Annual Federal Insurance Rule Includes Proposals to Address Prescription Drug Cost
The Trump Administration’s effort to address drug prices surfaced unexpectedly in the Department of Health and Human Services (HHS)’s recently issued proposed annual rule that regulates state health insurance markets, including coverage sold through the Affordable Care Act (ACA) marketplaces. The proposal encourages the use of generic drugs over brand-name drugs by both health plans and enrollees in an effort to “bring down overall health plan costs and perhaps premium increases.”
For more information, read this summary of all of the provisions in the federal proposed rule. HHS is accepting comments on the rule until Tuesday, Feb. 19, 2019.
State officials need to consider whether the proposed changes will result in cost shifting from health plan premiums, which are subsidized for many individuals through advance premium tax credits, to consumers’ unsubsidized, out-of-pocket cost responsibilities. If this cost shifting occurs, how would it affect overall individual and small group market affordability? Or, are there ways to implement the proposed changes to minimize cost shifting onto consumers and truly reduce overall health expenditures? Below are some key policy issues that state officials should consider when reviewing the proposed rule.
The proposal allows health plans to eliminate brand-name drugs from essential health benefit (EHB) coverage requirements if a generic equivalent is available.
Under the proposed rule, if a health plan covers both a brand-name prescription drug and its generic equivalent, the plan could specify that only the generic drug would qualify as EHB, and the brand-name drug would no longer be considered part of EHB coverage. If a plan takes this option, premium tax credits and advanced premium tax credits (APTC) could not be applied to any portion of the premium attributable to coverage of brand-name drugs that are not considered EHB. Issuers would have to calculate that portion of the plan’s premiums and report it to the appropriate health insurance exchange for accurate APTC calculation.
It is also important to remember that lifetime and annual out-of-pocket limits only apply to cost sharing for benefits classified as EHB. Therefore, HHS is seeking comments on whether any portion of enrollees’ out-of-pocket expenditures for brand-name drugs not considered EHB should be counted toward out-of-pocket limits. One HHS proposed strategy would apply the cost of the generic toward the individual’s out-of-pocket limit and the other would not apply any portion of the brand-name drug cost toward an individual’s cost-sharing limit. Issuers pursuing this option would need to establish an appeals process for enrollees to petition for EHB coverage of brand-name drugs.
HHS notes these proposals will provide “additional flexibility for health plans in individual and small group markets that must provide coverage of the EHB to consumers to use more cost-effective generic drugs.” State officials may consider the following questions:
- Would it be possible for a state to carve out brand-name drugs from EHB, and would this rule preempt state laws, particularly in states that have already adopted their own list of essential health benefits in response to ACA challenges?
- Can issuers currently calculate the portion of a qualified health plan’s premiums spent on brand-name drugs excluded from EHB? If not, what would it cost to perform that calculation?
- How would this change be explained to enrollees? Would enrollees receive an advance notice that certain brand-name drugs would not be covered, along with information explaining how to pursue an exception process? Would enrollees be informed at the point of sale? Would enrollees purchasing brand-name drugs receive a summary of benefits that show which costs are attributed to lifetime and annual limits?
The proposal allows health plans to limit prescription drug coupons.
In another effort to encourage generic drug use, HHS proposes that amounts paid toward cost sharing using any manufacturer coupons for a brand-name drugs that have a generic equivalent not be counted toward enrollees’ annual limits on cost sharing. According to HHS, “the proliferation of drug coupons supports higher cost brand drugs when generic drugs are available, which in turn supports higher drug prices and increased costs to all Americans.”
This proposal addresses a concern that coupons can distort the true cost of drugs by offering limited-time cost reductions for enrollees’ out-of-pocket expenses, and manufacturer coupons may inflate drug prices that insurers pay. Limiting the use of coupons for brand-name drugs may steer consumers toward less-costly generic medications with lower cost-sharing responsibilities. Additionally, HHS suggests that not counting coupon amounts toward the annual cost-sharing limit would “promote prudent prescribing and purchasing choices by physicians and patients based on the true costs of drugs [as well as] price competition in the pharmaceutical market.”
HHS seeks comments on whether states should be able to decide how coupons are treated. This proposal reflects state legislative action on coupons. In 2017, California banned the use of manufacturer coupons when a generic equivalent is available. Since the 2019 legislative session began, both New Jersey and New Hampshire have proposed similar measures. State officials may want to consider:
- How difficult would it be for insurers to carve out manufacturer assistance from their pharmacy benefit and the annual limitation on cost sharing (as well as exceptions)?
