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Minnesota and Indiana Governors Work to Improve Social Equity and Health in Every Zip Code

September 16, 2019/in Policy Indiana, Minnesota Blogs CHIP, CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Housing and Health, Infant Mortality, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health /by Elinor Higgins

In their 2019 state of the state speeches, 13 governors addressed social equity, acknowledging that reducing inequities and improving opportunities for all residents improves lives and health outcomes. Two of them — Indiana and Minnesota – offer examples of how states are orchestrating their legislative and administrative efforts to reduce health disparities and promote social equity.

Background

Of the many factors that influence health, 80 percent occur outside of the health care system, such as access to safe and affordable housing, high-quality education, and employment opportunities. Across the nation, health disparities persist where racial and ethnic discrimination, gender inequities, class distinctions, and other barriers systemically keep certain people from the opportunities and resources needed to live long and healthy lives.

These health disparities can be observed and tracked by state, county, zip code, or neighborhood. Indiana and Minnesota state policymakers are using budget appropriations, executive orders, and legislation to improve social equity.

Indiana

Gov. Eric Holcomb and a group of Indiana state leaders are tackling disparities in infant mortality under the umbrella of health equity. Their goal is to lower the state’s rate of infant mortality across all zip codes by improving services for expecting mothers.

“Now we’re seeking to implement two more programs that aim directly at reducing infant mortality…. These are the kinds of efforts it will take to get more babies to celebrate their first birthdays, regardless of their zip codes.” – Indiana Gov. Eric Holcomb

In May, Gov. Holcomb signed a bill to address infant mortality and establish a perinatal navigator program. The program engages pregnant women in evidence-based, early prenatal care to improve outcomes regardless of where a woman lives by providing referrals for wraparound services and community-based, home-visiting programs. There is an evidence base to support the positive impact on birth outcomes of community-based programs like these that address social determinants of health. The new law also establishes a program to provide more nurse partners and community health workers to coach, care for, and educate young women during pregnancy.

Across the United States, African Americans experience a higher infant mortality rate than any other racial group — and this is true in Indiana as well. From 2013 to 2015, Indiana’s infant mortality rate averaged 7.13 per 1,000 live births, compared to the 2015 national average of 5.90 per 1,000 live births. The non-Hispanic black population infant mortality rate in Indiana was much higher, at 13.26 per 1,000 live births. Indiana’s plan to boost resources for pregnant women and to engage women sooner in supportive care is designed to make pregnancy outcomes — and overall health outcomes — more equitable for all.

Minnesota

In Minnesota, Gov. Tim Walz and state leaders are using a variety of levers to address the structural components of inequity. The initiatives proposed in the budget or enacted through executive orders are designed to reduce disparities in educational achievement and hiring experienced by racial minorities in Minnesota. Though not directly tied to health, these disparities can lead to income inequality and other stressors that are strongly associated with poor health outcomes — so Minnesota’s upstream approach has the potential to improve health across the state.

“Every student in Minnesota deserves the opportunity to learn in the best schools in the country with caring, qualified teachers. But as I travel around the state, I see how the quality of a student’s education is too often dependent on their race or zip code. …Disparities in our educational system based on geography, race, or economic status hold back not only our students, but our entire state from reaching its full potential. We must make Minnesota the Education State for all children — black, white, brown, and indigenous.” — Minnesota Gov. Tim Walz

Minnesota’s state budget, approved in late May, included a 2 percent increase in per-pupil funding to public schools, which is part of Gov. Walz’s plan to reduce disparities in educational achievement by improving school resources across the state. He also proposed a Community Solutions Fund in his budget that would provide local groups with grants to help them address children’s health care issues in a flexible way.

Gov. Walz also issued an executive order at the beginning of his term creating the Diversity, Inclusion and Equity Council. Headed by Chris Taylor, the state’s new Chief Inclusion Officer, the council will focus in part on diversifying the state workforce as another strategy to address historic structural inequities. The council’s long-term approach to address disparities is designed to level Minnesota’s economic and social playing fields and improve social equity and health outcomes for all.

The approaches taken by Minnesota’s and Indiana’s governors demonstrate how state leaders can push for social equity with targeted or broad systemic changes to improve overall social conditions. As more policymakers adopt an upstream approach to health and address inequities, they can reduce economic, social, and discrimination-based obstacles to generate better health outcomes for all.

State Officials Fear Final Public Charge Rule Could Deter Health Coverage Enrollment

September 10, 2019/in Policy Blogs CHIP, CHIP, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Healthy Child Development, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health, State Insurance Marketplaces /by Maureen Hensley-Quinn and Anita Cardwell

The Department of Homeland Security (DHS) recently finalized a rule that significantly changes immigration policies related to “public charge” determinations. Under long-established US immigration policies, individuals who are deemed likely to become a “public charge” and require extensive government support can be denied an adjustment of their immigration status (e.g., issued a green card) or entry into the country.

