Medicaid health homes (originally established under Section 2703 of the Affordable Care Act – ACA) provide targeted and coordinated care for patients with chronic conditions who are enrolled in Medicaid. The goal of health homes providers is to “integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.”
Medicaid health homes do not allow states to specifically limit enrollment in health homes by age, but through health home provider requirements states may limit who can provide the health home services (e.g., pediatric providers). Since this option has been available, state Medicaid agencies have used health homes to target and provide coordinated care to specific populations, such as children with behavioral health needs. In a departure from the previous health home requirements, this new health home option would allow states to specifically target children under age 21 with complex health care needs.
The new legislation contains provisions that will be important for states to consider:

Start date: States may submit Medicaid state plan amendments related to health homes for children with medical complexity beginning Oct. 1, 2022.
Enhanced federal match: To encourage uptake of this state option and to help with start-up costs, during the first two fiscal year quarters that a Medicaid state plan amendment is in effect, the Federal Medical Assistance Percentages (FMAP) for payments made to designated health homes will be increased by 15 percent, but cannot exceed 90 percent. This is a more limited federal match than health homes established by the ACA, which receive a 90 percent FMAP for the first eight quarters.
Target population: The legislation stipulates that enrollment in a health home program must be provided as an optional basis for children with medical complexity. It clearly defines eligibility for children younger than 21 with medical complexity as having:
- One or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical functioning – such as the ability to eat, drink, or breathe independently – and that also requires the use of medication, durable medical equipment, therapy, surgery, or other treatments; or
- One life-limiting illness or rare pediatric disease, as defined in section 529(a)(3) of the Federal Food, Drug, and Cosmetic Act.
Types of services:
- Services provided by health homes will include the six core health home services required under Section 2703 of the ACA: comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, and referrals to community and social support services.
- Further, this new health home option for children with medical complexity must provide access to the full range of pediatric specialty and subspecialty medical services, including services from out-of-state providers if medically necessary.
Health home qualifications:
- Health home providers have traditionally included designated providers, teams of health professionals, and health teams.
- The legislation stipulates that the Secretary of Health and Human Services (HHS) will establish standards for qualifying as a health home. The standards will include requirements related to: coordinating prompt and coordinated care among various types of providers, establishing a family-centered care plan, working in a culturally- and linguistically-appropriate manner, and coordinating care with out-of-state providers.
State reporting requirements: States must report to HHS information including: the number of children participating in the program, the nature and prevalence of the chronic conditions of enrollees, the type of delivery systems and payment models used in the program, quality measures used in the program, and health home provider characteristics.
State planning grants: Beginning on Oct. 1, 2022, HHS can award up to $5 million in planning grants to interested states.

The legislation also requires the HHS Secretary to issue guidance to state Medicaid agencies by October 2020 on best practices for using and coordinating care from out-of-state providers for children with medical complexity. States will be required to report on implementation of this guidance within their health home programs.
The National Academy for State Health Policy (NASHP) will continue to monitor progress on this legislation and if signed into law, NASHP will follow its implementation and highlight potential issues for states as they pursue this new Medicaid option. For more information about state strategies to improve care to children with special health care needs, visit NASHP’s Children and Youth with Special Health Care Needs Resource Page.

Considerations for States Crafting Budgets to Support Children’s Coverage

March 11, 2019/in Policy Blogs Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Managed Care /by Anita Cardwell

After months of uncertainty and a three-month federal funding lapse, in early 2018 Congress passed the HEALTHY KIDS and ACCESS Acts, which appropriated federal funds for the Children’s Health Insurance Program (CHIP) through federal fiscal year (FFY) 2027. While the HEALTHY KIDS and ACCESS Acts’ long-term funding stabilizes CHIP programs and helps states develop forward-focused strategies to improve children’s coverage, a decrease in the federal CHIP match rate will require additional state funding beginning this October.

