New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD
Substance use disorders (SUD) and mental health conditions are prevalent among pregnant and parenting women in the United States, and they have far-reaching consequences for the health and well-being of women and their children. Integrated care models that support pregnant and parenting women’s physical and behavioral health and social service needs can improve outcomes for women and children and reduce health care costs.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau of the Health Resources and Services Administration (MCHB, HRSA), the National Academy for State Health Policy (NASHP) is working with states to support and advance innovative policy initiatives that improve access to quality health care for pregnant and parenting women.
As part of the MCH PIP initiative, NASHP is convening a two-year policy academy including eight state teams made up of representatives from state Medicaid agencies, public health agencies, mental health/substance use agencies, and other state stakeholders. States selected to participate in the first cohort of the NASHP policy academy include:
- Alabama
- Colorado
- Kentucky
- Mississippi
- New Jersey
- South Carolina
- Texas
- Virginia
Over the next two years, these states will identify, promote, and advance innovative, state-level policy initiatives to improve access to care for Medicaid-eligible pregnant and parenting women with or at risk of SUD and/or mental health conditions. NASHP will work with the states to identify high-priority policy issues, challenges, and opportunities through targeted technical assistance, peer-to-peer learning, analyses of policy issues, and development of policy briefs and other resources that will be disseminated nationally.
While many states have identified pregnant and parenting women as a priority population for their SUD and behavioral health efforts, challenges and opportunities persist. NASHP recently published two Issue Hubs that provide valuable resources, including information on the Centers for Medicare & Medicaid Services’ Maternal Opioid Misuse (MOM) Model. They are available at:
- Resources to Help States Improve Integrated Care for Pregnant and Parenting Women: This Issue Hub provides valuable resources for states interested in using the Maternal Opioid Misuse (MOM) model and others to improve access to comprehensive and coordinated care and implement innovative payment and care delivery models for pregnant and parenting women eligible for Medicaid.
- Resources to Help States Improve Integrated Care for Children: This Issue Hub provides valuable resources for states interested in the Integrated Care for Kids (InCK) Model and others working to implement payment, coverage, and cross-agency strategies to improve for integrated care coordination of behavioral, physical and health-related social needs for children eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
New Medicaid Funding Could Help States Better Integrate Care for Children with Medical Complexity
Earlier this month, the Senate passed the Medicaid Services Investment and Accountability Act of 2019 (H.R. 1839), which contains funding mechanisms and reforms that allow states to improve care coordination for children enrolled in Medicaid. As of early this week, the bill was on the President’s desk awaiting his signature.
This legislation significantly gives states the option to establish health homes for children with medical complexity (CMC) to promote better care coordination. The concept of giving states this option was originally proposed in the Advancing Care for Exceptional (ACE) Kids Act and was debated in Congress for several years before it was passed as part of H.R. 1839.
Medicaid health homes (originally established under Section 2703 of the Affordable Care Act – ACA) provide targeted and coordinated care for patients with chronic conditions who are enrolled in Medicaid. The goal of health homes providers is to “integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.”
Medicaid health homes do not allow states to specifically limit enrollment in health homes by age, but through health home provider requirements states may limit who can provide the health home services (e.g., pediatric providers). Since this option has been available, state Medicaid agencies have used health homes to target and provide coordinated care to specific populations, such as children with behavioral health needs. In a departure from the previous health home requirements, this new health home option would allow states to specifically target children under age 21 with complex health care needs.
The new legislation contains provisions that will be important for states to consider:
- Start date: States may submit Medicaid state plan amendments related to health homes for children with medical complexity beginning Oct. 1, 2022.
- Enhanced federal match: To encourage uptake of this state option and to help with start-up costs, during the first two fiscal year quarters that a Medicaid state plan amendment is in effect, the Federal Medical Assistance Percentages (FMAP) for payments made to designated health homes will be increased by 15 percent, but cannot exceed 90 percent. This is a more limited federal match than health homes established by the ACA, which receive a 90 percent FMAP for the first eight quarters.
- Target population: The legislation stipulates that enrollment in a health home program must be provided as an optional basis for children with medical complexity. It clearly defines eligibility for children younger than 21 with medical complexity as having:
- One or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical functioning – such as the ability to eat, drink, or breathe independently – and that also requires the use of medication, durable medical equipment, therapy, surgery, or other treatments; or
- One life-limiting illness or rare pediatric disease, as defined in section 529(a)(3) of the Federal Food, Drug, and Cosmetic Act.