State officials across the country who administer health coverage programs are concerned about the rule’s chilling effect – that it will deter many immigrants from applying for coverage or even dropping out of programs they are eligible for because they fear their participation could impact their immigration status, even when it may not.

The Department of Homeland Security’s final rule defining “public charge” applies to most people seeking admission or adjustment of status (e.g., a green card). Notably, it does not apply to:

Refugees and asylum-seeking;
Survivors of trafficking;
Special immigrant juveniles;
Other specified groups; and
People who already have green cards, with narrow exceptions.

Source: Greenberg, M. Public Charge presentation, Aug. 21, 2019

As originally proposed by DHS, the final rule significantly expands the list of non-cash public benefit programs that DHS can consider in its public charge determinations, including those providing health care coverage, food, and housing assistance that address many of the social determinants of health. Specifically, public charge determination processes will now consider immigrants’ use of:

Most forms of Medicaid;
The Supplemental Nutrition Assistance Program (SNAP); and
Several federal housing assistance programs.

The proposed rule had included the Medicare low-income subsidy program that provides assistance to pay for the prescription Part D coverage program, but the final rule excluded it. DHS also requested public comments on whether to include the Children’s Health Insurance Program (CHIP) on the list of benefits for public charge determinations, but the final rule also excluded CHIP. Additionally, the final rule excluded the following from determining whether an immigrant met the public charge definition:

Medicaid use by children and youth under age 21 and pregnant women up to 60 days postpartum;
Emergency Medicaid; and
Medicaid services provided through the Individuals with Disabilities Education Act (IDEA) and schools.

The rule stipulates that individuals can be considered a public charge if they are “more likely than not” to receive any of the identified public benefits for more than 12 months over a 36-month period, and it does not distinguish by benefit type. Receipt of two types of benefits in one month is considered as two months of benefit usage. As a result, families that receive support from more than one program would reach the threshold sooner.

The policies laid out in the rule are complicated and allow for DHS agent discretion, which further challenges state officials who want to provide accurate information to residents about whether accessing public health coverage will ultimately cost them citizenship. The rule identifies “heavily weighted” negative and positive factors to guide DHS agents’ consideration in determining an immigrant’s likelihood of being or becoming a public charge.

An example of heavily weighted negative factor is the receipt of Medicaid coverage for more than 12 months during a 36-month period. A heavily weighted positive factor is employment that provides household income of at least 250 percent of the federal poverty level. The rule requires that DHS consider the totality of the immigrant’s circumstances, and the rule’s preamble notes, “depending on the alien’s specific circumstances, a heavily weighted negative factor can be outweighed by a positive heavily weighted factor,” but the rule is not prescriptive about how that will be determined, resulting in some ambiguity.

The rule’s “totality of circumstances” test includes benefit usage, but also takes into account an individual’s age, health, financial status, and education level. For example, having a medical condition that could require significant treatment or institutional care, or not having the financial capability to cover these care costs, is considered a heavily weighted negative factor.

Although tax credits provided through health insurance marketplace are not listed explicitly on the benefit programs to be considered in public charge determinations, they are a factor that is taken into account. Specifically, while private health insurance coverage is considered a heavily weighted positive factor, an individual who receives subsidized marketplace coverage would not receive the same favorable weighting.

Some state officials told the National Academy for State Health Policy (NASHP) there was already evidence of a chilling effect from the proposed rule. According to a 2018 Urban Institute survey of nonelderly adults who are foreign-born or live with one or more foreign-born family members, approximately 14 percent reported they did not participate in a noncash program because they feared it would jeopardize their future green card status. Now that the public charge rule is final, many state officials expect that more immigrants – regardless whether they are directly impacted by the rule or not – will drop coverage because of this chilling effect. For example, the final rule excludes consideration of children’s enrollment in Medicaid in public charge determinations, but their foreign-born parents may not choose to enroll them for fear it may affect their pursuit of a green card.

The rule’s “totality of circumstances” test and the allowance that DHS agents will weigh different circumstances in determining whether an individual is or will become a public charge creates a challenge in messaging how applying for public health coverage could impact an immigrants future status. State officials representing Medicaid, CHIP, and state-based marketplaces acknowledge they are not immigration experts and are reluctant to encourage individuals to retain or apply for public coverage given the implication it could have on their citizenship status.

Officials in some states are engaging community-based immigration organizations to provide immigrants with individualized guidance and advice about whether to apply for public coverage. While this strategy will be helpful, states anticipate there may be many individuals whose fear will keep them from seeking assistance. State officials are concerned about the anticipated coverage lapses and expect there will be increased costs for safety net care, which at this time is hard to estimate.

Although lawsuits against the rule have been filed by nearly 20 states as well as two California counties and several advocacy groups to delay its implementation, as of early September the rule appears poised to go into effect Oct. 15, 2019.

New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD

April 29, 2019/in Policy Alabama, Colorado, Kentucky, Mississippi, New Jersey, South Carolina, Texas, Virginia Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Erin Bonzon

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).