The Affordable Care Act (ACA) increased states’ federal CHIP match rates by 23 percentage points — referred to as the “23 percent bump” — beginning in FFY 2016, which resulted in match rates ranging from 88 to 100 percent. While the HEALTHY KIDS and ACCESS Acts continued to fund the 23 percent bump through FFY 2019, beginning this October it will be phased down to 11.5 percentage points. Subsequently, in FFY 2021 and beyond, the percentage returns to the regular enhanced CHIP match rate that states received prior to the 23 percent bump.

States are currently finalizing budgets for their CHIP programs and must factor in this reduction in the federal match rate to determine the state financing needed to sustain these critical programs. State officials in Alabama estimate that $30 to $35 million in additional state funding will be needed for the state’s CHIP program in FFY 2020, and Oklahoma predicts it will need $14.8 million more. Planning for the phased reduction in the CHIP match rate may pose a particular challenge for states with legislatures that only meet every other year, considering additional state dollars will be needed in FFY 2021 as well.

Some states may consider modifying income eligibility levels for CHIP as a way to address the decreasing federal CHIP match rate, but that is not an option because the 2018 CHIP funding extension includes a requirement that states maintain certain coverage levels for children enrolled in Medicaid and CHIP — called the maintenance of effort (MOE). The HEALTHY KIDS and ACCESS Acts build on the ACA’s MOE provision, which requires states to maintain their Medicaid and CHIP eligibility levels for children that were in place as of March 23, 2010.

Through the ACA, the MOE for children was set to expire at the end of FFY 2019, but the HEALTHY KIDS and ACCESS Acts extend the MOE requirements through FFY 2027. However, beginning Oct. 1, 2019, the MOE protection targets children in families with incomes up to 300 percent of the federal poverty level (FPL). This means that states with Medicaid or CHIP eligibility levels for children above this level have flexibility to lower them to 300 percent of FPL. However, because the majority of states do not provide coverage above 300 percent of FPL, most states will be required to keep their current eligibility levels in place. The intent of the MOE is to help ensure coverage stability for children enrolled in Medicaid and CHIP, and it may become increasingly important if recently reported declines in children’s coverage continue. For more information about the MOE, read 101: Maintenance of Effort (MOE) Requirements for Children in Medicaid and CHIP Fact Sheet.

As state officials weigh these budgetary issues, many states are also seeking to implement initiatives to enhance children’s coverage and care. Some states are developing innovative Health Services Initiatives, strengthening coordination with schools and other community partners to better meet children’s health and behavioral health needs, or improving integrated care for children. In the coming months, the National Academy for State Health Policy (NASHP) will be gathering and sharing information highlighting state efforts to improve children’s coverage and care.

States Use Policy Levers and Emerging Research to Address Antipsychotic Use in Children in Foster Care

February 11, 2019/in Policy Reports Behavioral/Mental Health and SUD, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, EPSDT, Health Coverage and Access, Health Equity, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement /by Johanna Butler, Jennifer Reck and Maureen Hensley-Quinn

State policymakers must often take action during an emerging crisis even when evidence identifying the best policy approach is not be available. This report, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, explores successful state responses to dramatic increases in antipsychotic prescription rates in Medicaid-enrolled children in foster care. It highlights several strategies, including payment reforms, delivery system innovations, and quality supports for clinical care.

The report results from a convening by the National Academy for State Health Policy of researchers and state officials with expertise in financing and operating Children’s Health Insurance Program and Medicaid programs, children’s health, and health policy and pharmacy research. The meeting preceded the release of a Patient-Centered Outcomes Research Institute-funded study, which examines the comparative effectiveness of state oversight systems in Ohio, Texas, Washington, and Wisconsin.

Read or download: Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System

CMS Releases State Funding to Improve Integrated Care for Children and Pregnant and Postpartum Women Enrolled in Medicaid and CHIP

February 11, 2019/in Policy Blogs 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, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

Last week, the Centers for Medicare & Medicaid Services (CMS) released two highly anticipated initiatives — the Maternal Opioid Misuse (MOM) Model and the Integrated Care for Kids (InCK) Model — which will provide multi-year funding to states to improve integrated care for maternal and child health populations enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
NASHP has been tracking these important initiatives since they were first announced by the CMS Center for Medicare and Medicaid Innovation (Innovation Center) last year and has compiled and promoted exemplary integrated care delivery models, strategies, and innovations for pregnant and postpartum women and children that states can consider as they develop their applications for these initiatives.
The MOM Model is designed to:

Improve quality of care and reduce costs for pregnant and postpartum women with opioid use disorder (OUD) and their infants;
Expand access, service-delivery capacity, and infrastructure based on state-specific needs; and
Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.

