Chronic and Complex Populations – Page 6 – The National Academy for State Health Policy

Webinar: Strategies to Increase Access to PACE: Findings from the NASHP State PACE Action Network

April 7, 2022/in Policy Maryland, Massachusetts Webinars Chronic and Complex Populations, Long-Term Care /by NASHP Staff

The Direct Care Workforce

March 28, 2022/in The RAISE Act Family Caregiver Resource and Dissemination Center Featured News Home, Reports State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by NASHP Staff

New Report Offers Steps for Supporting Family Caregivers

March 18, 2022/in The RAISE Act Family Caregiver Resource and Dissemination Center The RAISE Family Caregiver Resource and Dissemination Center /by NASHP Staff

How States Are Getting Ready to Unwind Medicaid’s Continuous Coverage Requirement

March 18, 2022/in Health Coverage and Access Colorado, Massachusetts, Utah Blogs, Featured News Home COVID-19, Health Coverage and Access, Medicaid Managed Care /by Anita Cardwell

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.

State Innovations in Medicaid Managed Care for Mobile Crisis Services

March 18, 2022/in Medicaid Managed Care Arizona, New York, Virginia Blogs, Featured News Home Medicaid Managed Care /by Jodi Manz and Kitty Purington

Background

The American Rescue Plan Act (ARPA) establishes an enhanced 85 percent federal medical assistance percentage (FMAP) opportunity for mobile mental health crisis team services in Medicaid. This match supports states in ongoing efforts to build out mental health crisis systems that align to the core elements of a crisis continuum as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA): regional call centers, mobile response, and crisis stabilization facilities.

States may need to review and revise Medicaid state plans or other authorities in order to take full advantage of the enhanced FMAP opportunity. For states that deliver these services through managed care, Centers for Medicare and Medicaid Services (CMS) guidance indicates that qualifying crisis services must also be included in plan contracts, and the costs of those services integrated into corresponding capitation rates.

Prior to ARPA, several states expanded the delivery and payment of mobile crisis services under Medicaid care contracts. These innovations can continue as states seek the enhanced FMAP for mobile crisis services. Such innovations include:

Allowing assessments to be performed via telehealth. Section 9813 of ARPA requires that in order to qualify for the enhanced FMAP, mobile crisis teams must include at least one provider who can, under state requirements for scopes of practice, perform an assessment of an individual in crisis. Many states have or are considering allowing mobile crisis teams to conduct assessments via telehealth, as behavioral health workforce shortages and distance/transportation challenges can pose barriers, particularly in rural and underserved areas. For example:

Virginia’s Medicaid mobile crisis response services are included in the state’s Medallion 4.0 managed care contract, and the state’s mental health services manual outlines billing for “telemedicine assisted assessments” in which a non-licensed qualified mental health professional (QMHP) or certified substance abuse counselor (CSAC) can conduct an assessment with real-time remote support from a supervising licensed professional. This assessment is imperative to understanding the immediate factors contributing to a crisis, as well as the supports in place that can help to stabilize an individual; permitting the use of telehealth to provide an assessment can help to ensure that crises are de-escalated as quickly as possible and that mobile teams can make connections to follow up care as necessary.

Enabling managed care data transfer to support coordination and billing. As the first component of the crisis continuum, call centers triage crisis situations, assessing the for the need for higher levels of intervention from mobile crisis teams. Getting insurance information from callers in crisis may not be possible and may interrupt or distract from the primary functions of triage and assessment. This information is, however, necessary to facilitate Medicaid billing for these services.

Arizona takes a unique approach by contractually enabling information exchange among three entities: the state’s Regional Behavioral Health Authorities (RBHAs), their contracted call centers, and Medicaid managed care plans. Call centers receive minimal information from a caller – just first name, last name, and birth date – and use that to access an enrollment clearinghouse and data warehouse that contains both electronic health records and Medicaid managed care enrollment information submitted by the plans. Using these data, call centers can serve a further function, coordinating follow up services with community-based providers. This allows the centers to bill the managed care plans for both the call center services and care coordination after the call has been resolved.

