Health Coverage and Access – Page 15 – The National Academy for State Health Policy

States Increase Access to Oral Health Services and Support Overall Health

November 25, 2019/in Policy Child Oral Health, Community Health Workers, Health Coverage and Access, Health Equity, Maternal, Child, and Adolescent Health, Oral Health, Population Health, Workforce Capacity /by NASHP Staff

Across the nation, states are developing innovative approaches to increase access to oral health services. These policies underscore the critical relationship between overall health and oral health. This blog and two new National Academy for State Health Policy fact sheets explore how several states, including Minnesota and Arizona, are expanding their oral health workforce to increase access to care and promote health equity and patient safety.

Blog: States Increase Access to Oral Health Services to Support Overall Health
Fact Sheet: AZ Uses Dental Hygienists to Improve Hospital Patient Safety
Fact Sheet: MN Uses CHWs and Dental Therapists to Advance Equity

States Increase Access to Oral Health Services and Support Overall Health

November 25, 2019/in Policy Arizona, Minnesota Blogs, Featured News Home Chronic Disease Prevention and Management, Community Health Workers, Health Coverage and Access, Health Equity, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Workforce Capacity /by Carrie Hanlon and Neva Kaye

State officials continue to develop new approaches to increase access to oral health services, and many of their innovations were highlighted at National Academy for State Health Policy’s 2019 conference. There are ongoing initiatives, such as deploying community health workers in Minnesota, a New Hampshire Medicaid and Women, Infants, and Children Nutrition Program pay-for-prevention, bundled payment pilot for children’s preventive oral health services, and implementation of new Medicaid policies to expand access in Arizona and Utah.

These oral health policies underscore the critical relationship between increased access to oral health for overall health, a relationship that is highlighted in two new NASHP fact sheets that explore how states are expanding their oral health workforce: Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity and Arizona Uses Dental Hygienists to Improve Hospital Patient Safety.

For ventilator-assisted patients, good oral health supports patient safety. As an Arizona Department of Health Services representative discussed at NASHP’s conference, state legislation enacted in May 2019 changed scope-of-practice laws to allows dental hygienists working in hospital settings to practice under the supervision of a licensed physician.

A volunteer project enabled Arizona to test the use of dental hygienists to provide oral health care to ventilator-assisted patients — a strategy recommended by the US Centers for Disease Control and Prevention to reduce ventilator assisted pneumonia (VAP). VAP, which is usually caused by oral bacteria, was the leading cause of death from nosocomial infections in critically ill patients and significantly increased hospital costs. This project identified the scope-of-practice law, which required supervision by a dentist, as a key barrier to having dental hygienists in hospitals to improve oral health to support the overall health of ventilator-dependent patients. To learn more, read Arizona Uses Dental Hygienists to Improve Hospital Patient Safety.

Good oral health also supports overall health among adults with substance use disorder (SUD). As a representative from the Utah Department of Health’s Division of Medicaid and Health Financing highlighted at the conference, the state added dental benefits for targeted adult Medicaid beneficiaries with SUD in January 2019. The beneficiaries receive dental care at the University of Utah School of Dentistry and affiliated providers. The policy builds on the innovative Project FLOSS – Facilitating a Lifetime of Oral Health Sustainability for Substance Use Disorder Patients and Families. Project FLOSS demonstrated that providing comprehensive integrated dental and SUD care was associated with increased SUD treatment completion, employment, and drug abstinence, along with reduced homelessness among adults.

Emerging health professionals, such as community health workers (CHWs), promote overall health and health equity. Minnesota is one of just a few states that include a specific CHW role to promote oral health — helping to link oral health and overall health. In 2005, Minnesota became the first state to implement a for-credit, transferrable-credit CHW certificate program through its state college system and private higher education institutions. CHWs work under the supervision of eligible Medicaid providers in the state, including dentists. By providing culturally competent, high-quality access to services and increasing the health knowledge of the individuals they serve, CHWs can help reduce disparities. To learn more about the role of CHWs and dental therapists, read Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity.

In 2020, NASHP will continue to track state policy changes and efforts to increase access to pediatric and adult oral health services as part of states’ commitment to promote overall health.

The DentaQuest Partnership for Oral Health Advancement supported the conference session and these fact sheets.

Expanding the Oral Health Workforce to Promote Overall Health: Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity

November 25, 2019/in Policy Minnesota Reports Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Workforce Capacity /by Carrie Hanlon and Rebecca Cooper

Oral health access and quality varies across populations, with disparities related to income, age, sex, race, ethnicity, and medical status persisting despite its value to general health.[1] Minnesota is working to increase access and advance oral health equity through the adoption of emerging health professionals, including community health workers (CHWs) and dental therapists (DTs) and advanced dental therapists (ADTs).[2]

Eight states and tribal organizations in five states allow DTs to provide preventive and restorative dental care.[3] Forty-seven states and Washington, DC have programs designed to integrate CHWs into evolving health care systems, but only a few state programs allow CHWs to play a role in expanding oral health.[4]

Minnesota initiated an expansion of its oral health workforce because more than half of its counties are considered Dental Health Professional Shortage Areas (DHSPAs),[5] which poses a major barrier for rural and under-resourced residents to receive oral health care. Recent data from a Minnesota Department of Health (MDH) survey indicates that the overall dentist to population ratio is one dentist for every 1,641 Minnesotans.[6] This ratio increases for rural residents, with:

One dentist per 2,153 micropolitan or large rural city residents;
One dentist per 2,272 small town or small rural city residents; and
One dentist per 3,938 rural or geographically isolated residents.

Minnesota’s 2013-2018 Oral Health Plan details strategies to expand the oral health workforce to reduce these disparities. The following explores how Minnesota’s programs and policies are using CHWs and DTs/ADTs to address oral health needs.

Community Health Workers

The Minnesota Department of Human Services (DHS) defines CHWs as community-based workers who provide diagnosis-related patient education, health promotion, advocacy, and disease management for a range of health issues, including oral health. States have embraced the CHW model as a mechanism to engage more vulnerable populations in care.[7] CHWs can work in homes, schools, and in community-based organizations. To help build trust and relationships, CHWs typically come from the communities in which they serve. By providing culturally competent, high-quality access to services and increasing the health knowledge of the individuals they serve, CHWs can help reduce health disparities.[8]

The Minnesota legislature established the Healthcare Education-Industry Partnership (HEIP) in 1998 to address health disparities. In the early 2000s, HEIP worked with the Minnesota Community Health Worker Project, a group of 21 health care industry, university, and non-profit organizations, to develop a sustainable CHW profession. Through this work group, in 2005, Minnesota became the first state to implement a for-credit, transferrable-credit CHW certificate program through its state college system and private higher education institutions.

More than 650 CHWs been trained through Minnesota’s certificate program to date, and about 70 percent are racial and ethnic minorities.[9] The three largest racial and ethnic minority populations Minnesota’s CHWs work with are Latino, Somali/East African, and Hmong populations. Medicaid does not directly reimburse CHW for oral health services, so CHWs work under the supervision of eligible providers, such as dentists or physicians, to provide oral health services.[10] Minnesota’s Medicaid program covers care coordination and patient education services related to oral health and dental care from a CHW if the CHW received a certificate from the licensed CHW certificate program, or has at least five years of supervised experience with an enrolled dentist, physician, or other eligible provider.[11]

The state was awarded a three-year, $45 million State Innovation Model (SIM) grant in 2013 to expand and improve accountable care models in the state.[12] In Maplewood, a community dental clinic expanded to four clinics across the state using CHW interns. In Mankato, a federally qualified health center used SIM funds to integrate CHWs into a mobile dental unit serving rural areas, which led to a large increase in service utilization. For more information about how CHWs resources are used across the country, explore NASHP’s interactive map of State Community Health Worker Models.

Dental Therapists and Advanced Dental Therapists

In 2009, Minnesota’s legislature authorized the licensing of DTs and ADTs with the requirement that they primarily serve low-income, and under/uninsured patients.[13]

DTs are licensed oral health practitioners and members of an oral health care team who provide evaluative, preventive, restorative, and minor surgical dental care within their scope of practice.[14] DTs are mid–level practitioners licensed by the Board of Dentistry, and work under the supervision of a dentist.
ADTs provide the same services that a DT does, plus oral evaluation and assessment, treatment plan formulation, and non–surgical extraction of certain diseased teeth. ADTs are certified by the Board of Dentistry and can practice under the supervision of a licensed dentist, but the dentist does not need to be on-site during procedures and does not need to see the patient prior to them receiving care from an ADT.

Research shows that DTs improve underserved patients’ access to oral health care, including Medicaid enrollees, partly due to reduced waiting times and travel distances.[15] Minnesota has two dental therapy programs that accept and train 10 students per year. In 2018, 92 dental therapists, including ADTs, were licensed to practice in Minnesota.[16]

To ensure Minnesota has appropriate dental workforce coverage for rural areas, Minnesota’s Office of Rural Health and Primary Care implemented a state loan forgiveness program. The program is offered to final-year DTs and ADTs as well as licensed DTs and ADTs who plan to practice in a designated rural area for at least three years. These DTs and ADTs are eligible for $10,000 in annual loan repayments.

Next Steps and Reflections

Ensuring access to oral health care requires sufficient provider participation and provider reimbursement. The Minnesota Rural Health Advisory Committee’s[17] Oral Landscape for Rural Residents report[18] highlighted reimbursement rate challenges specifically for pediatric dental services. As a result, MDH pledged to work with DHS and legislators to promote a reimbursement system that covers the cost of providing oral health services and encourages providers to accept patients participating in public programs. MDH also plans to share workforce data with legislators to:

Highlight programs that succeed in expanding the workforce in rural Minnesota;
Facilitate work with stakeholders and within provider communities to encourage practices in order to extend the reach of the existing workforce to meet oral health needs.[19]

State officials across agencies recognize the importance of oral health for overall health and work collaboratively to expand the oral health workforce to ensure access for vulnerable populations and advance equity.

Notes

[1] National Institutes of Health. National Institute of Dental and Craniofacial Research. 2000 Surgeon General’s Report on Oral Health in America. July 2000. https://www.nidcr.nih.gov/research/data-statistics/surgeon-general

[2] Minnesota Department of Health. Office of Rural health and Primary Care. Community Health Worker Toolkit. 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf

[3] American Dental Hygienists’’ Association, “Expanding Access to Care Through Dental Therapy,” July 2019. https://www.adha.org/resources-docs/Expanding_Access_to_Dental_Therapy.pdf

[4] National Academy for State Health Policy, “State Community Health Worker Models.” https://www.oldsite.nashp.org/state-community-health-worker-models/

[5] Minnesota Department of Health. Minnesota Public Health Data Access. Dental Workforce Shortage Areas. January 2018. https://data.web.health.state.mn.us/hpsa-access

[6] Minnesota Department of Health. Oral Health in Minnesota. https://www.health.state.mn.us/people/oralhealth/data/oralhealthmn.html

[7] Clary, Amy. “Community Health Workers in the Wake of Health Care Reform: Considerations for State and Federal Policymakers,” National Academy for State Health Policy. November 2015. https://www.oldsite.nashp.org/wp-content/uploads/2015/12/CHW1.pdf

[8] Minnesota Department of Health. Community Health Worker Toolkit, 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf

[9] Minnesota Department of Health. Community Health Worker Toolkit, 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf

[10] Community Health Worker Toolkit, 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf

[11] Minnesota Legislature. Office of the Revisor of Statutes. Section 256B.0625 Covered Services. Subd. 49. Community Health Workers. https://www.revisor.mn.gov/statutes/2010/cite/256B.0625/subd/256B.0625.49#stat.256B.0625.49

[12] State Health Access Data Assistance Center, “Evaluation of the Minnesota Accountable Health Model,” September 2017. https://www.leg.state.mn.us/docs/2018/other/180336.pdf

[13] Minnesota Department of Health. Dental Therapists and Advanced Dental Therapists. Updated in 2017. https://www.health.state.mn.us/facilities/ruralhealth/emerging/dt/index.html

[14] Minnesota Legislature. Office of the Revisor of Statutes. 2019 Minnesota Statute. Section 150A.105 Dental Therapist. 2019, https://www.revisor.mn.gov/statutes/cite/150A.105

[15] Minnesota Department of Health. (2014, February). Early Impacts of Dental Therapists in Minnesota. https://www.health.state.mn.us/data/workforce/oral/docs/dtlegisrpt.pdf

[16] Minnesota Department of Health. Office of Rural Health and Primary Care. Minnesota’s Dental Therapist Workforce. September 2019. https://www.health.state.mn.us/data/workforce/oral/docs/2019dt.pdf

[17] The workgroup represented a variety of oral health perspectives and roles, including oral health professionals, dental professional associations, oral health educators, safety-net providers, and other oral health stakeholders.

[18] Minnesota Department of Health. Office of Rural Health and Primary Care. Strengthening the Oral Health System in Rural Minnesota. August 2018. https://www.health.state.mn.us/facilities/ruralhealth/rhac/docs/2018ruraloral.pdf

[19] Ibid.

Acknowledgements:
The authors would like to thank the officials with the Minnesota Department of Human Services and Minnesota Department of Health who shared their time and insights. Thanks also to Malka Berro, Trish Riley, and Jill Rosenthal for their assistance and contributions. Finally, our sincere thanks to Trenae Simpson, M. Parrish Ravelli, and the DentaQuest Partnership for Advancing Oral Health for funding this project.

Expanding the Oral Health Workforce to Promote Overall Health: Arizona Uses Dental Hygienists to Improve Hospital Patient Safety

November 25, 2019/in Policy Arizona Reports Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Workforce Capacity /by Neva Kaye

Arizona recently made an innovative change in its scope-of-practice rules governing supervision of dental hygienists to enable hospitals to more easily use these providers to help prevent ventilator-assisted pneumonia (VAP) – the leading cause of death from nosocomial infections in critically ill patients. VAP, the second most common nosocomial infection, increases the duration of hospitalizations by seven days and health care costs by approximately $40,000 per hospitalization.¹

Preventing VAP is important to reducing both hospital-acquired infections and health care costs. VAP usually occurs when a patient aspirates oral bacteria. The US Centers for Disease Control and Prevention, in recognizing the importance of oral care to VAP prevention efforts, suggests that hospitals, “develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute care settings or residents in long-term care facilities who are at high risk for health-care-associated pneumonia.”²

Nurses often provide oral-hygiene care to ventilator-dependent hospital patients, but some hospitals prefer to use dental hygienists to provide that service because of hygienists’ expertise and to give nurses more time for other responsibilities. However, hospitals in Arizona encountered challenges to assigning dental hygienists to this task. States’ scope-of-practice laws usually allow dental hygienists to provide care only under the supervision of a dentist. But hospitals may not have dentists on staff, or if they do, the dentist may not be available to order the care when needed.