- Would it be difficult for issuers to differentiate between manufacturer coupons and other types of assistance?
- What consumer education would be required?
The proposal explores implementing reference pricing for prescription drugs.
HHS is also exploring the possibility of implementing reference-based pricing for prescription drugs. Reference-based pricing, as described in the proposed rule, would allow an issuer covering a group of similar drugs (perhaps a therapeutic class of drugs) to set the price that its health plans would pay for those drugs. Enrollees would be responsible for paying the difference between the cost of a drug and the reference price that the health plan sets if enrollees desire a drug that exceeds the reference price. HHS notes that while reference-based pricing could “bring down overall health plan costs, and perhaps premium increases,” it could also increase consumer out-of-pocket costs if an enrollee opts for a drug priced above the reference price. When submitting comments, state officials might consider:
- How would issuers determine the reference prices? Would there be a standard process for selecting reference prices? What role would the states or HHS play in that process?
- Would enrollees’ entire out-of-pocket spending on drugs that exceeds the reference prices go toward their annual cost-sharing limit?
Under the proposed rule, HHS seeks to encourage use of generics over brand-name drugs to decrease overall spending on pharmaceuticals and reduce health plan premium price increases. The proposed rule would likely benefit plans by reducing spending on brand-name drugs, which could in turn lower premiums if savings are passed to enrollees. However, in the short-term, consumers could face increased out-of-pocket spending for brand-name drugs. Are there ways to minimize cost shifting and pursue such proposals to reduce overall costs?
For more information, read this summary of all of the provisions in the federal proposed rule. HHS is accepting comments on the rule until Tuesday, Feb. 19, 2019.
States Use Policy Levers and Emerging Research to Address Antipsychotic Use in Children in Foster Care
State policymakers must often take action during an emerging crisis even when evidence identifying the best policy approach is not be available. This report, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, explores successful state responses to dramatic increases in antipsychotic prescription rates in Medicaid-enrolled children in foster care. It highlights several strategies, including payment reforms, delivery system innovations, and quality supports for clinical care.
The report results from a convening by the National Academy for State Health Policy of researchers and state officials with expertise in financing and operating Children’s Health Insurance Program and Medicaid programs, children’s health, and health policy and pharmacy research. The meeting preceded the release of a Patient-Centered Outcomes Research Institute-funded study, which examines the comparative effectiveness of state oversight systems in Ohio, Texas, Washington, and Wisconsin.
Read or download: Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System
The Case for State Action on Health Prices in 12 Slides
In the last few months, NASHP has convened state leaders in two summits that addressed rising health care costs. With assistance from Larry Levitt of the Kaiser Family Foundation and Erin Fuse Brown of Georgia State University College of Law, NASHP compiled a slide presentation documenting the factors behind the health care cost trajectory to help states make the case for action. In the months ahead, NASHP will present strategies states are pursuing to address the cost conundrum.
Guest Blog: Massachusetts Report Recommends More Health Care Price Transparency and Simpler Payment Methods
Amara Azubuike and Sandra Wolitzky are assistant attorneys general in the Massachusetts Office of the Attorney General.
A new report released in October 2018 by Massachusetts Attorney General Maura Healey finds that complicated and varied methods used to determine health care payment rates contribute to administrative cost increases and make it difficult for market participants to identify high-quality health care options.
The report identifies factors that have significant implications for the health care marketplace in Massachusetts. First, commercial health care fee-for-service payments are determined using complex and varied methods with little consistency across payers, providers, or insurance products. The report finds that hospital outpatient payment methods are particularly complex, and in many cases this complexity makes it difficult, according to the report, to “predict which hospitals are competitively priced or are likely to be a good value within any particular payer” or “assess value across payers without detailed case-specific information.” Risk contracts — where providers are rewarded if they spend below a negotiated budget to care for a population, or penalized if they spend more — are similarly complex and vary from insurer to insurer. This adds another layer of complexity on top of the fee-for-service framework that underlies alternative payment methods. This varied payment system generates administrative costs that do not appear to add value to patient care. Complexity also serves as an obstacle to price transparency for consumers, employers, policymakers and providers.