Eliminating service authorization requirements. Behavioral health services may be subject to prior authorization requirements to ensure medical necessity before a service for a Medicaid beneficiary is approved for delivery. The nature of mobile mental health crisis services, however, makes prior authorization challenging. Several Medicaid managed care contracts explicitly state that plans may not require prior authorization for these services.

Virginia does not require prior authorization; instead, reimbursement for mobile crisis services is authorized using a registration process. This effectively notifies a Medicaid managed care plan of a provided service and indicates a need for ongoing coordination of care. This registration allows for eight hours (32 units) of services within a 72-hour period, and a service registration form must be submitted to the managed care plan within one business day.

Extending billable service windows post-crisis. Mobile crisis teams provide services for acute crisis events but also provide coordination of ongoing services or connections to higher levels of care upon resolution of the qualifying crisis.

New York’s billing guidance for mobile crisis intervention providers specifies that while services must be documented in clinical records within 24 hours of a crisis event, follow up services related to the event can be reimbursed within the 14-day period thereafter. During this time, providers can bill Medicaid managed care plans for follow up and coordination of services, including services to maintain stabilization and further engage community-based providers and other patient supports.

Aligning systems and innovation

The enhanced FMAP for team-based mobile crisis services offers an opportunity for states to develop innovations in mental health crisis systems, and Medicaid managed care contracts may be a helpful lever in maximizing state approaches. Issues such as workforce needs, systems coordination, and data infrastructure can be addressed in these contracts, connecting these services to broader state behavioral health systems. As states work across agencies to align existing resources and services in their Medicaid programs, leveraging managed care partners can help coordinate services and providers across the crisis continuum.

Acknowledgements: The authors at the National Academy for State Health Policy (NASHP) would like to thank the state officials from Arizona and Virginia who contributed their knowledge to this blog. In addition, we thank Health Resources and Services Administration Project Officer Diba Rab and her colleagues for their feedback and guidance. This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.

Webinar: Sustaining Emergency Department Buprenorphine Services: Panel Discussion with California Leaders

March 18, 2022/in Policy California Webinars Behavioral/Mental Health and SUD, Opioid Use Disorder /by NASHP Staff

How States Are Leveraging Payment to Improve the Delivery of SUD Services

March 15, 2022/in Opioid Center Featured News Home Behavioral/Mental Health and SUD, Relief and Recovery /by Neva Kaye

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

Seven Steps for Building a Community-Based Palliative Care Benefit Within Medicaid

March 14, 2022/in Palliative Care Featured News Home Chronic and Complex Populations, Palliative Care /by Salom Teshale

States Focus on Behavioral Health as They Consider the Future of Telehealth

March 14, 2022/in Behavioral/Mental Health and SUD Blogs, Featured News Home Behavioral/Mental Health and SUD /by Amanda Attiya and Christina Cousart

In November 2021, the Centers for Medicare and Medicaid Services (CMS) announced a series of new policies aimed at enabling access to behavioral health services via telehealth. The announcement comes as utilization of behavioral health services via telehealth has been on the rise, which is attributable to a couple of factors:

New flexibilities to use telehealth for both providers and patients to support access to health care throughout the COVID-19 pandemic; and
Increased behavioral health needs resulting from social isolation, economic challenges, grief, and other challenges spurred by the pandemic.

With increased access to, demand for, and utilization of behavioral health via telehealth, states are grappling with a number of challenges to ensure adequate yet quality access to remote behavioral services.

With Patient-Centered Outcomes Research Institute (PCORI) support, NASHP convened a call series with state health officials representing diverse agencies and programs, including Medicaid/CHIP, State Employee Health Plans (SEHPs), State-Based Exchanges, and Departments of Insurance, to discuss telehealth. Throughout these conversations, behavioral health emerged as a persistent theme and area of focus, as states seek to maintain robust yet appropriate access to these critical services.

Rapid state actions bolstered remote behavioral health access

Toward the beginning of the COVID-19 pandemic, state and federal officials worked quickly to enable the utilization of telemedicine across healthcare services. Some of these changes were untested, such as allowing a telehealth visit to prescribe medication and induction of controlled substances, as well as delivery of healthcare services over non-HIPAA compliant platforms such as Google Hangouts or Zoom. States also worked to support infrastructure needs, enabling some providers, including behavioral health practitioners, to practice remotely for the first time. Significant investments in broadband extended access to remote behavioral health services to communities that may not have an adequate network of local in-person providers.