In May 2019, Arizona enacted HB 2058, which allows dental hygienists working in hospital settings to practice under the supervision of a licensed physician. In addition, the supervising physician must be available for consultation but does not need to be physically present when the care is administered.

Changing the Scope of Practice Required Innovative Partnerships Among Providers

HB 2058 affects how physicians, oral hygienists, nurses, hospitals, and dentists work together. For example, nurses had traditionally provided oral health care in hospitals and they needed to understand that the change would not reduce their role, but rather free up their time to provide other critical services. Also, physicians needed to understand their responsibilities in supervising dental hygienists. As a result, crafting the legislation required partnerships and cooperation among the associations representing these providers. A volunteer project fostered these partnerships and generated real-life examples that confirmed that the scope-of-practice laws needed to be changed to enable hospitals to use dental hygienists to effectively provide dental hygiene in hospital settings.

Remaining Challenges and Next Steps

Although changing dental hygienists’ scope of practice facilitates their ability to practice in hospitals, challenges remain. For example, allowing hygienists to provide services does not obligate public and private insurers to pay for those services. Even before the bill passed, one regional hospital began hiring dental hygienists to work in its intensive care unit and the hospital then sought reimbursement for the hygienists’ services through medical billing — an action made possible by the change in the scope-of-practice rule. However, because Medicare does not recognize dental hygienists as a provider type, the hospital will not receive payment from Medicare. At this time, it is not known whether other payers will choose to pay for oral hygiene services provided to hospital patients by oral hygienists.

State health officials are tracking the results of this new innovation. They plan to assess patient outcomes, including VAP reduction, costs, and whether more hospitals implement this innovation. Depending on the results, officials are considering developing education programs or training to foster the innovation’s expansion. State policymakers are also considering expanding the physician-supervision model to long-term care facilities.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank officials with the Arizona Department of Health Services who shared their time and insights. The author also thanks Carrie Hanlon, Elinor Higgins, and Trish Riley of NASHP. She also would like to thank Trenae Simpson, M. Parrish Ravelli, and the DentaQuest Partnership for Advancing Oral Health for funding this project.

Notes

[1] Timsit, J.J., et al. (2017) Update on ventilator-associated pneumonia. F1000 Research. 6:2061. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710313/
[2] Centers for Disease Control and Prevention (2003). Guidelines for Preventing Health-Care—Associated Pneumonia. CDC Morbidity and Mortality Weekly Report. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

50-State Scan: How Medicaid Agencies Leverage their Non-Licensed Substance Use Disorder Workforce

November 21, 2019/in Policy Featured News Home, Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Workforce Capacity /by Eliza Mette, Charles Townley and Kitty Purington

Nearly one in every eight adults enrolled in Medicaid has a substance abuse disorder (SUD),[1] and a significant barrier to treatment is a shortage of SUD professionals[2] in every state. In response, state Medicaid agencies are developing and deploying a growing workforce of non-licensed, non-master’s-level treatment and support providers – such as peers, counselors, and other qualified staff – to provide a range of services to supplement licensed SUD provider capacity.[3] To help states address SUD workforce challenges and identify cutting-edge solutions, the National Academy for State Health Policy (NASHP) conducted a comprehensive review of how each state Medicaid program was paying for and overseeing non-licensed SUD staff. This brief summarizes what steps states are taking to reduce workforce shortages and provides resources to help states develop new approaches to expanding their SUD workforce.

How Medicaid Agencies Leverage their Non-Licensed SUD Workforce

To help states address SUD workforce challenges and identify cutting-edge solutions, NASHP conducted a comprehensive review of how each state Medicaid program was paying for and overseeing non-licensed SUD staff.

Background

NASHP analyzed publicly available materials to identify:

How Medicaid agencies reimburse for SUD services provided by non-licensed, non-master’s-level workforce;
What services they provide and in what settings; and
State education, training, and supervision requirements for non-licensed staff.

NASHP used the most recently available Medicaid provider and billing manuals, state regulations, and other public policy documents (including state plans and waivers) for all 50 states and Washington, DC. Findings were grouped and coded to allow for easier cross-state analysis. The data collected was shared with Medicaid and other state leaders.

States’ non-licensed workforce was categorized as:

Peers: Individuals with lived experience providing Medicaid-billable SUD services.

Counselors: Individuals providing Medicaid-billable SUD counseling or therapy services without a state license.

Other Qualified Staff: Other non-licensed professionals providing Medicaid-billable SUD services who did not meet the definition of a “peer” or “counselor.”

Services funded by resources other than Medicaid (e.g., state grant funding) were considered outside the scope of this research.

The majority of state Medicaid agencies (42) reimburse for SUD treatment services provided by non-licensed, non-master’s-level SUD staff. NASHP’s scan identified 45 types of peers in 39 states, 52 types of counselors in 31 states, and 43 types of other qualified staff in 24 states. The services these staff may provide, where they provide the service and how they are reimbursed, as well as education, training, and supervision requirements all varied to some degree across states. Key findings are summarized below.

Service Delivery

State Medicaid programs pay for a range of services and supports delivered by non-licensed staff. These services were grouped in the following categories:

Peer services;
Screening, assessment, and evaluation;
Brief intervention;
Community and rehabilitative supports (e.g., education, skills training, and family support);
Case management/care coordination; and
Crisis intervention.

States reimburse counselors for a broad range of SUD services. In addition to counseling/therapy services, more than half of non-licensed counselors can be reimbursed by state Medicaid programs for screening, evaluation, assessment, community and rehabilitative support, case management/care coordination, and/or crisis intervention services. Most state Medicaid agencies pay peers to provide peer support services-only, although approximately one-quarter of peers may also be reimbursed to provide rehabilitative or supportive services. Other qualified staff generally fell into one of two groupings: individuals primarily providing case management or care coordination services or unlicensed staff providing rehabilitative or supportive services who did not meet state qualifications to provide counseling services.

States vary in the types of counseling/therapy services that may be provided by non-master’s-level counselors. For example, every state permits their non-master’s-level counselors to provide individual and/or group counseling services, but only two-thirds of states reimburse certified counselors for family counseling services. Florida only reimburses its bachelor’s-level counselors for group services, limiting reimbursement for individual and family services to those with a master’s degree.

Setting and Reimbursement

Non-licensed staff deliver services in licensed behavioral health agencies or facilities, typically working within a multidisciplinary care team. Although employed by licensed agencies or facilities, services may often be provided in home and/or community settings to meet the needs of individuals receiving treatment.

How services delivered by this workforce can vary, depending on whether services are provided in outpatient or residential settings. State Medicaid agencies commonly pay licensed behavioral health clinics for services delivered by non-licensed staff on a fee-for-service basis, through Current Procedural Technology or Healthcare Common Procedure Coding System codes that may include modifiers to designate provider type. In contrast, services delivered by non-licensed staff in intensive outpatient programs (including day treatment and partial hospitalization) or residential treatment programs tend to be reimbursed as part of a bundled, per-diem rate. States may also include these types of staff in bundled rates for specialty opioid treatment programs. For example, Maine, Michigan, and Rhode Island all include peers in their opioid health home programs.

Education, Training, and Supervision

Training for peers tends to be more individualized and state-specific. Most states require peers to complete an in-person training program (typically one to two weeks), often offered through a state health agency. Counselors, on the other hand, may receive training though approved courses offered by community colleges or other professional development programs. States generally rely on national exams for counselors but were more likely to use state-developed training and exams for peers. Whether the state’s board membership was with the National Association for Alcoholism and Drug Abuse Counselors (NAADAC) or the International Certification & Reciprocity Consortium (IC&RC) determined which national exam the state required for certification. Some states, particularly those with multiple credentialing boards, allow either exam.

Most states require that non-licensed, non-master’s-level SUD treatment staff be supervised by certified or licensed SUD providers, who often held a master’s degree. In many cases, state regulations identify multiple eligible providers who could supervise staff rather than requiring one specific provider type. For example, a bachelor’s-level counselor might be supervised by a psychiatrist, an advanced practice nurse with specialized addictions training, or a master’s-level counselor with supervisory training. It is also common for individuals, particularly for those without a counseling certification, to be supervised by a more experienced colleague holding a similar credential – for example, a peer with two years of experience would supervise another peer. States also routinely set minimum standards for the supervisory relationship, such as defining frequency of meetings and on-call availability. Positions requiring less training and experience typically required closer supervision. Clinical oversight requirements were generally less specific than supervisory requirements and sometimes vary by type of service. State Medicaid agencies generally require assessments and treatment plans to be signed/authorized by a physician, master’s-level provider, or nurse care manager.

Some state Medicaid programs offer and reimburse for trainee positions. Several states noted the importance of trainee programs in expanding their non-licensed staff capacity. Louisiana reimburses services provided by counselors-in-training, who are permitted to provide screening/evaluation/assessment services, counseling, and crisis intervention services under the supervision of a licensed mental health provider. Similarly, Washington State reimburses a chemical dependency professional trainee, who can provide screening/evaluation/assessment services, counseling, and case management/care coordination under the supervision of a certified individual who has completed some college.

Looking Forward

The number of state Medicaid agencies utilizing non-licensed, non-master’s-level SUD treatment staff is expected to increase in the coming years. Since 2015, the number of states using Section 1115 Medicaid Demonstration Waivers to augment or entirely transform their SUD treatment systems has grown significantly,[5] and many of these states now pay for services delivered by non-licensed staff.[4] The use of these and other relevant Medicaid authorities (e.g., the Medicaid rehabilitative services option or health home state plan option) to increase access to peers and other non-licensed SUD treatment professionals presents both opportunities and challenges for states.

How to support best practices while recognizing state variability. Given the wide range of definitions and standards currently used by states, resources are needed for policymakers to better understand best practices, including where and how these non-licensed staff add the most value. While most non-licensed counselors need to pass a nationally recognized exam for certification, the roles permitted within diverse state Medicaid programs can be quite different. Similarly, training and examination requirements for peers and other qualified staff vary significantly from state to state. Sharing state resources on how non-licensed staff can support best clinical practices for SUD treatment and recovery may be helpful for future policy development.
Ensuring cross-system collaboration to address co-occurring needs in integrated care Given the significant correlation between SUD diagnoses and co-occurring mental health and physical health conditions, appropriate training and use of non-licensed staff offers another opportunity for states to promote integrated care for high-cost, high-needs individuals. Moreover, as states increasingly look to health clinics and primary care providers to provide SUD and opioid use disorder (OUD) treatment, defining how these non-licensed staff can and should operate within those settings raises additional issues (and potential opportunities) for state policymakers to promote access to treatment and better integrate care.
Supporting managed care: In states with managed care systems, important questions remain as to how plan-employed staff (particularly peer supports and care coordination/case management staff) can best work with their provider-level counterparts to efficiently and effectively meet the needs of individuals needing or receiving SUD treatment.
How to integrate non-licensed staff in larger inpatient and residential facilities: Historically, the “Institutions for Mental Disease exclusion” has prevented states from paying for Medicaid services provided to adults ages 21 to 64 in behavioral health facilities with more than 16 beds. Recent federal guidance and programmatic changes have enabled state Medicaid agencies to pay for services for adults in these settings using Section 1115 waiver authority.[6] While models exist, how to incorporate non-licensed staff into these settings will likely be of significant interest for state policymakers going forward.

Conclusion

State Medicaid agencies are increasingly using non-licensed workforce – including counselors, peers, and other qualified staff – to meet the growing need for SUD treatment and recovery services by their Medicaid-enrolled populations. NASHP’s review of how states oversee and pay for these services highlights opportunities. Understanding key trends in oversight and payment for this staff will provide a baseline for states as they seek to leverage and expand this workforce. Additionally, the significant variability in how states use these staff, what services they provide, and the kinds of training, education, and supervision they receive speak to a larger need for additional resources for state policymakers to effectively utilize this valuable part of the SUD workforce.

Other Resources

State Medicaid agencies are increasingly leveraging non-licensed workforce, including peers, to meet the growing need for SUD treatment and recovery services by their Medicaid-enrolled populations. For an overview of cross-cutting themes and additional analyses of how states are paying for other non-licensed workforce, please refer to the following companion documents in this series:

Key Findings from a 50-State Scan of State Medicaid Requirements for Non-Licensed SUD Workforce: Peers
Key Findings from a 50-State Scan of Medicaid Requirements for Non-Licensed SUD Workforce: Counselors
Key Findings from a 50-State Scan of Medicaid Requirements for Non-Licensed SUD Workforce:
Other Qualified Providers
Medicaid Reimbursement Categories Key for Non-Licensed SUD Workforce

State Medicaid Requirements for Peers

The National Academy for State Health Policy (NASHP) analyzed reports and regulations from all 50 states to identify how their Medicaid programs reimbursed for non-licensed, non-master’s-level substance use disorder (SUD) staff – including counselors, peers, and other qualified staff – who typically deliver services within licensed behavioral health agencies or facilities.

Peers are individuals with lived experience who provide Medicaid-billable SUD peer support services. NASHP identified 39 states that reimburse for 45 different types of non-licensed peers through their state Medicaid programs. No state requires more than a high school diploma (or equivalent) to become a peer, but training and supervision requirements for peers vary across states.

Key Findings

The majority of states require peers to have a high school diploma or equivalent. Thirty-two states require peers to have a high school diploma or equivalent, while six states do not specify a minimum educational requirement.

Lived experience is a universal prerequisite to working as a peer. Other peer eligibility requirements (e.g., minimum age and minimum time in recovery) vary. Some states also certify parents or other family members to provide peer services to other parents or families. Kentucky, for example, has distinct certification processes for parent, family, and youth peer support specialists serving SUD populations.

Most states require peers to participate in training or education, document their continuing education, and pass a certification exam.

State Medicaid Certification Requirements for Peers

Delaware, for example, requires peers to complete a nine-day training program in addition to passing a national exam, while Ohio requires peers to complete 56 hours of training – 16 hours online, 40 hours in-person – in addition to passing a state exam.