- One or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical functioning – such as the ability to eat, drink, or breathe independently – and that also requires the use of medication, durable medical equipment, therapy, surgery, or other treatments; or
- Types of services:
- Services provided by health homes will include the six core health home services required under Section 2703 of the ACA: comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, and referrals to community and social support services.
- Further, this new health home option for children with medical complexity must provide access to the full range of pediatric specialty and subspecialty medical services, including services from out-of-state providers if medically necessary.
- Health home qualifications:
- Health home providers have traditionally included designated providers, teams of health professionals, and health teams.
- The legislation stipulates that the Secretary of Health and Human Services (HHS) will establish standards for qualifying as a health home. The standards will include requirements related to: coordinating prompt and coordinated care among various types of providers, establishing a family-centered care plan, working in a culturally- and linguistically-appropriate manner, and coordinating care with out-of-state providers.
- State reporting requirements: States must report to HHS information including: the number of children participating in the program, the nature and prevalence of the chronic conditions of enrollees, the type of delivery systems and payment models used in the program, quality measures used in the program, and health home provider characteristics.
- State planning grants: Beginning on Oct. 1, 2022, HHS can award up to $5 million in planning grants to interested states.
The legislation also requires the HHS Secretary to issue guidance to state Medicaid agencies by October 2020 on best practices for using and coordinating care from out-of-state providers for children with medical complexity. States will be required to report on implementation of this guidance within their health home programs.
The National Academy for State Health Policy (NASHP) will continue to monitor progress on this legislation and if signed into law, NASHP will follow its implementation and highlight potential issues for states as they pursue this new Medicaid option. For more information about state strategies to improve care to children with special health care needs, visit NASHP’s Children and Youth with Special Health Care Needs Resource Page.
New Report Highlights Successful, Cross-Agency Strategies to Address Substance Use Disorder
States are realigning policies, funding, staffing, and data across agencies to better meet the needs of people living with or at risk of developing substance use disorder (SUD). In 2018, NASHP and the Association of State and Territorial Health Officials (ASTHO) convened a group of Medicaid and public health leaders to discuss state strategies for working across agencies to address SUD. Their new report highlights recommendations for structuring and advancing cross-agency approaches to SUD prevention and treatment.
Read or download: Cross-Agency Approaches to Substance Use Disorder Prevention and Treatment – National Recommendations
Watch the NASHP-ASTHO webinar Cross-Agency Approaches to Substance Use Disorder Prevention and Treatment, recorded March 20, 2019, which explores this topic.
CMS Releases State Funding to Improve Integrated Care for Children and Pregnant and Postpartum Women Enrolled in Medicaid and CHIP
Last week, the Centers for Medicare & Medicaid Services (CMS) released two highly anticipated initiatives — the Maternal Opioid Misuse (MOM) Model and the Integrated Care for Kids (InCK) Model — which will provide multi-year funding to states to improve integrated care for maternal and child health populations enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
NASHP has been tracking these important initiatives since they were first announced by the CMS Center for Medicare and Medicaid Innovation (Innovation Center) last year and has compiled and promoted exemplary integrated care delivery models, strategies, and innovations for pregnant and postpartum women and children that states can consider as they develop their applications for these initiatives.
The MOM Model is designed to:
- Improve quality of care and reduce costs for pregnant and postpartum women with opioid use disorder (OUD) and their infants;
- Expand access, service-delivery capacity, and infrastructure based on state-specific needs; and
- Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.
The CMS Innovation Center will award a maximum of $64.5 million through up to 12 cooperative agreements with state Medicaid agencies and their care delivery model partners for a five-year period. Applications for the MOM Model are due to CMS by 3 p.m. (EST), May 6, 2019. A CMS webinar about the MOM Model Notice of Funding Opportunity was held Feb. 21, 2019. The recording, slides, and transcript from the webinar are available here.
The InCK Model is designed to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and CHIP through prevention, early identification, and treatment of behavioral and physical health needs. States and local organizations will work to conduct early identification and treatment of children with health-related needs across settings to:
- Increase behavioral health access;
- Respond to the opioid epidemic; and
- Improve child health outcomes.
The CMS Innovation Center will award a maximum of $128 million through eight cooperative agreements with state and local participants for a seven-year period (awarding up to $16 million per recipient). Applications to implement the InCK Model are due to CMS by 3 p.m. (EST), June 10, 2019. A CMS webinar about the InCK Model NOFO is scheduled for 2:30 to 4 p.m. (EST) Tuesday, Feb. 19, 2019.