The report offers the following recommendations to address these key findings:
- Reduce complexity and explore increased standardization, where appropriate, of the methods for determining fee-for-service payments and the key terms that govern risk contracts.
- Establish real-time, service-level price transparency for employers, consumers, policymakers and providers. A simpler approach to health care payment practices would allow for new transparency initiatives that would enable purchasers and providers to compare options for specific services.
- Further study the administrative costs associated with current approaches to health care payment practices that significantly vary between insurers, insurance products, and providers.
This is the eighth cost trends report issued by the Massachusetts Attorney General’s Office. These reports aim to increase transparency around the forces and conditions that affect health care spending. Prior cost trends reports from the office have focused on inefficiencies in the distribution of health care dollars, including provider price variation unexplained by differences in quality, complexity of services, and other common measures of consumer value. Prior reports have also documented higher per capita spending on commercially insured people in more affluent communities compared to less affluent ones, despite the higher sickness burden found in less affluent communities “Health care costs are one of the highest expenses for Massachusetts families,” Attorney General Healey explained. “This report shows that there is more we can do to reduce administrative costs and make health care price comparisons easier for patients, employers and health care professionals.”
State Reinsurance Programs Lower Premiums and Stabilize Markets — Oregon and Maryland Show How
Across the nation, in response to rising health insurance premiums and unsettled markets, a growing number of states are using reinsurance programs to reduce premiums and stabilize jittery markets.
What is reinsurance?
A reinsurance program provides funds to health insurers to offset the costs of covering consumers with high medical costs. Generally, reinsurance funds become available when a total claim reaches a certain amount, or when enrollees have certain high-cost medical conditions. When a government guarantees funds, insurers are able to keep their premiums lower for all consumers until markets stabilize and pricing normalizes.
Medicare Part D uses reinsurance and the Affordable Care Act used a temporary federal reinsurance programs to stabilize markets during its early years of implementation.
A reinsurance program provides funds to health insurers to offset the costs of covering consumers with high medical costs. Generally, reinsurance funds become available when a total claim reaches a certain amount, or when enrollees have certain high-cost medical conditions. When a government guarantees funds, insurers are able to keep their premiums lower for all consumers until markets stabilize and pricing normalizes.
Medicare Part D uses reinsurance and the Affordable Care Act used a temporary federal reinsurance programs to stabilize markets during its early years of implementation.
Two states – Oregon and Maryland – have implemented reinsurance programs that provide funding to insurers who cover consumers with high medical costs to prevent them from raising insurance premiums on all enrollees. This approach, state officials explained during a recent National Academy for State Health Policy-sponsored webinar, has reduced premium prices and helped stabilize their insurance markets.
Reinsurance is not a new concept — the federal government uses a reinsurance program to support insurers who participate in Medicare Part D and the Affordable Care Act (ACA) temporarily implemented a reinsurance program during its first three years to keep insurers stable as they adjusted to new market dynamics triggered by the ACA’s legislative changes. Some estimates indicate that premiums rose about 4 to 7 percent in 2017 when the ACA’s reinsurance program ended, and some experts suggest that continuation of the federal reinsurance program would have helped keep premium rates lower.
Section 1332 of the ACA allows states to experiment with different approaches to coverage, and while there has been considerable discussion about new federal guidance about these Section 1332 waivers, seven states have used them to implement their own reinsurance programs. By reinsuring against high, unanticipated costs, these state initiatives lower premiums which, in turn, reduces the federal government’s costs to cover advanced premium tax credits, which are based on average premium rates. These federal “savings” are then reinvested to finance the reinsurance program, also known as pass-through dollars. In its recent webinar, officials from Oregon and Maryland shared their experiences with 1332 waivers and reinsurance.
Well-run reinsurance programs can temporarily lower premiums:
Oregon’s program led to an 8 percent reduction in 2018 premium rates and a 9 percent drop in 2019.
Maryland’s reinsurance program is credited with a 13.2 percent reduction in premiums in 2019.
Oregon’s program led to an 8 percent reduction in 2018 premium rates and a 9 percent drop in 2019.
Maryland’s reinsurance program is credited with a 13.2 percent reduction in premiums in 2019.