States also worked to bolster their workforce, taking action to waive in-state licensure requirements or by joining interstate licensure compacts such as PSYPACT which allows for out-of-state providers and those with lapsed or in-progress licenses to provide behavioral health services. To entice providers to deliver remote care, states mandated or encouraged parity in reimbursement and/or cost-sharing between in-person and telehealth services. States also allowed for more flexibility in health plans’ network definitions so that more provider types, including behavioral health professionals, could engage in telehealth delivery when clinically appropriate.

These changes incentivized the use of telemedicine services, with state coverage officials reporting that behavioral health service use via telehealth remains high, even as more patients are seeking in-person medical care again. A recent Commonwealth Fund analysis found that at the end of 2020, over half of all behavioral health visits nationally were being conducted via telehealth. Another analysis of behavioral claims data noted that over 60% of behavioral health patients now use virtual services, and 97% of the people that accessed behavioral health services between March and May 2020 did not have a behavioral telehealth claim before March 2020 when COVID-19 required closures. State officials speculate that the increased demand for behavioral health services could be indicative of both previously unmet needs and needs exacerbated by the effects of the COVID-19 pandemic.

Looking ahead, state officials balance practical concerns with emerging needs in behavioral health

As reported in a prior blog, policymakers are now grappling with many questions as they look to the future of telehealth. States seek to balance appropriate access to and coverage of both in-person and remote behavioral health services, accounting for changes in behavioral health use observed during the pandemic. States are also being funded to build out mental health and SUD service capacity and in so doing are considering the role of telehealth to support the behavioral health needs of their populations.

Policymakers flagged a few emerging issues as they consider decisions over telehealth delivery of behavioral health services.

Assessing appropriate modalities of care delivery

While flexible telehealth policies increased access to remote care and new modalities of service delivery, policymakers must consider whether these modalities are appropriate and safe to use in all circumstances. Patient needs could differ based upon specific circumstances or diagnoses that should perhaps be weighed in determining whether telehealth services will lead to optimal health outcomes. For instance, given the particularly sensitive nature of many behavioral health concerns, policymakers want to ensure appropriate measures are in place across all allowed technologies to ensure that privacy concerns are met.

In some cases, more flexible use of technology and increased capacity to receive care in an “at-home” environment, may help enable access for some, including for those with complex needs. However, certain technologies can also be prohibitive for some, especially if patients lack technological literacy, cognitive functionality, or adaptive or other resources to use them effectively. More information is needed to understand where technologies are, at minimum, adequately serving patients, and where continued flexibility does succeed at (or potentially inhibit) delivery of optimal care.

Ensuring equity in behavioral health accessed via telehealth

Despite increased investment in technological infrastructure by both states and the federal government, access to broadband remains an issue across many communities. In addition, the adoption of new technologies is limited for patients by both economic disparities, as well as disparities in tech literacy. In particular, communities of color, and low-income populations present lower rates of technology literacy. In tandem, these populations experience worse mental health outcommes, which may be further exacerbated if states shift to advance telehealth delivery without coordinated efforts to also address technological disparities across their populations.

Addressing behavioral health stigma while not fostering isolation

Some patients may have different comfort levels with receiving behavioral health services in person. This is driven in part by stigmatization around behavioral health that prevents some patients from seeking care at all. Individuals discussing sensitive or stigmatized topics such as substance use disorder or mental illness may feel more comfortable disclosing information in the privacy and comfort of their own homes. Additionally, Black and Hispanic communities experience higher levels of mistrust in health institutions and may feel less comfortable interacting with practitioners’ in their offices versus in a familiar space. Officials speculated that access to care from a safe, “at-home” environment, may be fueling some of the increased utilization of behavioral health services. However, others expressed concerns over the importance of community and relationship building to treating many behavioral health concerns and uncertainty over whether that could not be replicated in a virtual space.

State officials have many issues still to consider as they continue to debate the future of telehealth policy. Stay tuned for more NASHP resources to support states interested in exploring emerging telehealth and behavioral health policies.