The CMS Innovation Center will award a maximum of $64.5 million through up to 12 cooperative agreements with state Medicaid agencies and their care delivery model partners for a five-year period. Applications for the MOM Model are due to CMS by 3 p.m. (EST), May 6, 2019. A CMS webinar about the MOM Model Notice of Funding Opportunity was held Feb. 21, 2019. The recording, slides, and transcript from the webinar are available here.
The InCK Model is designed to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and CHIP through prevention, early identification, and treatment of behavioral and physical health needs. States and local organizations will work to conduct early identification and treatment of children with health-related needs across settings to:

Increase behavioral health access;
Respond to the opioid epidemic; and
Improve child health outcomes.

The CMS Innovation Center will award a maximum of $128 million through eight cooperative agreements with state and local participants for a seven-year period (awarding up to $16 million per recipient). Applications to implement the InCK Model are due to CMS by 3 p.m. (EST), June 10, 2019. A CMS webinar about the InCK Model NOFO is scheduled for 2:30 to 4 p.m. (EST) Tuesday, Feb. 19, 2019.

Medicaid Managed Long-term Services and Supports Programs for Children and Youth with Special Health Care Needs

December 4, 2018/in Policy Webinars Behavioral/Mental Health and SUD, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Long-Term Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration /by Erin Kim

Tuesday, December 04, 2018
3-4 p.m. (ET)
States are increasingly providing services to Medicaid beneficiaries with complex health care needs through managed care delivery systems to help control the cost of care, improve health outcomes of enrollees, and improve the quality of the care enrollees receive. States are also starting to include behavioral health and long-term services and supports (LTSS) in Medicaid managed care – services that historically have been provided in fee-for-service systems. States have used MLTSS delivery systems less frequently to serve CYSHCN. However, MLTSS may have great potential to improve quality of life for CYSHCN in Medicaid, by increasing access to care, as well as beneficiaries’ control over their care.
This national webinar will provide an overview of a recent National Academy of State Health Policy (NASHP) analysis of how state MLTSS programs serve CYSHCN. It will also feature presentations from Texas and Iowa, highlighting their approach to providing LTSS for CYSHCN through managed care.
Listen to the Webinar.
Download the Slides.

How States Use Medicaid Managed Care to Deliver Long-Term Services and Supports to Children with Special Health Care Needs

December 3, 2018/in Policy Reports Care Coordination, Children/Youth with Special Health Care Needs, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health System Costs, Healthy Child Development, Integrated Care for Children, Long-Term Care, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Primary Care/Patient-Centered/Health Home /by Kate Honsberger, Erin Kim and Karen VanLandeghem

An increasing number of state Medicaid agencies are using managed care to provide long-term services and supports to children and youth with special health care needs (CYSHCN). This new NASHP issue brief explores the strategies and critical contract language and policies that states are using to implement these Medicaid managed care programs to provide long-term services and supports to CYSHCN.
View or download the issue brief: How States Use Medicaid Managed Care to Deliver Long-Term Services and Supports to Children with Special Health Care Needs
Read the blog: How States Provide Long-Term Services and Supports to Children in Medicaid Managed Care

How States Provide Long-Term Services and Supports to Children in Medicaid Managed Care

December 3, 2018/in Policy Blogs Behavioral/Mental Health and SUD, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by Kate Honsberger and Erin Kim