Twenty-seven states require peers to participate in training or education in addition to passing an exam. The exam may be a state-specific test, either the National Association of Alcoholism and Drug Abuse Counselors (NAADC) exam or the International Certification & Reciprocity Consortium (IC&RC) exam. Within these states, there are variations in the number and type of training/education and work-related experience required, and in the need for supervised practicum and continuing education;
Five states require peers to participate in training or education, and to complete continuing education requirements;
Four states require peers to participate in training or education; and
One state requires passing an exam as its single requirement for peers.

The majority of states require peers to be supervised by certified or licensed SUD providers who hold at least a master’s degree. NASHP examined how states take different approaches to imposing minimum educational requirements on those who supervise non-licensed peers:

Fifteen states require supervisors to have a master’s degree and/or certification or license;
Seven states do not have specified requirements for supervisors;
Six states require supervisors to have a bachelor’s degree and be certified or licensed;
Six states require supervisors to have completed high school and be certified;
Four states require supervisors to have completed other requirements; and
Three states require supervisors to have an associate’s degree and be certified or licensed.

Many states identify multiple eligible providers who can supervise staff, rather than requiring one specific provider type. For example, Nebraska permits its peers to be supervised by psychiatrists, licensed psychologists, provisionally licensed psychologists, advanced practice registered nurses, or nurse practitioners, in addition to numerous licensed mental health providers.

While 36 states reimburse for peer services, states often pay for additional services delivered by peers.

Nine states reimburse for community/rehabilitative supports;
Seven states reimburse for crisis intervention;
Four states reimburse for screening, evaluation, and assessment;
Three states reimburse for case management/care coordination; and
Two states reimburse for counseling services.

State Medicaid programs reimburse for a variety of peer services. Peer services may include activities such as recovery support specialist services, individual peer support services, and group peer support services. For more information about the types of services included in each of these service categories, please refer to the Medicaid Reimbursement Categories Key.

Reference Data – Peers: Education, Examination, and Minimum Supervision Requirements

This chart describes the education, training, supervision, and other state requirements for non-licensed peers to deliver and be paid for Medicaid-reimbursable substance use disorder services. Reimbursements are made to licensed specialty behavioral health organizations and facilities – not to the individual provider. This data was collected from state Medicaid regulations, provider manuals, and policy guidance, state professional board websites, and other resources.

State Medicaid Requirements for Counselors

The National Academy for State Health Policy (NASHP) analyzed reports and regulations from all 50 states to identify how their state Medicaid programs reimbursed for non-licensed, non-master’s-level substance use disorder (SUD) staff – including counselors, peers, and other qualified staff – who typically deliver services within licensed behavioral health agencies or facilities.

Counselors provide Medicaid-billable SUD counseling or therapy services without a master’s degree or a state license. Based on these definitions, NASHP identified 31 states that reimburse for services delivered by 52 different types of counselors through their state Medicaid programs. Requirements related to the education, training, and supervision for these counselors vary significantly across states.

Key Findings

State Medicaid educational requirements for counselors range from no specified minimum education to a bachelor’s degree.

Seventeen states require counselors to have a bachelor’s degree;
Sixteen require counselors to have a high school diploma or equivalent;
Five states require counselors to have an associate’s degree;
Two states require counselors to have some college; and
Two states do not specify minimum educational requirements for counselors.

Some states, such as Georgia and Oregon, rank these counselors by education level (e.g., those with a high school diploma are a Counselor I and those with a college degree are a Counselor II). States vary as to whether counselors with an associate’s degree had a different designation, and whether those counselors were grouped with high school- or bachelor’s-level staff.

The majority of states require counselors to complete some training or education, acquire and document work experience and supervised practice hours, and take an exam. However, there is still significant diversity in state approaches to overseeing this SUD workforce.

State Medicaid Certification Requirements for Counselors

For example, Florida requires its counselors to be certified and pass its state-based exam, while Vermont requires counselors to complete at least 40 hours of substance use disorder education. New York, alternatively, requires counselors to complete both a national exam and additional training to provide administrative and clinical supervision. State Medicaid programs may also permit reimbursement for more than one level or type of counselor, each with its own requirements.

Twenty-nine states require counselors to pass an exam in addition to completing some combination of training/education, work or volunteer experience, supervised practice, and participation in continuing education;
Eighteen states require counselors to pass an exam, complete some training or education, and have some level of experience, but may not require additional elements such as a supervised practicum or continuing education;
Six states do not require counselors to take an exam, but do require some combination of training/education, experience, and supervision; and
Three states require passing an exam as its single requirement for counselors, which may be a state-specific test, the National Association of Alcoholism and Drug Abuse Counselors exam, or the International Certification & Reciprocity Consortium exam.

The majority of state Medicaid programs require non-licensed counselors to be supervised by certified or licensed SUD providers holding at least a master’s degree. NASHP examined states’ approaches with respect to the minimum educational requirements for those who supervise non-licensed counselors.

Fourteen states require supervisors to have a master’s degree and/or certification or license;
Eight states do not have specified requirements for supervisors;
Six states require supervisors to have a bachelor’s degree and be certified or licensed;
Five states require supervisors to have a high school diploma and be certified;
Three states require supervisors to have an associate’s degree and be certified or licensed; and
One state requires supervisors to have completed some college and be certified.

States reimburse for a wide variety of services delivered by counselors within licensed behavioral health settings. NASHP found that states use this non-licensed workforce to deliver a number of services across their state Medicaid SUD service array.

Twenty-eight states reimburse for counseling services;
Twenty-three states reimburse for screening, assessment, and evaluation;
Eighteen states reimburse for community/rehabilitative support services;
Fourteen states reimburse for case management/care coordination;
Thirteen states reimburse for crisis intervention; and
Six states reimburse for brief intervention.

Within the counseling services category, most states reimburse for individual and group behavioral health therapy and counseling services. Other reimbursed services within this category include individual, family, and counseling/psychotherapy; psychoanalysis; psychotherapy for crisis; and counseling. For more information about the types of services included in each of these categories, explore the Medicaid Reimbursement Categories Key.

Reference Data – Counselor: Education, Examination, and Minimum Supervision Requirements

This chart describes the education, training, supervision, and other state requirements for non-licensed counselors to deliver and be paid for Medicaid-reimbursable substance use disorder services. Reimbursements are made to licensed specialty behavioral health organizations and facilities – not to the individual provider. The data comes from state Medicaid regulations, provider manuals, and policy guidance, state professional board websites, and other resources.

State Medicaid Requirements for Other Qualified Providers

Other qualified staff are non-licensed professionals who provide Medicaid-billable SUD services who do not meet the definition of a peer or counselor. NASHP identified 24 states that reimburse for 43 different types of other qualified staff through their state Medicaid programs. Requirements related to the education, training, and supervision of the other qualified staff workforce sector vary significantly across states.

Key Findings

Of the state Medicaid programs that reimburse for this workforce, approximately one-third require other qualified staff to have a high school diploma or equivalent. The minimum educational requirements for other qualified staff vary across states.

Fifteen states require other qualified staff to have a high school diploma or equivalent;
Eight states require other qualified staff to have a bachelor’s degree;
Six states do not specify minimum educational requirements for other qualified staff; and
One state requires other qualified staff to have completed some college.

Of states that require a high school diploma as the minimum educational level for other qualified staff, most require some additional training and experience. Delaware, for example, requires its non-licensed credentialed behavioral health technicians to have a high school diploma and training in topics such as basic first aid, principles of recovery-oriented services, and American Society of Addiction Medicine (ASAM) criteria. States that require a bachelor’s or associate’s degree often require coursework in pertinent fields or relevant training and experience.

While the majority of states do not require this workforce to pass an exam, state approaches to certifying other qualified staff vary greatly across the country.

State Medicaid Certification Requirements for Other Qualified Staff

Seven states require other qualified staff to participate in training or education;
Six states require other qualified staff to have work-related experience;
Three states require passing an exam as the single requirement for other qualified staff. The exam may be a state-specific test, the National Association of Alcoholism and Drug Abuse Counselors (NAADC) exam, or the International Certification & Reciprocity Consortium exam;
Eight states require other qualified staff to meet some combination of training/education, experience, supervision, and continuing education requirements; and
Seven states require other qualified staff to complete a combination of passing an exam and training/education, experience, and supervision requirements.

In some cases, other qualified staff may substitute education for certification or other requirements. For example, Virginia allows some other qualified staff categories to substitute a bachelor’s degree for the certification requirement. Similarly, Minnesota permits its treatment coordinators to substitute a bachelor’s degree for state certification.

The majority of states require other qualified staff to be supervised by certified or licensed SUD providers holding at least a master’s degree. NASHP examined how states take different approaches to ongoing supervision.

Eleven states require supervisors to have a master’s degree and/or certification or licensure;
Seven states require supervisors to have a bachelor’s degree and be certified or licensed;
Seven states do not specify requirements for supervisors;
Two states require supervisors to have an associate’s degree and be certified or licensed;
One state requires supervisors to have completed high school and be certified; and
One state requires supervisors to be licensed physicians.

Many states identify multiple eligible providers – or categories of providers – who can supervise staff, rather than requiring one specific provider type. Nebraska takes a common approach, permitting its other qualified staff to be supervised by a licensed professional, including licensed physicians, licensed psychologists, licensed clinical social workers, licensed mental health counselors, licensed marriage and family therapists, licensed clinical addiction counselors, and other qualified behavioral health professionals.

States reimburse other qualified staff for a wide variety of services. Among the 25 states that reimburse for services delivered by other qualified staff, states pay for the following kinds of services –note that states may pay for multiple services.

Twenty states reimburse for community/rehabilitative support;
Fourteen states reimburse for case management and care coordination;
Ten states reimburse for crisis intervention;
Nine states reimburse for screening, assessment, and evaluation;
Four states reimburse for brief intervention;
Three states reimburse for counseling services; and
Two states reimburse for peer services.

Other qualified staff perform a range of care coordination and case management functions. Services reimbursed by state Medicaid agencies include service plan development, SUD case management, ongoing case management, targeted case management, and targeted plan development. For more information regarding these service categories, view the Medicaid Reimbursement Categories Key.

Reference Data – Other Qualified Staff: Education, Examination, and Minimum Supervision Requirements

This chart describes the education, training, supervision, and other state requirements for non-licensed staff to deliver and be paid for Medicaid-reimbursable substance use disorder services. Reimbursements are made to licensed specialty behavioral health organizations and facilities – not to the individual provider. The data comes from state Medicaid regulations, provider manuals, and policy guidance, state professional board websites, and similar resources.

Medicaid Reimbursement Categories Key

Peer Services

H0038 – Peer Support Services
H2015 – Recovery Support Specialist Service
H2016 – Comprehensive Community Support Services (Peer), per diem
S9445 – Group Peer Support Services
T1012 – Individual Peer Support Services

Screening/Evaluation/Assessment

90791 – Psychiatric Diagnostic Evaluation/Intake Interview
96127 – Brief Assessment
99408 – SBIRT/Screening (15-30 mins)
99409 – SBIRT/Screening (30+ mins)
H0001 – Alcohol and/or Drug Assessment
H0002 – Behavioral Health Screening to Determine Admission Eligibility; Extended Assessment (75+ mins); Screening and Referral
H0031 – Behavioral/Mental Health Assessment by Non-Physician
H0049 – Screening
H2000 – Comprehensive Assessment
T1011 – Evaluation/Determination of Placement
T1023 – Program Intake Assessment; Brief Assessment

Brief Intervention

99408 – SBIRT
H0004 – Brief Treatment
H0022 – Alcohol and/or Drug Intervention Services; Early Intervention
H0049 – Screening and Intervention (less than 15 mins)
H0050 – Brief Intervention

Counseling Services

90832 – Individual Counseling/Psychotherapy, 30 mins (16-37 mins)
90834 – Individual Counseling/Psychotherapy, 45 mins (38-52 mins)
90837 – Individual Counseling/Psychotherapy, 60 mins (53+ mins)
90839 – Psychotherapy for Crisis, first 60 mins
90840 – Psychotherapy for Crisis, additional 30 mins
90485 – Psychoanalysis
90846 – Family Counseling/Psychotherapy (without client)
90847 – Family Counseling/Psychotherapy (with client)
90849 – Multiple Family Counseling/Psychotherapy
90853 – Group (non-family) Counseling/Psychotherapy
90877 – Collateral Therapy/Family Consultation
96153 – Group Therapy
96154 – Family Therapy (with client)
96155 – Family Therapy (without client)
99354 – Prolonged Individual Counseling/Psychotherapy Service (additional 30-60 mins)
99355 – Additional Prolonged Individual Counseling/Psychotherapy Service (per 15-30 mins)
H0004 – Individual Behavioral Health Therapy and Counseling
H0005 – Group/Family Counseling
H2019 – Individual/Group Therapy
G0396 – Substance Use Disorder Counseling (25-45 mins)
G0397 – Substance Use Disorder Counseling (45+ mins)
T1006 – Family/Couple Counseling

Community/Rehabilitative Supports

H0025 – Behavioral Health Prevention Education
H0034 – Medication Monitoring/Training/Support
H0036 – Basic Living Skills Training
H0043 – Supported Housing
H2014 – Individual/Family Skills Training and Development; Behavioral Modification
H2015 – Comprehensive Community Support Services; Addictive Diseases Support Services
H2017 – Individual/Group Psychosocial Rehabilitative Services; Living Skills Training
H2019 – Individual/Family Therapeutic Behavioral Services
H2022 – Intensive In-Home Services
H2025 – Supported Employment
H2026 – Supported Employment (per diem)
H2027 – Psychoeducational Services; Didactic Counseling
S5110 – Family Support (Home Care Training)
S5111 – Family Support and Training
S9482 – Family Support
T1012 – (Non-Peer) Recovery Support; Family Education
T1019 – Personal Care Services
T1020 – Personal Care Services (per diem)

Case Management/Care Coordination

H0006 – Substance Use Disorder Case Management
H0032 – Service Plan Development
H2036 – Recovery Navigation Support
G9012 – Substance Use Care Coordination; Ongoing Case Management
T1007 – Treatment Plan Development
T1016 – Case Management; Treatment Coordination
T1017 – Case Management; Targeted Case Management
T2023 – Targeted Case Management

Crisis Intervention

90791 – Crisis Evaluation
90839 – 24 Hour Access to Crisis Response, first 60 mins
90840 – 24 Hour Access to Crisis Response, additional 30 mins
99510 – Mobile Crisis Response
H2011 – Crisis Intervention/Management/Follow-up; Mobile Crisis Management
H2018 – Crisis Residential Services
S9484 – Crisis Stabilization/Intervention; Crisis Service Center; Mobile Crisis Service
S9485 – Crisis Stabilization (per diem)