A Tale of Two Models
Oregon established its reinsurance program under a legislative mandate (HB 2391) in July 2017, with federal approval of its waiver coming three months later. Oregon’s reinsurance program follows a “traditional” model — the state sets a fixed range at which insurers will be paid back for “high cost” expenditures and also a rate at which insurers will be reimbursed for costs that fall within that range, known as coinsurance. The range is fixed each year, though Oregon may adjust the coinsurance rate based on the amount of funds available to the program. Proposed regulations set the 2018 range to start at $95,000, with a coinsurance rate of 50 percent. The range is capped at $1 million. Modeled after Oregon, Maryland’s reinsurance program was established by statute in April 2018 and its waiver was approved in August 2018. While also a traditional reinsurance program, Maryland has set its expenditure cap at $250,000 and a coinsurance rate of 80 percent.
Financing State Reinsurance Programs
States have broad latitude to design their reinsurance programs — they can balance the trade-offs between making a robust reinsurance investment and achieving market stability and affordability. Based on their choices (e.g., generosity of coinsurance rates), states may be accountable for considerable program costs not covered by federal pass-through dollars. In states with reinsurance programs, it is estimated that federal funds will cover between 36 to 98 percent of total program costs.
Oregon officials estimated that their reinsurance program will cost approximately $90 million in 2018 (the webinar occurred in late December 2018), with a slight increase to $95 million in 2019. The state has estimated it will receive $54 million and $42 million, respectively, in federal pass-through dollars during those two years, meaning the state will need to cover $89 million in costs over those two years to cover the program’s anticipated expenditures. State funding for the program comes from:
- A portion of a 1.5 percent premium assessment on individual market and small group plans; and
- Funding from Oregon’s former high-risk pool and reserves from the state’s health insurance marketplace.
Maryland officials estimate its program will cost $462 million in 2019, and decrease to $287 million by 2021. The state will need to cover approximately $264 million in costs over those three years. Maryland aimed to be strategic in financing its program. First, it delayed a two–year anticipated federal tax on insurers and instead instituted its own assessment on health plans in 2019 in order to finance the reinsurance program from 2019 to 2021. The 2.75 percent premium assessment applies to all health plans regulated by the state. The assessment also applies to Medicaid managed care organization (MCO) plans, which are financed by federal matching funds at a rate of 62 percent.
Maryland estimates that it will draw down an additional $168 million from its assessment on MCOs — approximately $104 million of which will be financed by the federal match. Second, to reduce administrative costs, Maryland is working with the Centers for Medicare & Medicaid Services (CMS) to leverage existing federal servers and databases established to support claims data collection and processing for the federal reinsurance and risk adjustment programs. By using its existing systems, the state anticipates saving money that would have otherwise been used to maintain its own claims collection and processing infrastructure. Third, to ensure that it was maximizing its reinsurance dollars, Maryland included an adjustment to its reinsurance formula to mitigate against duplicative payments insurers might receive under the federal risk adjustment program.
Officials expressed caution about the estimates of federal pass-through dollars to finance reinsurance programs, indicating that states should prepare for some variability between estimates calculated in their waiver applications and actual program costs. The insurance markets remain dynamic and calculations will be adjusted as CMS gains a better understanding of state enrollment trends, risk mix, and/or the effect of policy changes on insurance markets. Because of these adjustments, Minnesota received nearly $100 million less than expected in federal payments in 2018, while New Jersey and Wisconsin will each receive approximately $40 million less than expected. In contrast, Oregon received nearly a $4 million boost in funding from what it had expected. New guidance issued in early December 2018 addresses some concerns by providing greater transparency about the CMS process for completing pass-through calculations.
Impact of Reinsurance Programs to Date
Officials from both states described their reinsurance programs as a “quick” and effective way to reduce premium costs and add stability to markets. In Oregon, the program led to an 8 percent reduction in 2018 premium rates and a 9 percent drop in 2019. Maryland’s program led to a 13.2 percent decline in premiums for 2019. Maryland and Oregon officials anticipate longer-term benefits from reinsurance.
- In Oregon, reinsurance has helped secure statewide participation of insurers in its markets, insurers who may not have participated if not for the stabilizing effect of reinsurance.
- Maryland anticipates that lower premiums enabled under the program will help entice younger and healthier enrollees to participate, which, will help sustain lower rates and continued participation of low-risk populations in the future.
While effective, the state reinsurance programs are designed as temporary solutions, designed to help insurers calibrate risk as insurance markets and policies continue to evolve post-ACA. As Oregon officials noted during the webinar, while reinsurance can help states bring down premium costs, it does not, in itself, address any of the underlying drivers of premium costs, such as rising costs of health care. They are looking toward more sustainable solutions to maintain lower costs in the future.