For years, states have used managed care delivery systems to help control costs and improve health care and outcomes for adult Medicaid beneficiaries with complex health care needs. Now, more than a dozen states are using managed care to provide long-term services and supports (LTSS) to children and youth with special health care needs (CYSHCN).
LTSS are costly for federal and state governments to deliver. Nationally, public LTSS spending exceeds $242 billion annually. Medicaid is responsible for about $145 billion or 60 percent of these expenditures and LTSS currently accounts for 30 percent of all Medicaid spending. Annual Medicaid spending per enrollee is more than 12-times higher for children who use LTSS ($37,084) compared to those who do not ($2,863).
LTSS encompass a range of medical and non-medical services provided to people who are chronically ill or disabled. They typically include services such as nursing facility care, home nursing services, and home- and community-based services, such as in-home nursing care. LTSS often provide support for daily living activities, including eating, dressing, and maintaining personal hygiene. CYSHCN who receive LTSS are typically children with significant health care conditions and may need LTSS services over their childhood, and perhaps for the rest of their lives. Their LTSS needs may change as they grow and mature. Some CYSHCN receive care in a nursing home facility due to their extensive medical and/or behavioral health care needs and limitations in available community-based services.
Until now, few national reports have explored how states are redesigning their programs to include children in state Medicaid managed long-term services and supports (MLTSS). In early 2018, the National Academy for State Health Policy (NASHP) analyzed state Medicaid managed care programs nationwide that provide LTSS for children. NASHP reviewed state contracts to identify which pediatric populations were covered, how the programs were structured, and what approaches states used when evaluating the quality of LTSS and requirements for cross-agency collaboration.
This new NASHP issue brief and its accompanying chart highlight strategies that states have used to implement MLTSS and identify key contract language that helped states establish these programs.
Currently, one-quarter of states (14 states) provide MLTSS to children through 17 Medicaid managed care (MMC) programs. In some cases, states have more than one MMC program to serve specific groups of Medicaid enrollees. In contrast, 24 states provide 39 MLTSS programs to adults. The CYSHCN that states enroll in their MLTSS programs vary across the country. Most enroll children who receive Supplemental Security Income, are enrolled in Medicaid as the result of foster care placement, and/or are enrolled in 1915(c) HCBS waivers. Nearly all provide these services as part of a comprehensive set of physical, behavioral, and LTSS benefits.
There are a number of ways that states can ensure that MLTSS programs serve the unique needs of children, including instituting specific network adequacy requirements for LTSS providers, implementing new or adapting existing quality measurement strategies for children receiving LTSS, and requiring coordination between managed care organizations, LTSS state agencies, and community-based partners.
Using MMC to provide LTSS to children is an emerging trend that is likely to expand as managed care becomes the dominant delivery system for all Medicaid enrollees and services. This issue brief includes strategies states may consider in implementing MLTSS for children including family engagement, preparing LTSS providers, and designing programs to meet the specific needs of children. As states implement new delivery system models and respond to new federal rules, NASHP will continue to monitor the delivery of MLTSS services to children and identify promising practices.

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.

Strengthening Health Care Delivery Systems for Children with Special Health Care Needs and the Role of Quality Measurement

November 28, 2018/in Policy Webinars Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, EPSDT, Health Coverage and Access, Health System Costs, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care /by Hannah Eichner

Wednesday, Nov. 28, 2018
2-3 p.m. (EST)
States are in the midst of rapid transformation of their health care delivery systems, including how they provide services to children and youth with special health care needs (CYSHCN). As of June 2017, 47 states and Washington, DC, use some form of managed care to provide services to all or some children with special health care needs enrolled in Medicaid. Of the states with managed care delivery systems serving CYSHCN, 37 states rely exclusively on risk-based managed care organizations to deliver services.
As more states serve CYSHCN in Medicaid managed care, it is important to understand the unique needs of CYSHCN and how program and policy changes impact their access to high quality care. This webinar will feature presenters from Delaware, Rhode Island, and Massachusetts, who recently participated in a NASHP learning collaborative focused on improving Medicaid managed care for CYSHCN. The webinar will also feature an overview of resources that NASHP has recently developed to help states implement quality measurement and improvement efforts for CYSHCN in Medicaid managed care.
Listen to the Webinar.
Download the Slides.