Bundles

H0010 – Subacute Detoxification (Residential Setting) (ASAM 3.2-WM); High Intensity Residential Treatment; Clinically Managed Residential Treatment (ASAM 3.3; 3.5)
H0011 – Acute Detoxification (Residential Setting) (ASAM 3.7-WM); Medically-Managed Residential Treatment (ASAM 4)
H0012 – Subacute Detoxification (Outpatient Setting) (ASAM 2-WM); Non-Medical Community Residential Treatment (ASAM 3.5)
H0013 – Outpatient Detoxification (Residential Setting) (ASAM 2-WM); Medically Monitored Community Residential Treatment (ASAM 3.7)
H0014 – Outpatient Detoxification (Ambulatory Setting) (ASAM 2-WM)
H0015 – Intensive Outpatient Program (ASAM 2)
H0018 – Short-Term Residential Services; Medically Monitored Intensive Residential Treatment (ASAM 3.7); Residential Treatment Program with 17+ beds
H0019 – Long-Term Residential Services; Clinically Managed High-Intensity Residential Treatment (ASAM 3.5)
H0035 – Partial Hospitalization (ASAM 2.5)
H0043 – Residential Alcohol and Drug Services (ASAM 3)
H2001 – Outpatient Rehabilitation (2-4 hours)
H2012 – Day Treatment (≤5 hours) (ASAM 2.1)
H2015 – Day Treatment (after 5 hours) (ASAM 2.5)
H0020 – Opioid Treatment Program
H2034 – Low-Intensity Residential Treatment/Halfway House (ASAM 3.1)
H2035 – Outpatient Alcohol and/or Drug Treatment Services
H2036 – High-Intensity Residential Treatment (ASAM 3.3/3.5/3.7); Outpatient Alcohol and/or Drug Treatment Service, per diem/>4 hours; Medically Supervised Detoxification Crisis Stabilization (ASAM 3.7-WM); Residential Treatment Program with <16 beds; Residential Treatment Program (ASAM 3.1/3.3/3.5/3.7)
S0201 – Partial Hospitalization Services in Acute Care or Psychiatric Hospital; Partial Hospitalization Services (ASAM 2.5)
S2080 – Health Home initial Recovery Action Plan
S2081 – Health Home Ongoing Care Management
S9480 – Intensive Outpatient Program

Download PDF version

Notes

[1] “Medicaid Works for People with Substance Use Disorders,” Center on Budget and Policy Priorities, January 19, 2018, https://www.cbpp.org/sites/default/files/atoms/files/1-19-18health-factsheet-suds.pdf.

[2] Ellen Bouchery, and Judith Dey, “ASPE Issue Brief: Substance Use Disorder Workforce,” HHS Office of the Assistant Secretary for Planning and Evaluation, June, 2018, https://aspe.hhs.gov/system/files/pdf/259346/ExamSUDib.pdf.

[3] Angela J. Bech, Cory Page, Jessica Buche, Danielle Rittman, and Maria Gaiser, “Scopes of Practice and Reimbursement Patterns of Addiction Counselors, Community Health Workers, and Peer Recovery Specialists in the Behavioral Health Workforce,” Behavioral Health Workforce Research Center, University of Michigan School of Public Health, http://www.behavioralhealthworkforce.org/wp-content/uploads/2019/06/Y3-FA3-P1-SOP-Full-Report-Updated-6.5.19.pdf.

[4] Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, Larisa Antonisse, and Cornelia Hall, “Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,” Kaiser Family Foundation, February 12, 2019, https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/.

[5] Angela J. Bech, Cory Page, Jessica Buche, Danielle Rittman, and Maria Gaiser, “Scopes of Practice and Reimbursement Patterns of Addiction Counselors, Community Health Workers, and Peer Recovery Specialists in the Behavioral Health Workforce,” Behavioral Health Workforce Research Center, University of Michigan School of Public Health, http://www.behavioralhealthworkforce.org/wp-content/uploads/2019/06/Y3-FA3-P1-SOP-Full-Report-Updated-6.5.19.pdf.

[6] Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, Larisa Antonisse, and Cornelia Hall, “Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,” Kaiser Family Foundation, February 12, 2019, https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank state officials who generously shared their time and insights in reviewing this material. The authors also thank Trish Riley and Jodi Manz of NASHP, as well as Lynnette Araki and her colleagues at the Health Resources and Services Administration for their guidance and helpful feedback.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

Behavioral Health Workforce Innovations: How Massachusetts and New York Engage Community Health Workers and Peers to Address Racial and Ethnic Disparities

November 21, 2019/in Policy Massachusetts, New York Featured News Home, Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Health Coverage and Access, Health Equity, Population Health, Social Determinants of Health, Workforce Capacity /by Jill Rosenthal

Racial and ethnic inequities in access and quality of health care affect outcomes and increase the cost of care, especially among racial and ethnic minorities with behavioral health conditions. New York and Massachusetts are using innovative regulatory levers, such as revising training and certification requirements and reforming their payment and delivery systems, to improve behavioral health care for their racial and ethnic minority populations.

Background

Racial and ethnic inequities in health status and quality of care affect individuals’ health outcomes and increase the cost of care. This is especially pronounced for racial and ethnic minorities with behavioral health conditions.[1] Racial and ethnic minorities are less likely to receive diagnoses and treatment for mental illnesses, have less access to mental health services, and often receive poorer quality of mental health care.[2]

There are a variety of ways states are addressing these issues, such as broadening access to and building capacity of, their behavioral health workforce. Cultural and linguistic competency is an important strategy for improving the quality of care provided to people of all backgrounds and there are training tools available to enhance this skill.[3]

In addition to building the capacity of trained and licensed health care providers, evidence suggests individuals benefit from relationships with people who have similar lived experiences and are members of their community, such as community health workers (CHWs) and peer supports. These professionals include, but are not limited to, promotores, peer support specialists, and natural helpers.[4]

CHWs may be uniquely positioned to build trust and address barriers traditionally underserved communities face to seeking care.[5] Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities.[6] CHWs can reduce the stigma associated with receiving mental health care and provide collaborative, patient-centered approaches to care, including understanding and incorporating patient preferences.

As states transform their health systems, they have opportunities to integrate innovative workforce approaches to meet the needs and understand the lived experiences of individuals with behavioral health needs, particularly among racial and ethnic minority populations. Many state programs are enlisting CHWs to address challenging aspects of their health improvement initiatives, such as facilitating care coordination, enhancing access to community-based services, and addressing social determinants of health.[7] Massachusetts and New York are incorporating CHWs and credentialed family peer advocates respectively into their redesigned payment and delivery systems in ways that can address these disparities. They are using a range of strategies and working across state agencies and with private to ensure that this new workforce is able to address patient needs.

The National Academy for State Health Policy (NASHP) interviewed officials from Massachusetts and New York to learn how they regulatory levers, such as training and certification requirements, along with payment and delivery reform, to improve behavioral health care for racial and ethnic minority populations. They also shared their models at the 2019 NASHP annual health policy conference.

How Massachusetts Builds Community Health Worker Capacity

The Massachusetts Delivery System Reform Incentive Payment (DSRIP) Program, under the authority of its 1115 Demonstration waiver,[8] provides $1.8 billion over five years (through June 30, 2022) to support MassHealth (Massachusetts Medicaid) providers as they transition to value-based payment. Entities that have signed contracts to be MassHealth accountable care organizations (ACOs) or Community Partners (behavioral health or long-term support and services) are eligible to participate in DSRIP. DSRIP supports the development of infrastructure and the implementation of care coordination activities for ACOs and Community Partners throughout the state, helps providers transition to new care delivery models, improves enrollees’ care and experience, and strengthens provider capacity.[9]

In addition to funding ACOs and Community Partners directly, there is a dedicated funding stream to support s, which allows the state to scale up statewide infrastructure and workforce capacity to better prepare the workforce for a newly emerging health care environment. Investing in training CHWs, recovery coaches, and peer specialists, along with their supervisors is among the workforce development and training priorities.[10] MassHealth chose this area of focus because ACOs and Community Partners recognized that CHWs and peer specialists have a unique ability to engage and help improve the health of MassHealth enrollees who are most likely to be disconnected from health care, and they expect to increase the size of this workforce. Although MassHealth does not reimburse CHWs, ACOs can spend DSRIP dollars in a variety of ways and many have chosen to hire CHWs as part of their efforts to improve health outcomes and decrease total cost of care.

Cultural competency is woven into the 10 recognized core competencies of CHWs.[11] The Massachusetts Board of Certification of CHWs administers a voluntary CHW certification program designed to help integrate CHWs into the health care and public health systems. The board develops standards for the education and training of CHWs and CHW trainers.

According to a 2016 survey, mental/behavioral health is the second-most frequently cited issue that CHWs report addressing, and the area that CHWs who work within clinical organizations expressed the most interest in receiving training.[12] The Massachusetts Department of Public Health currently funds curriculum development of specialized training for CHWs in behavioral health and substance addiction. In addition to expanding the capacity of existing training programs to accommodate new needs, MassHealth supported the design and implementation of a new training curriculum for CHW supervisors, as well as the design of a nine-month learning community to provide peer support, mentorship, and professional development for CHWs and peer specialists and to promote primary care/behavioral health integration. MassHealth plans to share data and knowledge gained from these programs with ACO and Community Partner leaders to better equip them to create workplaces that support CHWs and peer specialists.

Levers Massachusetts Uses to Support CHW Capacity to Address Health Disparities

State and public health agency partners:

MassHealth (Medicaid program)
Department of Health
Office of Community Health Workers, Bureau of Community Health and Prevention
Board of Certification of CHWs, Bureau of Health Professions Licensure
Boston Public Health Commission, Cambridge Public Health (CHW core competency training programs)

Legislation: Chapter 58, Acts of 2006 Section 110 [13] and Chapter 224, Acts of 2012.[14] Chapter 322, Acts of 2010 [15] to establish a board within the Department of Public Health to certify CHWs.

Regulation and guidance: Core Competencies for Community Health Workers

Federal authority: Massachusetts’ Delivery System Reform Incentive Payment (DSRIP) Program, under the authority of its 1115 demonstration waiver.

How New York Expands Family Peer Support for Child Health

New York is in the process of transitioning its Medicaid-funded behavioral health services into Medicaid managed care and is using this opportunity to build on its experience using family peer supports. New York has a long history of including family peers in its state programs, engaging families in accessing services, and in policy development. The state has provided peer support services as an integral component of children’s behavioral health system for many years. Family peers have:

Engaged families and addressed concerns about the mental health system;
Explained how services can help their children;
Alleviated stigma; and
Addressed cultural barriers to services.

New York’s Children and Family Treatment and Support Services (CFTSS) program was developed under a State Plan Amendment (SPA)[i] as part of the Children’s Medicaid Redesign. The program is available to children and youth up to and including age 20 who are Medicaid-eligible under the Medicaid EPSDT benefit. Family peer services, previously only accessible to a subset of children under a Home and Community Based Services (HCBS) waiver, will be more universally available to all children who meet medical necessity criteria. The expanded access to the new CFTSS, including family peer support services as a reimbursable service, became available in January 2019.[ii] Provider agencies that employ peer advocates bill Medicaid using a specified set of rate codes.

According to the state plan, CFTSS, including family peer supports, can be provided by those with a state-recognized Family Peer Advocates (FPA) credential[iii] for children with mental health needs and Certified Peer Recovery Specialist certification with a family parenthetic (CRPA-F) for children with substance use needs. Families Together in New York State (FTNYS) administers the two levels of the FPA credential, which includes parent empowerment training. FTNYS also provides training for certification on the Family Needs and Strengths[iv] assessment and awareness tool to help FPAs ensure their work is family-driven and youth-guided. The Community Technical Assistance Center (CTAC),[v] in partnership with the state and FTNYS, offers Family Peer Support Services training including how to provide the services within a Medicaid managed care environment.

Eligibility for the FPA credential includes, among other criteria, demonstrating “lived experience” as a parent or primary caregiver who has navigated multiple child-serving systems on behalf of their child(ren) with social, emotional, developmental, health and/or behavioral health care needs and adherence to cultural competency guidelines. Cultural awareness and competence are among the requirements to complete the credential. A component of the curriculum incorporates the impact of structural and cultural factors that may shape families’ tendencies to care for their health in certain ways.[vi] It is intended to facilitate understanding of how structural factors determine beliefs, attitudes, values, and behaviors.[vii]

Formal and informal services and supports are provided through a structured, strength-based relationship between an FPA and the parent or caregiver, based on goals and objectives that a licensed practitioner recommends in the child´s treatment plan.[viii] All SPA services can be delivered in the community where the child/youth lives, attends school, and/or engages in services.

Levers New York Uses to Help Family Peer Advocates Address Health Disparities

State agency partners:

Department of Health (Medicaid program)
Office of Mental Health
Office of Alcoholism and Substance Abuse Services
Office of Children and Family Services
Office for People with Developmental Disabilities

Legislation and guidance: Children and Family Treatment and Support Services

Federal authority: New York SPA and 1115 Waiver

Lessons and Considerations

Massachusetts and New York offer examples of ways that states can work to develop and deploy unique workforces to meet the behavioral health needs of racial and ethnic minority populations. Other states may consider the following early lessons:

Incorporate peer supports and CHWs during transitions to new payment and delivery approaches. Both Massachusetts and New York are redesigning their delivery systems to improve their quality of care and control Medicaid costs. As they do, they are expanding and adapting this workforce with the recognition that CHWs and peer supports may be uniquely positioned to address barriers to care and address mental health disparities. They are making these workforce investments through the federal authority of 1115 waivers and state plan amendments.

Partner across state agencies to maximize state resources and opportunities to engage CHWs and peer supports most effectively. Medicaid agencies can be critical to transforming payment and delivery systems. Departments of health, mental health, and other state agencies with responsibilities and expertise can support efforts through training, certification, and unique approaches to behavioral health and health equity. Massachusetts is drawing on its national leadership in CHW training and credentialing, and New York is building on its strong history of employing family peer supports.