Maryland officials are wondering how to leverage the reinsurance program to drive health care management and quality improvement initiatives. The state has proposed a series of regulatory standards that require participating insurers to display information about how they are utilizing reinsurance funds, and how the insurer is working to offset costs. Longer term, the state hopes to leverage this work to address total costs of care by working with carriers on social determinants of health and health literacy.
As other states explore options to improve health insurance affordability, reinsurance remains an attractive opportunity. Tools, like a Reinsurance Pass-Through Funding Savings Calculator may help states get an initial sense of the impact a reinsurance program could have on premiums and the level of state investment needed to properly finance a program. However, this is a standard baseline estimate, and any state considering a program will need to conduct in-depth actuarial analysis to fully consider all conditions that could uniquely affect a state’s markets. States may also seek to leverage flexibility under new 1332 guidance in order to couple reinsurance with other reforms to bolster their markets.
The National Academy for State Health Policy is working to develop new state policy solutions to address rising costs, including those waivers, and will continue to report on these efforts.
As Drug Prices Rise, Oklahoma’s Medicaid Agency Advances Alternative Payment Models
Escalating drug prices are forcing state Medicaid agencies to explore new payment models. According to Burl Beasley, director of Pharmacy Services for Oklahoma’s Medicaid program, older Medicaid payment strategies, such as negotiating enhanced rebates and multi-state purchase agreements, are not keeping pace with rising drug expenditures.
Beasley cited the strain prescription drug costs were putting on Oklahoma’s Medicaid budget as a driver behind the decision to pursue alternative payment models (APMs) during a Dec. 12, 2018 National Academy for State Health Policy (NASHP) webinar. The webinar featured Beasley, Terry Cothran, director of Pharmacy Management Consultants at the University of Oklahoma College of Pharmacy, and Russell Knoth, director of Health Economics and Outcomes Research at Eisai, a drug manufacturer that entered into an APM agreement with Oklahoma. Since committing to APMs, Oklahoma’s Medicaid agency has become a national leader, with four separate Medicaid APM agreements executed with drug manufacturers.
Oklahoma Medicaid Alternative Payment Models for Prescription Drugs
| Drug Name | Manufacturer | Therapeutic Class | Outcome Measured |
| Aripiprazole lauroxil (Aristada) | Alkermes | Long-acting, injectable antipsychotic | Patient adherence to medication |
| Oritavancin (Orbativ) | Melinta | IV antibiotic for bacterial skin infections | Net costs to the state |
| Fycompa | Eisai | Epilepsy | Reduced hospitalizations |
| Invega Trinza and Sustenna | Janssen/Johnson & Johnson | Long-acting, injectable antipsychotic | Overall population adherence |
Beasley drew an important distinction between the two main types of APMs — financial APMs and health outcome-based APMs. Financial APMs are essentially price/volume agreements and may include target measures such as adherence. Financial APMs, which can be managed with claims data, are easier to administer than health outcomes-based APMs, which often require clinical data. The four contracts that Oklahoma has executed to date are all financial APMs, though Oklahoma continues to explore potential health outcomes-based APMs. Oklahoma’s fee-for-service Medicaid payment model helped expedite the execution of APMs, which otherwise may have required additional negotiation and coordination with managed care organizations.
To enable Medicaid APMs, Oklahoma submitted a Medicaid State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services, and received approval for the amendment on June 27, 2018. The SPA allows Oklahoma to negotiate supplemental rebate agreements that could produce extra rebates for the state depending on a drug’s performance against outcomes agreed upon in the contract with the drug manufacturer. The extra rebates are excluded from “best price” implications, an important consideration to encourage manufacturer participation in APMs.
Michigan has since followed Oklahoma’s lead, receiving approval in November 2018 for a SPA to enable APMs there. Both states received support from SMART-D, the State Medicaid Alternative Reimbursement and Purchasing Test for High-Cost Drugs, including development of a contract template. NASHP provided a grant to Oklahoma to support the extensive data analysis necessary to explore potential drugs and outcomes for measurement in order to execute contracts. NASHP provided the grant through its Center for State Rx Drug Pricing, supported by the Laura and John Arnold Foundation.
Results, including assessments of potential cost savings, are not expected for any of Oklahoma’s APMs until 2019. In the meantime, Cothran was able to share some lessons learned from Oklahoma’s successful efforts to pursue and finalize contracts with manufacturers.