Fact Sheet Highlights Medicaid’s Critical Role in Screening for Maternal Depression
Despite evidence that maternal depression is common and can impede the development of young children, it is often undiagnosed and untreated. Medicaid can play a leading role in identifying at-risk mothers and connecting them to treatment. NASHP’s new fact sheet provides background on maternal depression while also presenting a summary of state Medicaid policies for screening for maternal depression in the context of well-child visits.
Read or Download the Fact Sheet
New Federal Initiatives Help States Expand Support for Children and Families Affected by Substance Use
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In the recent election, Republican and Democratic gubernatorial candidates offered strategies to address the opioid epidemic and meet the needs of children and families affected by substance use disorder (SUD). Incoming and incumbent executives will have new federal resources – including the new Maternal Opioid Misuse (MOM) and Integrated Care for Kids (InCK) models and the SUPPORT for Patients and Communities Act – to bolster their state efforts.
The MOM and InCK models, recently announced by the Center for Medicare & Medicaid Innovation (CMMI), are designed to help selected states better coordinate and integrate treatment and support to improve outcomes and reduce costs.
- Under the MOM model, state Medicaid agencies and care-delivery partners will work to improve care for pregnant and postpartum women with opioid use disorder (OUD). CMMI will award up to $64.5 million over five years, with the funds divided in varying amounts among up to 12 MOM cooperative agreements.
- Under the InCK model, state Medicaid agencies and community partners will collaborate to bolster prevention, early identification, and treatment for children covered by Medicaid. CMMI will award up to eight InCK cooperative agreements, with up to $16 million available to each awardee over a seven-year period.
More information about applying for these initiatives is expected in early 2019.
The recent SUPPORT for Patients and Communities Act includes a number of provisions that also support children and families affected by SUD, including several provisions that could provide new funding to states and new ways for states to use existing federal funds. A previously-published NASHP blog described some of the law’s provisions affecting state Medicaid agencies, while this blog focuses on other key provisions targeting children and families.
Several of the act’s provisions address the impact of childhood trauma. There are multiple connections between SUD and trauma — childhood trauma is a risk factor for SUD and growing up with a parent who has an SUD is itself considered a traumatic experience. Recognizing the significant and long-lasting impacts of childhood trauma, the SUPPORT Act:
- Creates an interagency task force to develop best practices for identifying and supporting children and families who have experienced or are at risk of experiencing trauma. The task force is also responsible for crafting a coordinated federal response to families impacted by SUD and other forms of trauma. These best practices and coordinated federal approach will help states as they promote evidence-based approaches to care. (Section 7132)
- Permits the US Centers for Disease Control and Prevention to collect data about adverse childhood experiences through existing public health surveys, in cooperation with states, with $2 million in annual funding. States can use the findings to track trends, allocate resources, and refine programs that address adverse childhood experiences. (Section 7131)
- Authorizes $50 million per year for grants to state, local, and tribal educational agencies to increase student access to trauma support services by linking educational agencies with mental health systems. The US Secretary of Education would administer the grants in coordination with the Assistant Secretary for Mental Health and Substance Use. (Section 7134)
Other parts of the law are designed to strengthen care delivery systems for children and families affected by SUD. These provisions:
- Authorize $20 million in grants to state governments and other entities to develop and evaluate family-focused SUD residential treatment programs, which permit children to reside with parents in the treatment facility. Due to the recently-enacted Family First Prevention Services Act, evidence-based SUD treatment services for certain parents will soon be eligible for funding from current state allocations of Title IV-E child welfare dollars (learn more in this NASHP blog.) The grants will help additional programs qualify Title IV-E funding. An additional provision requires the US Department of Health and Human Services (HHS) to issue guidance on how states can promote family-focused residential treatment programs and leverage both Medicaid and Title IV-E funds to support them. (Sections 8083 and 8081)
- Appropriate $15 million for HHS to conduct a randomized evaluation of a “recovery coach” program that provides integrated treatment and supportive services to parents who have temporarily lost custody of their children due to SUD. If the evaluation shows positive results, the program could potentially be funded using a state’s existing Title IV-E dollars under the Family First Prevention Services Act. (Section 8082)
- Authorize HHS to provide grants to any state agency to improve implementation of plans of safe care for substance-exposed infants. Existing law requires states to create plans of safe care for all substance-exposed infants. If HHS chooses to award these grants, funds could be used for a number of purposes, including to improve access to treatment, train health professionals and child welfare staff, and strengthen cross-agency collaboration. This provision also requires HHS to provide written guidance and technical assistance outlining how to implement plans of safe care. (Section 7065)
To learn more about how states are supporting children and families with SUD:
- View NASHP’s issue hubs that highlight important information and resources about the InCK and MOM models.