Provide capacity-building support to employ and supervise the workforce. Massachusetts and New York offer training for supervisors and organizations that employ CHWs and peer supports. Massachusetts provides technical support to employers and sister agencies, such as the departments of Mental Health and Corrections and MassHealth, so they are prepared to meet CHW workforce needs. Knowing that managed care organizations want to ensure that the family peer support providers with whom they contract are effective in the delivery of services that they provide to families, New York provides toolkits to help organizations support and integrate peers and CHWs and online self-assessments to evaluate organizational readiness.

Embrace the cultural shift needed to employ CHWs and peer supports as equal partners within treatment teams. Massachusetts and New York recognize that providers must collaborate on care teams and with communities, and must value the lived experiences of CHWs and peer supports. Their criteria for CHWs and peer supports, including cultural competency, reflect these values. Massachusetts requires ACOs to partner with community partners in order to qualify for DSRIP funding. New York includes family peer support among an array of professionals serving children.

Recognize the unique needs of racial and ethnic minority populations with behavioral health needs. Engaging CHWs and peer supports can build trust, reduce stigma, and address barriers to care. Massachusetts and New York are expanding the reach of this workforce in innovative ways that can address care inequities. They are using a range of patient-centered approaches to facilitate care coordination, enhance access to community-based services, and address social determinants of health to meet patient .

As states transform their health systems, they have opportunities to integrate innovative workforce approaches that acknowledge the lived experiences of individuals with behavioral health needs in order to better meet their needs. CHWs and family peer advocates hold promise for improving health outcomes and reducing costs, particularly for racial and ethnic minority populations. States can use their purchasing and regulatory levers to advance innovative strategies and improve behavioral health.

Notes

[1] Artiga, Samantha, Julia Foutz, Elizabeth Cornachione, and Rachel Garfield. “Key Facts on Health and Health Care by Race and Ethnicity” (Kaiser Family Foundation, June 7, 2016), https://www.kff.org/report-section/key-facts-on-health-and-health-care-by-race-and-ethnicity-section-2-health-access-and-utilization/.

[2] “Minority Mental Health Awareness Month – July” (United States Department of Health and Human Services, Office of Minority Health, July 1, 2019), https://www.minorityhealth.hhs.gov/omh/content.aspx?ID=9447.

[3] The HHS OMH has developed a free and accredited e-learning program: Improving Cultural Competency for Behavioral Health Professionals .

[4] Taylor, Beck, Jonathan Mathers, and Jayne Perry. “Who Are Community Health Workers and What Do They Do? Development of an Empirically Derived Reported Taxonomy,” Journal of Public Health 40, no. 1 (March 2018): 199–209, https://doi.org/10.1093/pubmed/fdx033.

[5] Katigbak, Carina, Nancy Van Devanter, Nadia Islam, and Chau Trinh-Shevrin. “Partners in Health: A Conceptual Framework for the Role of Community Health Workers in Facilitating Patients’ Adoption of Healthy Behaviors,” American Journal of Public Health 105, no. 5 (May 2015): 872–80, https://doi.org/10.2105/AJPH.2014.302411.

[6] Barnett, Miya L., Araceli Gonzalez, Jeanne Miranda, Denise A. Chavira, and Anna S. Lau. “Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review,” Administration and Policy in Mental Health 45, no. 2 (March 2018): 195–211, https://doi.org/10.1007/s10488-017-0815-0.

[7] “State Community Health Worker Models,” National Academy for State Health Policy, accessed October 24, 2019, https://www.oldsite.nashp.org/state-community-health-worker-models/.

[8] Centers for Medicare and Medicaid Services, “MassHealth Medicaid Section 1115 Demonstration,” June 26, 2019, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf.

[9] “State Delivery System and Payment Reform Map,” National Academy for State Health Policy, accessed October 24, 2019, https://www.oldsite.nashp.org/state-delivery-system-payment-reform-map/#toggle-id-3.

[10] Although the Massachusetts focus in this case study is on CHWs, the state is also investing in Certified Peer Specialists and Recovery Coaches. For a comparison of roles, see Commonwealth of Massachusetts Peer Support Worker Comparison Chart: Adult Services Department of Public Health Bureau of Substance Addiction Services (DPH/BSAS), February 27, 2019, https://www.mass.gov/files/documents/2019/03/20/Peer%20Support%20Worker%20Comparison%20Chart%203.14.pdf.

[11] “Board of Certification of Community Health Workers,” Commonwealth of Massachusetts, accessed October 31, 2019, https://www.mass.gov/orgs/board-of-certification-of-community-health-workers.

[12] Pokhrel, D, Community Health Workers, Health Inequity, and the Massachusetts Landscape: Results from Massachusetts Statewide Community Health Worker Workforce Surveillance Survey. Fifth Annual Massachusetts Department of Public Health Epidemiology Conference, Boston MA, November, 2018.

[13] Chapter 58, Acts of 2006 Section 110, (MA 2006), https://malegislature.gov/Laws/SessionLaws/Acts/2006/Chapter58.

[14] Chapter 224, Acts of 2012, (MA 2012), https://malegislature.gov/Laws/SessionLaws/Acts/2012/Chapter224.

[15] Chapter 322, Acts of 2010, (MA 2010), https://malegislature.gov/Laws/SessionLaws/Acts/2010/Chapter322.

[16] “State Plan Amendment #19-0003,” Centers for Medicare and Medicaid Services, February 7, 2019, https://www.health.ny.gov/regulations/state_plans/status/non-inst/approved/docs/app_2019-02-07_spa_19-03.pdf

[17] New York State Department of Health, “New York State Medicaid Update” 35, no. 6 (May 2019), https://www.health.ny.gov/health_care/medicaid/program/update/2019/2019-05.htm#behavioral.

[18] “Family Peer Advocate Credential (FPA),” Families Together in New York State, 2018, https://www.ftnys.org/training-credentialing/family-peer-advocate-credential/.

[19] “Family Needs & Strengths (FANS),” Families Together in New York State, 2018, https://www.ftnys.org/training-credentialing/family-needs-strengths-fans/.

[20] “Community Technical Assistance Center of New York,” accessed October 28, 2019, https://www.ctacny.org.

[21] “Center for Research on Cultural & Structural Equity,” accessed October 28, 2019, http://ccase.org.

[22] Lekas, Helen-Maria, Crystal Fuller Lewis, and Joanne Trinkle. “Integrating the Social and Cultural Determinants of Health into Peer Advocates Training.” Behavioral Health News, Summer 2019.

[23] “SPA Services Chart,” New York State Department of Health, November 30, 2015, https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/spa_distinct_chart.htm.

Acknowledgements: The author wishes to thank the state officials and stakeholders in Massachusetts (Masachusetts Department of Public Health, Commonwealth of Massachusetts Executive Office of Health and Human Services) and New York (New York State Office of Mental Health, New York State Department of Health, Families Together in New York State) who graciously shared their experiences or reviewed a draft of this publication. Trish Riley, Malka Berro, and Ariella Levisohn of NASHP helped inform its development. Finally, the author wishes to thank Dr. Margarita Alegria and her colleagues at the Disparities Research Unit/Department of Medicine/Massachusetts General Hospital for their guidance and support.

Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health under Award Number

R01MD009719. The content is solely the responsibility of the author and does not represent the official views of the National Institutes of Health.

State Medicaid Strategies to Promote Early Identification and Treatment of Pregnant Women with Substance Use Disorder

November 18, 2019/in Policy Featured News Home, Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health Equity, Health IT/Data, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health /by Carrie Hanlon, Taylor Platt, Eddy Fernandez and Lyndsay Sanborn

States face rapidly rising rates of substance use disorder (SUD) and overdoses among pregnant women and increases in maternal deaths and poor birth outcomes, such as neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS).[1] To understand how states promote early identification of SUD and treatment access for pregnant women, the National Academy for State Health Policy (NASHP) researched Medicaid quality measures and targeted initiatives for pregnant women with or at risk of SUD in every state and Washington, DC. This issue brief highlights state strategies, such as developing a state Medicaid Opioid Strategy with a focus on pregnant and parenting women, and leveraging financial incentives, quality measures, waivers, and public-private partnership to improve maternal and birth outcomes and curb state costs associated with SUD.

Introduction

Key Terms

Substance use disorder (SUD) occurs when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.
Opioid use disorder (OUD) is a problematic pattern of opioid use leading to clinically significant impairment or distress.
Medication-assisted treatment (MAT)is an evidence-based treatment treatment approach for individuals with SUD that combines medications with counseling and behavioral therapy.
Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or misused during pregnancy.
Neonatal opioid withdrawal syndrome (NOWS) occurs when in-utero opioid exposure leads to a well-described complex of withdrawal signs and symptoms.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice to identify, reduce, and prevent problematic substance use and dependence.

Substance use during pregnancy is a contributing factor in maternal deaths, poor birth outcomes among infants, and NAS/NOWS, which have significant impact on women, children, families, and society.^[2] Additionally, it is costly for states to treat infants with NAS.[3] Medicaid is the largest payer of pregnancy-related and behavioral health care, including SUD treatment. Medicaid spends an estimated $8.7 billion annually on opioid use disorder (OUD)-related health care costs.^[4] The Substance Abuse and Mental Health Services Administration (SAMHSA) projects that the total share of Medicaid spending on SUD services will increase from 21 percent in 2009 to 28 percent in 2020.[5] As a key payer, Medicaid plays a significant role in covering and delivering services to identify and treat SUD in pregnant women.

Pregnant women and new mothers with SUD have unique needs. As a result of stigma, pregnant women with SUD are more likely to delay prenatal care and experience limited access to critical care during pregnancy.[6] During the postpartum period, women with SUD can experience stigma while caring for an infant with NAS and may lack child care required for them to attend treatment.[7] In addition, pregnant and parenting women may be hesitant to seek SUD treatment or prenatal care for fear of criminal justice or child welfare involvement.[8] Health centers can play a key role in providing high-quality care to pregnant women covered by Medicaid. Seventy-four percent of women attending health centers have early entry into prenatal care and many centers can provide SUD treatment along with prenatal care.[9] Several medical and professional associations recommend universal screening of pregnant and postpartum women for mental health and substance use disorders through a brief counseling intervention and appropriate referral as the standard of care.[10] Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice that providers, including obstetricians and gynecologists, can use to identify, reduce, and prevent problematic substance use and dependence.[11] Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy, including preeclampsia, gestational diabetes, cystic fibrosis, and anemia.[12]

NASHP researched how Medicaid agencies meet the unique needs of pregnant women with SUD by assuring quality measurement addresses that needs are met or other related targeted initiatives. States engage Medicaid providers and managed care organizations to address this issue through a variety of strategies, including a statewide Medicaid opioid strategy, quality measures, financial incentives, waivers and public-private partnerships. Through these efforts, states promote early identification and screening, support provider education, facilitate referral and follow-up, increase access to medication-assisted treatment (MAT), and monitor birth outcomes.

Medicaid SUD Coverage and Benefits for Pregnant Women

State interagency strategies to promote early identification and access to treatment among Medicaid-eligible women with SUD:

Expand postpartum coverage for SUD treatment and facilitate transitions between care settings.
Implement innovative care delivery models that integrate reproductive health care and SUD treatment, offer family-centered treatment, or provide community-based supports to address women’s unique needs.
Consider workforce policies such as provider licensing changes or use of peer support specialists or telehealth to increase access to SUD care in rural areas.
Align financing and policy across systems, such as health care and child welfare.
Educate providers and patients to reduce the stigma associated with pregnant and parenting women accessing SUD treatment.
Involve women who are in recovery in policy design and implementation.

Source State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder, NASHP, October 2018.

There is no formal federal definition for the services to pregnant women that states must cover, beyond inpatient and outpatient hospital care. Each state determines the specific scope of maternity benefits for beneficiaries, including those related to SUD identification and treatment. However, state benefits must meet essential coverage guidelines. Behavioral health and SUD minimum essential coverage includes: behavioral health treatment such as psychotherapy and counseling; mental and behavioral health inpatient services; and SUD treatment.^[13]^,[14] Covered SUD services vary from state to state, but typically include detoxification, individual and group therapy, and MAT.

Federal law –The Support for Families and Patients (SUPPORT) Act – underscores the importance of MAT as a treatment approach. The SUPPORT Act requires all states to cover MAT, including all Food and Drug Administration-approved treatment, counseling, and behavioral therapy by 2020.[15] All states currently cover MAT medications, but vary in terms of which medications are covered (buprenorphine, naltrexone, methadone).[16] Currently, more state Medicaid programs cover buprenorphine and naltrexone than methadone. Both buprenorphine and methadone are safe and effective treatments for OUD during pregnancy.^[17]

The SUPPORT Act also provides states with different opportunities to increase access to services for pregnant women with SUD. For example, its Medicaid SUD waiver demonstration seeks to increase Medicaid provider capacity. Fourteen states and Washington, DC received an 18-month planning grant to support ongoing assessment of SUD treatment needs and to bolster the network and treatment capacity of Medicaid providers who offer SUD treatment or recovery services.[18] States also have the opportunity under the SUPPORT Act to waive the exclusion of coverage for services provided in institutions for mental diseases (IMD). This waiver allows states to receive federal financial participation for the continuation of substance use services in residential treatment facilities.[19] Currently, 25 states have waived the IMD exclusion and four states have waiver applications pending.[20]

Examples of State Medicaid Coverage and Quality Improvement Strategies

There are a number of ways states can promote early identification and access to SUD treatment among pregnant and parenting women (see textbox). NASHP’s research identified the following four key strategies that state Medicaid agencies are implementing addressing coverage or quality improvement.

Develop a statewide Medicaid opioid strategy with a focus on pregnant and parenting women.

Medicaid agencies can leverage contracts with managed care organizations (MCOs) to prioritize outreach and enrollment for pregnant women to ensure early identification of SUD, access to services such as MAT, and coordination of services. Tennessee Medicaid (TennCare) has developed an opioid strategy[21] that includes women of childbearing age as a priority population. Tennessee incorporated multiple data sources, including medical claims, pharmacy claims, dental claims, and data from the state’s Prescription Drug Monitoring Database. Then, the state requires the MCOs to use data to engage with and directly outreach to women of childbearing age who may be at risk for developing use disorder and/or having an NAS/NOWS birth. The member engagement and outreach focuses on patient education and linkage of members to primary care, SUD treatment, and behavioral health services. As a result, all MCOs have increased their screening and care coordination efforts and focused on expanding access to high-quality MAT services. A major emphasis has been placed on training and increasing the number of high-quality MAT providers across the state. Additionally, TennCare’s opioid strategy includes partnering with the MCOs and pharmacy benefit managers to implement opioid prescribing guidelines and benefit limits to reduce opioid overexposure for first-time and non-chronic users.