- Building a strong relationship and trust between the state and a manufacturer is necessary.
- Smaller manufacturers may have greater flexibility than larger manufacturers to enter into APMs more quickly.
- Manufacturers are new to Medicaid APMs and are generally not yet ready to take on high-risk contracts.
- State Medicaid programs should be willing to pull initial data on drug utilization to get manufacturers to the table.
Knoth shared the manufacturer’s perspective on APMs, which he believes can be a win-win for payers and manufacturers. He stressed that though the concept of an APM is easy to grasp, transitioning from the concept to a signed contract can be challenge because it requires designing an agreement with the power to measure a real effect. Eisai’s contract with the Oklahoma Health Care Authority measures reductions in hospitalizations following initiation of its epilepsy drug Fycompa, and is Eisai’s first APM.
- Read a Q&A about how Oklahoma implemented its APM and how it plans to evaluate and expand this innovative model here.
- Listen to the Dec. 12, 2019 webinar Medicaid Alternative Payment Models for Prescription Drugs: Do They Add Value for States? here.
- Listen to the May 9, 2019, webinar Medicaid Alternative Payment Models for Prescription Drugs: A Look at Three States here.
Medicaid Alternative Payment Models for Prescription Drugs: Do They Add Value for States?
Wednesday, Dec. 12, 2018
2-3 pm (EST)
Listen to the Webinar.
Download the Slides.
As states struggle with the increasing cost of prescription drugs, they are testing various alternative payment models (APMs). The Oklahoma Health Care Authority is a national leader with four alternative payment models in the form of direct contracts with pharmaceutical manufacturers. These contracts are each based on a specific drug, agreed-upon outcomes, and approaches to measurement. Speakers included:
- Burl Beasley, BS Pharm, MPH, MS Pharm, Director, Pharmacy Services, Medicaid Operations Division, Oklahoma Health Care Authority
- Terry Cothran, DPh, Director, University of Oklahoma College of Pharmacy, Pharmacy Management Consultants
- Russell Knoth, MA, PhD, Director, Health Economics and Outcomes, Eisai
Listen to the related, May 9, 2019, webinar Medicaid Alternative Payment Models for Prescription Drugs: A Look at Three States here.
Webinar: How States Use 1332 Waivers to Develop Reinsurance Programs to Stabilize Markets
Tuesday, Dec. 11, 2018
4 to 5 p.m. (EST)
Listen to the Webinar.
Download the Slides.
Section 1332 waivers empower states to think creatively about how they can deliver quality and affordable health coverage to their populations. As new state leaders take office, time will be ripe for states to consider how to best use waivers to bring greater choice and stability to their markets. New federal criteria gives states even greater flexibility in how they can use the waivers, some states have already found success in using 1332 waivers to stand up a reinsurance program, lowering premiums and maintain choice in their markets.
In this webinar, we dive into key questions for states as they consider development of a reinsurance program. A state panel, including officials from Maryland, shares lessons learned in applying for and implementing 1332 waivers for reinsurance. In addition, experts from Oliver Wyman share a new tool to help states evaluate financial implications and opportunities using federal pass-through funding under a Section 1332 reinsurance waiver.
This webinar is sponsored by Blue Cross Blue Shield Association, with content development at the sole discretion of NASHP.
Medicaid Managed Long-term Services and Supports Programs for Children and Youth with Special Health Care Needs
Tuesday, December 04, 2018
3-4 p.m. (ET)
States are increasingly providing services to Medicaid beneficiaries with complex health care needs through managed care delivery systems to help control the cost of care, improve health outcomes of enrollees, and improve the quality of the care enrollees receive. States are also starting to include behavioral health and long-term services and supports (LTSS) in Medicaid managed care – services that historically have been provided in fee-for-service systems. States have used MLTSS delivery systems less frequently to serve CYSHCN. However, MLTSS may have great potential to improve quality of life for CYSHCN in Medicaid, by increasing access to care, as well as beneficiaries’ control over their care.
This national webinar will provide an overview of a recent National Academy of State Health Policy (NASHP) analysis of how state MLTSS programs serve CYSHCN. It will also feature presentations from Texas and Iowa, highlighting their approach to providing LTSS for CYSHCN through managed care.
Listen to the Webinar.
Download the Slides.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