- Read the NASHP issue brief and view the webinar addressing State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to NASHP’s webinar on the topic.
- View presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
NASHP is also in the process of creating a new policy academy that will support states working to improve access to care for Medicaid-eligible pregnant and parenting women with SUD and/or mental health conditions. The call for applications will be released in December 2018.
Virginia’s BabyCare Program: Working to Improve Birth Outcomes through Medicaid
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Nationally, Medicaid finances 45 percent of births and is a critical resource to improve maternal health and birth outcomes and lower avoidable costs. With an increasing number of initiatives focusing on pregnant and postpartum women, such as the federal Maternal Opioid Misuse (MOM) Model, states can learn from innovative programs, including Virginia’s BabyCare initiative. This new NASHP report explores how Virginia utilizes Medicaid’s reach to improve birth outcomes through behavioral risk screening, case management services, and expanded prenatal services.
View or download: Virginia’s BabyCare Program: Working to Improve Birth Outcomes through Medicaid
To learn about other state initiatives, visit NASHP’s Healthy Child Development State Resource Center.
States Add Coverage Mandates to Cover Infertility Treatment following Cancer Treatments
Under the Affordable Care Act (ACA), individual and small group plans must cover essential health benefits, such as pre-existing conditions. However, states can go beyond the ACA’s requirements and mandate coverage for other conditions, such as infertility or autism, though they must cover those additional costs.
A new wave of state mandates have expanded what insurers must cover in the area of infertility treatment. Since 2017, 15 states have introduced legislation that would mandate coverage of fertility preservation – which includes the removal and storage of eggs and sperm – prior to radiation and chemotherapy treatment for cancer. Five states – Connecticut, Rhode Island, Maryland, Delaware, and Illinois — have enacted this legislation, and New Jersey has a bill pending.
According to the Oncofertility Consortium, a multi-institutional and disciplinary organization focused on advancing the understanding of the impact of cancer treatment on the reproductive health of patients, more than 150,000 people age 45 and younger in the United States will be diagnosed with cancer. Most of these patients face excellent prospects for survival, but that survival will also carry consequences. One of the long-term side effects of many cancer treatments is infertility. Patients undergoing some surgeries — having radiation to particular parts of their body or receiving specific types of chemotherapy — may suffer damage to their reproductive system that makes it difficult, or in some cases, impossible, to have children after treatment. As a result, these consumers have increasingly looked to fertility preservation.
Fertility preservation is a process that allows patients to remove and store reproductive cells – eggs and sperm – from their body, before undergoing potentially sterilizing medical treatments. Over the past decade, reproductive technologies have evolved, creating new and more efficient options for fertility preservation. Much of this work has been driven by organizations like the Oncofertility Consortium, a multi-institutional, multi-disciplinary organization focused on advancing the understanding of the impact of cancer treatment on the reproductive health of patients.
Currently, standard techniques for fertility preservation include sperm banking for men and egg or embryo freezing for women. Emerging techniques such as ovarian and testicular tissue banking allow prepubertal patients, who do not have mature eggs or sperm, to preserve their possibility for genetic children in the future.
Despite guidelines from the American Society of Clinical Oncology (ASCO) identifying oncology providers’ responsibility to inform all eligible patients about the reproductive risks and options for mitigating these risks, studies continue to show that patients don’t always understand their risks or feel adequately informed about their options. One factor in keeping fertility preservation use low is the high cost of services, particularly for women. Sperm banking can cost several hundred dollars; egg or embryo freezing often exceeds $10,000.00. For patients who are newly diagnosed with cancer who must access these services immediately, these costs, which are typically not covered by insurance, are often insurmountable.
While bills mandating this insurance coverage have differed slightly, generally they provide coverage for standard fertility preservation procedures as recognized by the American Society for Reproductive Medicine (ASRM) and/or ASCO, and anyone (not just cancer patients) facing “iatrogenic infertility” — infertility caused by a necessary medical intervention. They do not include:
- Coverage for “elective” fertility preservation, such as egg freezing sought due to natural aging;
- Coverage for infertility treatments such as in vitro fertilization that might be needed after cancer treatment to achieve a pregnancy, only for the preservation of the eggs/sperm; or
- Long-term storage costs.
Several states are expected to either introduce or reintroduce fertility preservation coverage bills in 2019. On the federal level, in May the Access to Infertility Treatment and Care Act (H.R. 5965 and S. 2920), was introduced. This bill would require health plans in group and individual markets to cover treatments for the infertility. It would also require coverage of fertility preservation services for patients undergoing medically-necessary procedures that may result in infertility.
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. 