Implement Medicaid incentives or measures to promote SBIRT and increase pregnant women’s access to SUD treatment.

Medicaid agencies can promote women’s access to SBIRT and follow-up treatment through quality measures, provider or MCO incentives, and performance improvement projects (PIPs). (To learn more about state Medicaid agency quality improvement approaches, explore NASHP’s State Medicaid Quality Measurement for Women’s Heath 50-state map). For example, Connecticut’s Department of Social Services (DSS) introduced its Obstetrics Pay-for-Performance (OBP4P) Program in 2013 in order to improve care for pregnant women and the outcomes of their newborns covered by Medicaid.[22] Providers participating in the OBP4P program receive an additional payment on top of the current fee-for-service payments. In 2019, DSS introduced the newest cycle of its OBP4P program which, in addition to improving care for pregnant women and outcomes of newborns, seeks to decrease the incidence of avoidable maternal mortality and morbidity by identifying risk factors, such as substance use.[23] These payments incentivize providers to provide a postpartum visit between 22 and 84 days after delivery in which substance use, along with other health and risk factors, may be addressed.[24]

Florida Medicaid recently kicked off Birth Outcomes Initiatives to reduce primary cesarean-section, pre-term birth, and NAS rates. The state’s Medicaid health plans have committed to achieving regional targets for reducing the rate of NAS each year over a five-year period. The baseline NAS rates statewide were 19.6 per 1,000 live births in 2016 and 17.7 per 1,000 live births in calendar year 2017. The common interventions the health care plans are implementing to reach their targets include substance misuse treatment programs, healthy behavior programs, provider engagement, and value-based payment/incentive programs. Specific interventions for substance use programs include early identification of pregnant women using opioids and increased access and referrals to MAT. The Healthy Behavior Programs include incentives to reward members for meeting medication and substance use treatment milestones. Different ways to engage providers include education on early identification and referrals as well as training in SBIRT.[25]

Leverage waivers to expand coverage and access to SUD treatment.

States use Medicaid waivers to promote innovation, including expanding coverage and access to SUD treatment. Within federal Medicaid waiver guidance, states can specifically focus on care for pregnant women with SUD. Vermont’s 1115 waiver facilitates a multi-faceted approach to addressing the opioid epidemic that includes:

Preventing SUD/opioid use disorder (OUD);
Creating a continuum of care for SUD/OUD treatment and recovery;
Aligning with the American Society of Addiction Medicine Level of Care guidelines;
Using evidence-based patient placement criteria; and
Monitoring provider capacity.

As part of its continuum of care for SUD/OUD treatment and recovery, Vermont offers several residential programs for people covered by Medicaid, Medicare, or commercial insurance and for self-payers. A specialized 26-bed residential program exists specifically for pregnant women and mothers with children under the age of five. These programs provide access to a variety of professionals and services, including services for individuals with co-occurring needs and clinically necessary MAT services.[26] The Department of Vermont Health Access and the Department of Children and Families are responsible for quality oversight of this specialized residential program.[27]

Participate in public-private partnerships to promote access to coordinated, team-based care for women

State Medicaid agencies also can participate in innovative public-private partnerships that help finance care for pregnant women with SUD. The partnerships can support pilots to demonstrate impact or help scale up initiatives with demonstrated success. Hospital-based quality improvement projects support innovation in coordinated inpatient care. In Florida, Medicaid is on the steering committee of the state’s Perinatal Quality Collaborative (FPQC) and administers two of the FPQC’s performance improvement projects. The Neonatal Abstinence Syndrome (NAS) Performance Improvement Project is working to standardize NAS management with Florida NICUs and decrease the length of stay related to NAS. The Maternal Opioid Recovery Effort (MORE) Performance Improvement Project focuses on improving treatment and care within hospital delivery systems for pregnant women affected with OUD. These quality improvement projects run in parallel with each other with the overall goal of improving birth outcomes, identification, clinical care and coordinated treatment for pregnant women and their infants.^[28]

Montana Medicaid and the Montana Health Care Foundation partnered to form the Perinatal Behavioral Health Initiative (PBHI). PBHI aims to improve timely access to care and outcomes for pregnant and postpartum women experiencing behavioral health challenges. The initiative will provide funding and technical assistance to allow medical practices to implement a coordinated and team-based approach for women with SUD or mental illness. The teams will include obstetric providers, behavioral health specialists, and care coordinators.[29]

Conclusion

States are innovating new ways to provide access to SUD treatment for pregnant women enrolled in Medicaid. Promoting early identification of SUD, increasing access to MAT, and focusing on improving birth outcomes are strategies states use to improve treatment and outcomes for pregnant women with SUD. State Medicaid agencies leverage waivers, public-private partnerships, MCO guidance and engagement, and performance-based measures and incentives to promote early identification and access to treatment for Medicaid-eligible pregnant women to decrease costs and improve the lives of women and their families.

Notes

[1] Jilani SM, Frey MT, Pepin D, et al. Evaluation of State-Mandated Reporting of Neonatal Abstinence Syndrome — Six States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;68:6–10. DOI: http://dx.doi.org/10.15585/mmwr.mm6801a2

[2] Winkelman, Tyler NA, Nicole Villapiano, Katy B Kozhimannil, Matthew M Davis, and Stephen W Patrick. “Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014.” Pediatrics 141, no. 4 (April 2018). https://pediatrics.aappublications.org/content/141/4/e20173520.

[3] Corr, Tammy E., and Christopher S. Hollenbeak. “The Economic Burden of Neonatal Abstinence Syndrome in the United States.” Addiction 112, no. 9 (June 13, 2017): 1590–99. https://doi.org/10.1111/add.13842.

[4] Corwin Rhyan, “The Potential Societal Benefit of Eliminating Opioid Overdoses, Deaths, and Substance Use Disorders Exceeds $95 Billion Per Year,” Center for Value in Health Care, November 2017, https://altarum.org/sites/default/files/uploaded-publication-files/Research-Brief_Opioid-Epidemic-Economic-Burden.pdf

[5] Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020.pg 41. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. https://store.samhsa.gov/system/files/sma14-4883.pdf

[6] Davida Schiff et al., “Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts,” Obstetrics & Gynecology 132, no. 2 (August 2018): 466-474, https://doi.org/10.1097/AOG.0000000000002734

[7] Normile, Becky, Carrie Hanlon, and Hannah Eichner. “State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.” National Academy for State Health Policy, October 30, 2018. https://www.oldsite.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf.

[8] Normile, Becky, Carrie Hanlon, and Hannah Eichner. “State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.” National Academy for State Health Policy, October 30, 2018. https://www.oldsite.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf.

[9] “Quality of Care Measures.” Health Center Data. Health Services Resource Administration. Accessed November 1, 2019. https://bphc.hrsa.gov/uds/datacenter.aspx?q=t6b&year=2018&state=.

[10] Opioid Use and Opioid Use Disorder in Pregnancy.” ACOG Committee Opinion, no. 711 (August 2017). https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy.

[11] Opioid Use and Opioid Use Disorder in Pregnancy.” ACOG Committee Opinion, no. 711 (August 2017). https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy.

[12] Wright, T.E., Terplan, M., Ondersma, S.J., Boyce, C., Yonkers, K., et al. (2016). The role of screening, brief intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics & Gynecology, 215(5), 539-547.

[13] “Mental Health and Substance Abuse Health Coverage Options.” HealthCare.gov. Accessed October 16, 2019. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/.

[14] Gifford, Kathy, Jenna Walls, Usha Ranji, Alina Salganicoff, and Ivette Gomez. “Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey.” The Henry J. Kaiser Family Foundation, June 19, 2019. https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-pregnancy-and-perinatal-benefits-results-from-a-state-survey/.

[15] Walden, and Greg. “H.R.6 – 115th Congress (2017-2018): SUPPORT for Patients and Communities Act.” Congress.gov, October 24, 2018. https://www.congress.gov/bill/115th-congress/house-bill/6.

[16] Published: Jun 03, 2019. “Medicaid’s Role in Addressing the Opioid Epidemic.” The Henry J. Kaiser Family Foundation, July 15, 2019. https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/

[17] National Institute on Drug Abuse. “Treating Opioid Use Disorder During Pregnancy.” NIDA, July 2017. https://www.drugabuse.gov/publications/treating-opioid-use-disorder-during-pregnancy/treating-opioid-use-disorder-during-pregnancy.

[18] “Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act: Section 1003.” Medicaid.gov. Accessed October 16, 2019. https://www.medicaid.gov/medicaid/benefits/bhs/support-act-provider-capacity-demos/index.html.

[19] Cash, Judith. Strategies to Address the Opioid Epidemic, Strategies to Address the Opioid Epidemic § (2017). https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf

[20] “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State.” The Henry J. Kaiser Family Foundation, October 9, 2019. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/.

[21] “TennCare’s Opioid Strategy.” Tennessee State Government – TN.gov. Accessed October 17, 2019. https://www.tn.gov/tenncare/tenncare-s-opioid-strategy.html.

[22] Obstetric Pay for Performance Program, Obstetric Pay for Performance Program § (2014). https://www.huskyhealthct.org/providers/provider_postings/Obstetric_Pay_for_Performance_Program.pdf.

[23] Obstetric Pay for Performance Program, Obstetric Pay for Performance Program § (2019). https://www.huskyhealthct.org/providers/provider_postings/OBP4P_PayForPerformance.pdf

[24] Obstetric Pay for Performance Program, Obstetric Pay for Performance Program § (2019). https://www.huskyhealthct.org/providers/provider_postings/OBP4P_PayForPerformance.pdf

[25] Statewide Medicaid Managed Care Quality Initiatives Public Meeting, Statewide Medicaid Managed Care Quality Initiatives Public Meeting § (2019). https://ahca.myflorida.com/Medicaid/Policy_and_Quality/Quality/QI-initiatives/Stakeholder_Meeting_Presentation_FINAL012519_v1_Shared.pdf.

[26] Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017, Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017 § (2017). https://dvha.vermont.gov/global-commitment-to-health/vt-gc-1115-waiver-sud-amendment-draft-for-public-notice.pdf.

[27] Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017, Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017 § (2017). https://dvha.vermont.gov/global-commitment-to-health/vt-gc-1115-waiver-sud-amendment-draft-for-public-notice.pdf.

[28] “Florida Perinatal Quality Collaborative.” Florida Perinatal Quality Collaborative | USF Health. Accessed October 17, 2019. https://health.usf.edu/publichealth/chiles/fpqc.

[29] “The Meadowlark Initiative.” Montana Healthcare Foundation – Helping to change the lives of people across Montana through innovative healthcare services. Accessed October 17, 2019. https://mthcf.org/the-meadowlark-initiative/.

Acknowledgements: Thank you to the officials in Connecticut, Florida Tennessee, Montana, and Vermont for reviewing their respective highlighted strategies, and to our project officer Kelsi Feltz and her colleagues at the Health Resources and Services Administration for their feedback and guidance. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

Promising State Strategies to Improve Continuity of Substance Use Disorder Treatment following Incarceration

November 18, 2019/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health IT/Data, Health System Costs, Physical and Behavioral Health Integration, Population Health /by Kristina Long and Jodi Manz

Corrections-involved populations have higher rates of opioid and substance use disorders (SUD) than the general population, with more than 75 percent of recently released individuals reporting an SUD or a chronic medical and/or psychiatric condition. These individuals face numerous barriers to receiving treatment, including stigma, limited access to medication-assisted treatment (MAT), and disconnected systems of care.

While many states have begun to increase access to MAT in jails and prisons, coordinating continuous treatment following release remains a challenge. This disruption contributes to recidivism, drug use, and poor and costly health outcomes. Researchers in Washington State estimate that the risk of death from overdose was 12-times greater for a recently released individual than among the general public, resulting in high health care costs. Those costs, particularly to treat overdose episodes, are affecting state budgets in multiple ways. Researchers in Kentucky estimated that 12 months of overdoses cost the state $7 million in charity care in addition to $59 million in annual Medicaid expenditures.

To address the range of physical and behavioral health care needs during this critical transition period, states are working to streamline enrollment and re-enrollment in Medicaid, provide care management and supports, and better address social determinants of health for this vulnerable population.

States have implemented various initiatives across agencies to address the need for continuity in coverage post-release. Policymakers are focusing on different entry points and policy levers, all of which are aimed at easing transitions to ensure care across systems, including clinical-level interventions to coordinate care between corrections and community settings. While health care in the corrections system is subject to internal procedures and regulations, providing continued coverage upon release requires significant coordination at both policy and clinical levels.

Care Management and Supports for Continued Medicaid Coverage

Application and enrollment assistance: States are dedicating staff to conduct screenings and help complete and process Medicaid applications to address individuals’ literacy and access challenges. States may mandate Medicaid enrollment within legislation or may include such requirements in their state Medicaid plan.

A 2015 New Mexico law states that incarcerated individuals must be allowed to submit a Medicaid application. In 2018, the state expanded this when it passed an additional legislative directive to enhance data-sharing activities among state agencies in support of Medicaid eligibility and care coordination for corrections-involved populations. This legislation also mandates that correctional facilities must:

Facilitate Medicaid eligibility determinations during an individual’s incarceration or upon re-entry, and
Require that county jails be provided with technical assistance, training, and certification of county jail presumptive eligibility determiners upon written request.

Suspension – rather than termination – of Medicaid during incarceration: In 2016, the Centers for Medicare & Medicaid Services (CMS) clarified that states may suspend rather than terminate Medicaid on incarceration. Suspension – rather than termination – allows for quicker reinstatement of coverage after incarceration and may be a cost-saving option for both Medicaid expansion and non-expansion states. Examples of states moving in this direction include:

California passed legislation in 2014 to suspend rather than terminate Medicaid benefits upon incarceration. Benefits may be suspended for up to one year of incarceration.
Washington State passed SB 6430 in 2016, which allows for indefinite suspension of Medicaid benefits during incarceration.

Managed care contracting: States are exploring ways to establish routine and robust care transition processes by leveraging managed care organization (MCO) contracts to support care coordination.

Arizona contractually requires MCOs, Regional Behavioral Health Authorities, and community-based behavioral health entities to provide “reach in” care coordination services in correctional settings. Detailed “reach in” plans must be submitted to the Arizona Health Care Cost Containment System (AHCCCS).

Health homes: Health homes are integrated, team-based clinical approaches through which providers coordinate care for people with serious or multiple chronic conditions. States, through state plan options within Medicaid, may have multiple health home models, serving beneficiaries with different types of chronic conditions and/or beneficiaries in different geographic areas. States may draw down a 90 percent federal match for specified care coordination services for two years for each health home.

Through an 1115 waiver, New York policymakers want to implement a prerelease, in-reach transitional service in order to ensure corrections-involved populations receive needed care management and critical social supports on release into the community. A large part of this waiver includes criminal justice health home pilots to provide integrated, person-centered care for Medicaid enrollees with chronic conditions.

Data sharing and exchange to support care continuity: Research indicates that disruption in care for this vulnerable population can be especially detrimental to recovery. States are creating processes to share and use data to ease the transition from incarceration to community settings:

Ohio developed the Medicaid Pre-Release Enrollment Program, a pre-enrollment system for corrections-involved populations not already enrolled in Medicaid. The program requires data to be shared between the Medicaid agency and the Ohio Department of Rehabilitation and Correction to coordinate efforts and ensure direct enrollment into manage care plans upon release.
Arizona’s Data Exchange System is an automated data-exchange system that identifies when a Medicaid beneficiary is released from jail, developed through intergovernmental agreements between counties and the Arizona Department of Corrections and administered by the Arizona Medicaid agency, AHCCCS. The data within this system is also used by managed care plans to better provide support to recently released individuals.

Areas to Explore

Recovery support innovations: State officials are interested in implementing collaborative strategies that can support recovery and address re-entry-related social determinants of health as part of comprehensive case management.

The Pennsylvania Department of Corrections has established a program that allows qualifying incarcerated individuals to become certified peer support specialists to help others in the facility identify and meet recovery goals. Such initiatives provide incarcerated individuals with a potential career path and build in recovery supports on re-entry into their communities, dramatically decreasing the risk of recidivism.

As state policymakers explore strategies to provide treatment (medical/psychological interventions) and support (non-medical, recovery activities) to corrections-involved populations, they may consider:

Policies to ensure the continuation of coverage;
Cross-sector collaboration; and
Comprehensive, patient-centered approaches.

For more information about how states can promote treatment coverage and continuity for justice-involved populations, explore the National Academy for State Health Policy’s State Strategies to Enroll Justice-Involved Individuals in Health Coverage Toolkit.

Medicaid Incentives, Performance Measures, and Workforce Innovations Foster Access to Pediatric Oral Health Care

November 15, 2019/in Medicaid Managed Care Featured News Home, Reports Child Oral Health, CHIP, CHIP, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, Health IT/Data, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Oral Health, Population Health, Program Design, Safety Net Providers and Rural Health, Special Populations and Services, Workforce Capacity /by Carrie Hanlon and Malka Berro

While state policymakers across the country grapple with oral health care access challenges, California, Pennsylvania, and Connecticut are incentivizing their Medicaid plans and providers to deliver pediatric oral health services in innovative ways, with a special focus on community-based solutions.

Under its Medicaid section 1115 waiver, California incentivizes dental care coordination by community health workers and the use of telehealth.
Pennsylvania has a number of Medicaid managed care strategies in place to foster innovation, including making dollars available to managed care organizations (MCOs) to engage public health dental hygiene practitioners.
Connecticut similarly includes oral health in its statewide Medicaid payment and delivery reform.

Through these incentives and performance measures, explored below, Medicaid agencies are supporting workforce innovations to address children’s oral health.

The Case for Oral Health Workforce Innovation in Medicaid

Dental decay is preventable, yet it is the most common chronic condition among children.[1] Because oral health and overall health are interconnected, unmet oral health needs can negatively affect overall health by making chewing difficult, leading to lost school days, and damaging self-esteem.[2],[3],[4] Inability to access dental care can be fatal – in 2007 Deamonte Driver, a 12-year-old boy enrolled in Medicaid, died after an untreated tooth infection spread to his brain.

Medicaid is a key lever in addressing oral health care needs, particularly for children, because the Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit requires dental coverage for children and adolescents. The Centers for Medicare & Medicaid Services (CMS) encourages state Medicaid agencies to increase children’s access to dental services through Medicaid and the Children’s Health Insurance Program (CHIP).[5] The Child Core Set of measures that Medicaid agencies can report to CMS includes dental and oral health. The 2011 CMS Oral Health Strategy outlines options for state Medicaid agencies to increase children’s access to care, including workforce strategies, such as provider outreach and recruitment, and reimbursement for services provided by additional types of providers to deliver preventive services.

Workforce strategies are critical to address children’s oral health needs in part because oral health care provider shortages persist across the country. Health Professional Shortage Areas (HSPAs) for dental care exist in 49 states.[6] Rural communities have significantly fewer oral health providers than urban communities and therefore less access to services.[7] To offset shortages, states are introducing new provider types or expanding the services existing providers can deliver. Dentists and dental hygienists (working independently or under dentist or physician supervision) practice in every state. Pediatricians and other primary care medical providers deliver preventive oral health services and refer children to dentists.[8] In 10 states, dental therapists can provide preventive and restorative care.[9] Five states have introduced legislation for advanced dental hygiene practitioners, and 21 states allow community dental health coordinators to assist in community-based care coordination and prevention outreach.[10],[11]

To address children’s oral health needs and access to care, Medicaid officials in California, Pennsylvania, and Connecticut use payment and performance-based strategies to engage the providers authorized to deliver oral health services in their states in the continuum of care.

California’s Dental Transformation Initiative

California’s current 1115 waiver focuses on transforming health care service delivery and quality for Medicaid (Medi-Cal) members, and it includes the Dental Transformation Initiative (DTI). The DTI aims to increase pediatric preventive dental service utilization, diagnose early childhood caries[12] through caries risk assessment (CRA) and disease management, and continuity of care for children enrolled in Medicaid. The DTI budget is up to $740 million over five years (through 2020) for provider incentive payments in four domains: pediatric preventive dental service utilization, caries risk assessment and disease management, continuity of care, and local dental pilot programs (LDPPs).

DTI incentives include:

Semi-annual payments to dental service office locations or safety net clinics that provide preventive services to more children;
Payments to dentists for performing pre-identified treatment plans for children ages 6 and younger (where treatment plans include CRA with motivational interviewing, nutritional counseling, and antimicrobials; fluoride varnish application; toothbrush prophylaxis; exams; and increased frequency of services depending on risk level);
Annual, tiered payments to dental service office locations that provide exams to an enrolled child (up to age 20) for continuous years (e.g., tier one payments are provided on a per-child basis for those with two or more exams from the same service location for two consecutive years); and
Payments specific to each LDPP program.

The LDPPs use innovative strategies to address the primary DTI aims of pediatric preventive dental service utilization, risk assessment and disease management, and/or continuity of care. Community organizations submitted applications for LDPPs, and as of July 2019, the state Medicaid agency had contracts with 13 LDPPs. Many LDPPs employ workforce strategies such as telehealth and care coordination or case management to meet the DTI goals.[13]

Five LDPPs are piloting a virtual dental home (VDH)[14] — in this system children receive preventive and other oral health services in community settings, such as schools. Dental hygienists and assistants with special training collect information and provide preventive services. Using technology, dentists in a different physical location review the information and may direct provision of additional services. The VDH also connects children with complex dental needs to a local dentist. The VDH model began at The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry. A Health Resources and Services Administration (HRSA) State Oral Health Workforce Grant to the California Department of Public Health enabled expansion of the VDH to additional sites.[15],[16]
The Sonoma County LDPP (“Cavity Free Sonoma”) is training and integrating community dental health workers (CDHWs) into dental teams at seven federally qualified health centers (FQHCs) to decrease dental disease among Medicaid-eligible children ages six and younger. The CDHWs provide culturally appropriate oral health information to caregivers and children, assist with caries risk assessment, track patient data, and provide dental case management. CDHWs help caregivers navigate medical and social service systems, and they follow up with caregivers to ensure children complete appointments.

A number of state policies underpin and support the DTI. The VDH was initially tested under the state’s Health Workforce Pilot Projects Program, which allows organizations to test or evaluate new or expanded provider roles before changing licensing laws. Based on the VDH results, the state made scope-of-practice changes for dental hygienists and dental assistants, amended the state Medicaid plan to allow allied dental professional enrollment and billing, and to cover the technology used in VDH. These changes facilitated additional VDH piloting and implementation.

Additionally, the state legislature directed a portion of state tobacco tax revenue to be used for supplemental payments to dentists for certain services, and a $30 million loan repayment program for dentists who commit to serve Medicaid patients for five or ten years.[17] (The American Dental Education Association maintains a list of loan repayment programs by state). Dentists in California can receive up to $300,000 through the loan repayment program, and awardees must agree to ensure Medicaid beneficiares comprise 30 percent of their patient caseload. In July 2019, the Medicaid agency announced $10.5 million in loan repayment awards to 40 dentists.

The Medicaid agency and public health department collaborate through these efforts and the statewide oral health plan,[18] which complements and references the DTI. As part of the oral health plan, California aims to support community-clinical linkages by maximizing the use of trained personnel, such as community health workers and public health nurses, as well as co-locating medical and dental providers.[19]

DTI results to date indicate improvement. The statewide pediatric preventive service utilization rate increased 7.48 percentage points from 2014 to 2017, and continuity of care increased 2.6 percentage points from 2015 to 2017.[20]

Pennsylvania’s Medicaid Managed Care Strategies

Pennsylvania also encourages MCOs and providers to increase access to dental care for children in a number of ways that promote workforce innovation. Two specific strategies are performance-based incentives and allocating a portion of MCOs’ capitated payments to initiatives that focus on community-based care management, including for oral health.

Pennsylvania has a carved-in (or comprehensive managed care) Medicaid dental delivery system in which MCOs (physical health – PH – MCOs in the state) are responsible for medical and dental services. The state has an MCO and provider dental pay-for-performance (P4P) measure with related performance improvement projects (PIPs) to improve access to pediatric oral health services.[21]

The measure is annual dental visit for youth ages 2 to 20. The PH-MCO receives an incentive payment for meeting the state benchmark and an incremental improvement compared to past performance on the measure. PH-MCOs are eligible to earn a double payout for meeting certain benchmarks or being responsible for a double offset if they do not meet those benchmarks. PH-MCOs also must include an incentive for the dentist as part of provider P4P for the measure. The dental P4P consists of two age bands, 0-5 years and 6-20 years. There is an emphasis placed on the lower age band and children who have not received a preventive dental service within the previous calendar year in order to increase education and obtaining early preventive dental care.

To improve access, some PH-MCOs offer incentives to pediatricians who make dental referrals for children who then receive a dental service (as evidenced by a dental claim). Some PH-MCOs partner with FQHCs to improve access by supporting co-location of primary medical and dental care. Examples of other innovative plan efforts to increase access include the use of a mobile dental unit with pediatric dental providers and the implementation of a small dental home pilot project.

What services can Pennsylvania’s Public Health Dental Hygiene Practitioners (PHDHPs) provide?

In Pennsylvania, a registered dental hygienist can be certified as a PHDHP to provide dental hygiene services without dentist supervision in specific public health practice sites, such as schools, correctional facilities, health care facilities, and FQHCs. PHDHPs can clean teeth, take X-rays, polish fillings, identify cavities, evaluate patients, and provide oral health education to patients without dentist supervision.

Source: Pennsylvania Code, Chapter 33, section 33.205b

The P4P dental measure and related dental PIPs have been successful. From 2016 to 2018, annual dental visit rates increased by 3.09 absolute percentage points, making the annual dental visit rate 63 percent statewide. Every Pennsylvania plan is currently above the 50 percent national benchmark, and while there is still room for improvement, each plan has improved since the inception of these projects. The state will continue to monitor progress in these areas and especially look at demographics and oversight of the managed care program. A specific area of focus is examining racial/ethnic or geographic disparities in dental care.

Another managed care strategy in Pennsylvania is the availability of Community-Based Care Management (CBCM) dollars for PH-MCOs to implement innovative initiatives that increase access to oral health services. CBCM dollars must be used for community-based projects, either for staffing or for the initiatives themselves. With this funding, PH-MCOs have embedded registered nurses or community health workers (CHWs) in care settings, helped enrollees with transportation to appointments, and conducted public education. Some PH-MCOs use CBCM dollars for oral health services, including mobile dental vehicles, and working with public health dental hygiene practitioner (PHDHP) initiatives. MCOs can enroll PHDHPs, and CBCM guidance specifically requires PHDHP initiatives. In this way, CBCM dollars assist plans in meeting P4P benchmarks and PIP goals.

An Emerging Model: Connecticut’s Oral Health Focus in Medicaid Payment and Delivery Reform

Connecticut’s State Innovation Model (SIM) initiative aims to improve overall community health, access to and quality of care, and health equity through payment and delivery reform. One component of SIM, the Community and Clinical Integration Program (CCIP), provides technical assistance to help provider organizations and FQHCs improve primary care delivery and patient outcomes.[22] CCIP has three core standards: comprehensive care management, health equity improvement, and behavioral health integration, as well as three elective standards, one of which is oral health. This standard includes screening for oral health risk factors and symptoms, developing treatment plans, providing treatment, and tracking oral health outcomes and improvement over time. Although implementation is in the early stages, one participating FQHC has chosen this oral health elective standard. Connecticut recognizes the importance of oral health as it relates to overall health and this awareness will be a consideration in any future practice transformation and payment reform efforts.

Considerations and Conclusion

Some lessons from these state efforts to promote pediatric oral health care access through workforce innovation include:

Engage the dental community. States with comprehensive managed care can elevate dental care within MCOs, for example, by requiring each plan to have a dental director. Pennsylvania has seen increased dental provider engagement since implementing this change.
Consider pilot programs. Pilot programs offer the opportunity to start small, build buy-in, and receive early input. They also can help states determine possible impact and address challenges on a small scale before rolling out statewide.
Leverage multiple funding streams, when possible, and consider a multi-pronged approach for oral health workforce innovation. California has leveraged tobacco tax revenue and federal grants to support innovations across Medicaid and public health, and with an academic partner.
Consider the unique needs of FQHCs and safety net providers. FQHCs often can lead the way in co-location of dental and overall health services and providers, but some safety net facilities/organizations establish contracts for dental care with the private sector. Additionally, due to federal law, FQHCs bill Medicaid agencies for services differently than other providers.[23] These realities can create challenges tracking utilization or other data. A contractor and a dental consultant have provided assistance engaging and supporting safety net providers who opt in to participate in the California DTI.

Dental decay is preventable, yet unmet oral health needs persist. Payment and quality measurement policies in California, Connecticut, and Pennsylvania demonstrate how Medicaid agencies — often in collaboration with public health agencies — can promote oral health workforce innovation to help Medicaid-eligible children access needed dental and oral health care. While states often face financial and data barriers, emerging efforts to engage providers, such as community dental health workers, or dental hygienists and assistants, with advanced training, and to leverage telehealth show promise.

Notes

[1] Centers for Disease Control and Prevention. “Dental Caries (Tooth Decay).” Hygiene-related Diseases. September 22, 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html.

[2] Jackson, Stephanie L., William F. Vann, Jonathan B. Kotch, Bhavna T. Pahel, and Jessica Y. Lee. “Impact of Poor Oral Health on Children’s School Attendance and Performance.” American Journal of Public Health 101, no. 10 (2011): 1900-906. doi:10.2105/ajph.2010.200915. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222359/

[3] Kelekar, Uma, and Shillpa Naavaal. “Hours Lost to Planned and Unplanned Dental Visits Among US Adults.” Preventing Chronic Disease 15 (2018). doi:10.5888/pcd15.170225.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772383/

[4] Health Policy Institute, American Dental Association. “Oral Health and Well-Being in the United States.” https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/OralHealthWell-Being-StateFacts/US-Oral-Health-Well-Being.pdf?la=en.

[5] CMS recently completed the Medicaid Innovation Accelerator Program Children’s Oral Health Initiative Value-Based Payment Technical Support Opportunity for states focused on selecting, designing, and testing a value-based payment approach to improve children’s oral health outcomes. See https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-functional-areas/value-based-payment/index.html

[6] National and State-level Projections of Dentists and Dental Hygienists in the U.S.: 2012-2025. Washington, D.C.: U.S. Deparment of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Information and Analysis, 2015. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nationalstatelevelprojectionsdentists.pdf

[7] National Advisory Committee on Rural Health and Human Services, Improving Oral Health Care Services in Rural America: Policy Brief and Recommendations. December 2018. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2018-Oral-Health-Policy-Brief.pdf

[8] For example, see: Centers for Medicare and Medicaid Services. “Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children & Adolescents.” September 2013. https://www.medicaid.gov/medicaid/benefits/downloads/keep-kids-smiling.pdf; Cantrell, Chris. “Engaging Primary Care Medical Providers in Children’s Oral Health” (National Academy for State Health Policy, 2009). https://www.oldsite.nashp.org/engaging-primary-care-medical-providers-childrens-oral-health/.

[9] “New Mexico’s Passage of Dental Therapy Law Builds National Momentum for Changing Provision of Dental Care Amid Oral Health Crisis.” Community Catalyst. March 29, 2019. https://www.communitycatalyst.org/news/press-releases/new-mexicos-passage-of-dental-therapy-law-builds-national-momentum-for-changing-provision-of-dental-care-amid-oral-health-crisis.

[10] American Dental Hygienists’ Association. “The Benefits of Dental Hygiene-Based Oral Health Provider Models.” April 2016. https://www.adha.org/resources-docs/75112_Hygiene_Based_Workforce_Models.pdf.

[11] American Dental Association. “Solutions: About CDHCs.” Action for Dental Health. https://www.ada.org/en/public-programs/action-for-dental-health/community-dental-health-coordinators.

[12] Early childhood caries is the presence of one or more decayed, missing, or filled tooth surfaces in a primary tooth in children younger than six years of age. See American Academy of Pediatric Dentistry, “Definition of Early Childhood Caries” https://www.aapd.org/assets/1/7/D_ECC.pdf

[13] California Department of Health Care Services, “Medi-Cal 2020 Waiver Dental Transformation Initiative, Domain 4 Summary of Local Dental Pilot Program Applications,” March 8, 2018. https://www.dhcs.ca.gov/provgovpart/Documents/DTI/Domain%204/Medi-Cal_2020_DTI_D4_LDPP_Summary_030818.pdf

[14] University of the Pacific, Arthur A. Dugoni School of Dentistry. ”About Virtual Dental Home” https://dental.pacific.edu/departments-and-groups/pacific-center-for-special-care/innovations-center/virtual-dental-home-system-of-care

[15] University of the Pacific, Arthur A. Dugoni School of Dentistry. “Pacific Center Receives More than $3.5 Million in New Grants for Virtual Dental Home Projects,” October 13, 2017.

https://dental.pacific.edu/news-and-events/news-archive/pacific-center-receives-more-than-35-million-in-grants-for-virtual-dental-home

[16]California Department of Public Health Office of Oral Health. “Oral Health Program Projects.” https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/Pages/OralHealthProgram/OralHealthProjects.aspx

[17] See www.CalHealthCares.org to learn more about loan repayment program eligiblilty and requirements.

[18] California Department of Public Health Office of Oral Health, Statewide Oral Health Plan 2018-2028, January 2018. https://www.cdph.ca.gov/Documents/California%20Oral%20Health%20Plan%202018%20FINAL%201%205%202018.pdf

[19] Kumar, Jayanth. “Public Health and Dental Care Collaboration in California.” Webinar presentation for the National Academy for State Health Policy. July 30, 2019.

[20] Jackson, Alani. “California Oral Health Innovations.” Webinar presentation for the National Academy for State Health Policy. July 30, 2019.

[21] To learn more about relevant PIPs, see Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for States. Centers for Medicare & Medicaid Services Oral Health Initiative, 2015. https://www.medicaid.gov/medicaid/benefits/downloads/pip-manual-for-states.pdf

[22] Connecticut State Innovation Model (SIM) Report of the Practice Transformation Taskforce on Community and Clinical Integration Program Standards for Advanced Networks and Federally Qualified Health Centers. Core Elective Standards. CT.gov, 2016. https://portal.ct.gov/-/media/OHS/SIM/PracticeTransformationTaskForce/CCIP-Reports-and-Publications/ccip_report_standards_updated_12_30_16.pdf?la=en

[23] To learn more, see for example, Medicaid and CHIP Payment and Access Commission. Medicaid Payment Policy for Federally Qualified Health Centers, December 2017. https://www.macpac.gov/publication/medicaid-payment-policy-for-federally-qualified-health-centers/

Acknowledgements

The authors wish to thank the state officials in California, Connecticut, and Pennsylvania who graciously shared their experiences and reviewed a draft of this publication. Trish Riley, Kitty Purington, and Elinor Higgins of NASHP provided helpful guidance or assistance. Finally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

Georgia Proposes New Changes to its Individual Market and Medicaid Program in Two Federal Waivers

November 11, 2019/in Policy Georgia Blogs, Featured News Home Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces, Work Requirements /by Anita Cardwell

This spring, Georgia passed the Patients First Act authorizing the state to seek federal approval for a Section 1115 waiver to implement an alternative Medicaid expansion model and an Affordable Care Act (ACA) Section 1332 waiver to pursue a range of options affecting individual market coverage. Last week, the state released draft versions of both waivers, outlined below.

Most of the components of the state’s 1115 waiver proposal are similar to Medicaid expansion models that have been approved in other states. However, the changes Georgia proposes through its 1332 waiver are more notable for their potential implications and the questions they raise about the parameters and administration of the state’s individual market. This is also the first example of a state seeking a broader 1332 waiver based on guidance released by the Centers for Medicare & Medicaid Services last year, which changed the interpretation of the 1332 waiver’s “guardrails.”

Proposed 1332 Waiver

Georgia is seeking to use Section 1332 waiver authority to implement significant changes to coverage available through its individual market. The proposal includes two phases — the first part of the plan would implement a reinsurance program, and the second portion involves transitioning from a federally-facilitated marketplace (FFM) to a more state-controlled, decentralized model — though it would not be the same as an ACA state-based marketplace.

Reinsurance program: Similar to many other states, Georgia is proposing to create a statewide reinsurance program beginning in plan year 2021 with the goal of stabilizing the individual market, reducing premiums, and ensuring an adequate selection of insurance carriers. The program would reimburse carriers at tiered rates according to geographic regions in order to provide larger reimbursements to areas with higher premiums.
Georgia Access Model: Beginning in plan year 2022, the state would implement a number of changes through the proposed Georgia Access Model, including:
- State individual market operational changes: As part of the state’s plan to no longer use the FFM, the state’s Office for Health Strategy and Coordination along with other state agencies would be responsible for determining consumers’ eligibility for coverage, certifying plans offered on the individual market, licensing web brokers, and distributing tax credit dollars and addressing any related appeals.
- State-run subsidy program: The state would develop and administer its own subsidy program, using both federal advance premium tax credits (APTCs) as well as state funds, to help individuals who earn 100 to 400 percent of the federal poverty level (FPL) purchase individual market coverage. The state is also requesting permission to cap consumer enrollment if state costs reach a certain threshold, and if this occurs individuals seeking coverage would be placed on a waiting list.
- Enrollment through web brokers and carriers: The state is proposing to allow consumers to directly enroll in individual market coverage through web brokers and carriers rather than through a centralized state agency model. This would involve giving the web brokers and carriers the responsibility for developing the functions needed to help consumers enroll in coverage, such as plan comparison tools and shopping portals.
- Allowing consumers to purchase alternative coverage options: Although consumers using the Georgia Access Model will still be able to use subsidies to purchase qualified health plans (QHPs), state-certified “non-QHPs” will also be available as a subsidized coverage option. These non-QHPs will not be required to meet QHP standards, including Essential Health Benefit requirements, and consequently would likely be less expensive — although they will be required to maintain pre-existing condition protections. They will also be required to be a major medical health plan and in the individual market’s single risk pool, but they will not be allowed to be medically underwritten.
Implementation timeline: The state is seeking comments on the proposal through Dec. 3, 2019, and plans to submit the waiver application to federal officials by Dec. 20, 2019, after which a federal comment period would be opened.

Proposed Pathways to Coverage – 1115 Waiver

Rather than implement the ACA’s full Medicaid expansion, Georgia is requesting to expand Medicaid only up to 100 percent of the FPL — at the enhanced ACA Medicaid expansion match rate, which has not yet been approved in any other state — along with the following conditions:

Eligible individuals: Individuals ages 19 to 64 who are not currently eligible for Medicaid, which would include adults without dependent children with incomes up to 100 percent of the FPL, and parents, caretakers, or guardians with income between 35 to 100 percent of the FPL.
Work requirement: To be eligible for coverage through the Georgia Pathways to Coverage program, individuals would be required to demonstrate they are working or engaged in other approved activities (e.g., community service, job training) for at least 80 hours per month.
Employer-sponsored insurance (ESI) premium assistance program: If an eligible individual has access to ESI, the individual will be enrolled in that coverage instead of Medicaid and the state will pay the ESI premiums for the individual if it is more cost-effective for the state.
Premiums: Some individuals will be required to pay premiums (tiered based on family income), and these premiums will be deposited in a Member Rewards Account.
- Individuals required to pay premiums: Individuals who are eligible for the Georgia to Pathways Coverage program who have incomes of 50 to 100 percent of the FPL, and individuals enrolled in transitional medical assistance.
- Exempt individuals: Individuals with incomes below 50 percent of the FPL; individuals in the ESI premium assistance program; and individuals who are enrolled in and two months after graduation from certain vocational education training programs of highly sought-after trades.
- Penalties for nonpayment: Enrollees required to pay premiums who fail to pay have a three-month period to retain eligibility before being disenrolled.
Copayments: The same individuals who are subject to premiums will be required to make copayments for certain services that will be assessed retrospectively, but they are not to exceed 5 percent of an individual’s household income when combined with premium payments. Copayments are the same as in the existing state plan, with the addition of a copayment for non-emergency use of the emergency room.
Member Rewards Accounts: Enrollees’ premium payments will be deposited in a Member Rewards Account, which will also be funded with state contributions. Funds in these accounts can be used for copayments or to pay for additional services that are not covered, such as vision or dental care. Individuals can earn points in their accounts by engaging in healthy behaviors.
Benefit package and delivery system: The benefit package will mostly align with those provided through the state plan, with the exception of non-emergency medical transportation. Also, while the Early and Periodic Screening, Diagnostic and Treatment benefit for 19- and 20-year-old individuals is part of the state plan benefit package, the proposal requests to waive vision and dental services for these enrollees. For individuals for whom the state is covering the cost of ESI, wraparound benefits are not covered. The program will use a managed care delivery system exclusively.
Eligibility effective date: The state is requesting to waive retroactive eligibility, and to have eligibility begin the month following the determination of eligibility and the payment of any premium required.
Implementation timeline: The state is seeking comments on the proposal through Dec. 3, 2019, and is planning to submit the waiver to federal officials on or before June 30, 2020 for a federal comment period. However, if approved, implementation of the program would not begin before July 7, 2021.

Although the timing for implementation of the two waivers differs, the state comment period for both waivers closes on Dec. 3, 2019. For more information and to view the waiver documents, explore the state’s informational page. The National Academy for State Health Policy (NASHP) will be tracking Georgia’s plans as they evolve and will report on other states’ emerging proposals.

For more information about states’ implementation of the ACA’s Medicaid expansion, explore NASHP’s interactive map, Where States Stand on Medicaid Expansion, and for information about states’ marketplace models, view NASHP’s map, Where States Stand on Exchanges.

States Increase Access to Oral Health Services and Support Overall Health

States Increase Access to Oral Health Services and Support Overall Health

Expanding the Oral Health Workforce to Promote Overall Health: Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity

Expanding the Oral Health Workforce to Promote Overall Health: Arizona Uses Dental Hygienists to Improve Hospital Patient Safety

50-State Scan: How Medicaid Agencies Leverage their Non-Licensed Substance Use Disorder Workforce

Background

Service Delivery

Setting and Reimbursement

Education, Training, and Supervision

Looking Forward

Conclusion

Other Resources

State Medicaid Certification Requirements for Peers

Key Findings

State Medicaid Certification Requirements for Counselors

Key Findings

State Medicaid Certification Requirements for Other Qualified Staff

State Medicaid Strategies to Promote Early Identification and Treatment of Pregnant Women with Substance Use Disorder

Promising State Strategies to Improve Continuity of Substance Use Disorder Treatment following Incarceration

Medicaid Incentives, Performance Measures, and Workforce Innovations Foster Access to Pediatric Oral Health Care

Georgia Proposes New Changes to its Individual Market and Medicaid Program in Two Federal Waivers

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