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

February 11, 2019/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

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

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

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

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

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

Fact Sheet Highlights Medicaid’s Critical Role in Screening for Maternal Depression

January 29, 2019/in Policy Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Coverage and Access, Healthy Child Development, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by NASHP Writers

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

December 4, 2018/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Hannah Eichner

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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.

How States Promote Recovery for Pregnant and Parenting Women with Substance Use Disorder

October 30, 2018/in Policy Colorado, Pennsylvania, Texas Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by Hannah Eichner, Becky Normile and Carrie Hanlon

Substance use disorder (SUD), including opioid use disorder (OUD), is prevalent among pregnant and parenting women, and these women have unique and often un-met treatment needs. Despite significant efforts, states report that access to treatment continues to lag for this population. In 2014, half of pregnant women with OUD who were enrolled in publicly-funded treatment programs received medication-assisted treatment (MAT) – considered the standard of care for people with OUD. New mothers are also at increased risk of relapse and overdose during the postpartum period.

The number of women with opioid use disorder during pregnancy has increased dramatically, affecting 6.5 of every 1,000 women at delivery in 2014.

Recognizing the needs of this population, Congress recently passed the SUPPORT for Patients and Communities Act, which orders a Government Accountability Office study into the coverage gaps that persist for pregnant and postpartum women with SUD who were eligible for Medicaid during pregnancy. And last week, the federal Center for Medicare & Medicaid Innovation announced the Maternal Opioid Misuse Model, which will offer cooperative agreements to up to 12 states to transform their delivery systems for pregnant and postpartum women with OUD and reduce fragmentation in delivery of care.
As SUD impacts mothers, it also affects their children. Between 2000 and 2012, rates of neonatal abstinence syndrome (NAS), caused by opioid exposure during pregnancy, rose five-fold, accounting for $462 million in Medicaid hospital costs in 2014. Exposure to other substances, such as alcohol, can also affect child development and parental substance use is linked to increased risk of child welfare involvement and childhood trauma.
A new National Academy for State Health Policy (NASHP) report, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder, supported by the Health Resources and Services Administration Office of Women’s Health, identifies promising strategies from Colorado, Pennsylvania, and Texas to support pregnant and parenting women with SUD. These states:

Support access and coverage through early identification of substance misuse by expanding postpartum coverage for SUD treatment, and by facilitating transitions between care settings. In Texas, a state that has not expanded Medicaid, women may become ineligible for Medicaid coverage 60 days after giving birth. As a result, they face challenges continuing SUD treatment beyond 60 days postpartum. To address this issue, Texas expanded state-funded SUD treatment slots for postpartum women. Under this initiative, when a woman’s Medicaid coverage ends after giving birth, she can seamlessly transition to a treatment slot funded by state general revenue without being on a waiting list, and experience no change or disruption in her providers or services.
Implement innovative care delivery models that consider the unique needs of women and families, such as integrating reproductive health care and SUD treatment, family-centered care models, and supports for social determinants of health. For example, Pennsylvania offers a Centers of Excellence (COE) program, funded by Medicaid and state general revenue, which provides coordinated and team-based care to individuals with OUD. Six COEs focus on meeting the unique needs of pregnant and postpartum women. These COEs coordinate services including SUD treatment, obstetric and postpartum care, and services that address social determinants of health, such as housing and transportation.
Promote cross-system financing and collaboration to develop alignment across policies and programs and to leverage multiple federal and state funding streams. For example, Colorado’s Special Connections program offers comprehensive and coordinated SUD treatment services for Medicaid enrollees who are pregnant and the services continue up to 12 months postpartum. The program is administered through a partnership between the state’s Department of Health Care Policy and Financing and Office of Behavioral Health. The program weaves together funding from Medicaid (authorized under the Medicaid state plan and a 1915(b) waiver), the federal Substance Abuse Prevention and Treatment Block Grant, and state general funds.

To learn more:

Read NASHP’s new issue brief, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.
Listen to a recording from an Oct. 24, 2018 webinar that explores how Colorado supports pregnant and parenting women with SUD.
Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.

State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

October 30, 2018/in Policy Colorado, Pennsylvania, Texas Reports Behavioral/Mental Health and SUD, Care Coordination, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Hannah Eichner, Becky Normile and Carrie Hanlon

The opioid epidemic has heightened states’ efforts to prevent and treat of substance use disorder (SUD) in pregnant and parenting women. The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration, interviewed Colorado, Pennsylvania, and Texas officials about the unique interagency approaches they are using to promote recovery for this population. This new report explores:

State coverage, care delivery, and financing strategies to support pregnant and parenting women with SUD;
Available state and federal funding sources for these initiatives; and
Key considerations for states working to promote recovery.

Read or download: State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

Download webinar slides and listen to the webinar that explored how Colorado supports pregnant and parenting women with SUD. The speakers were:
- Amy Cooper, Women’s Services Coordinator, Office of Behavioral Health, Colorado Department of Human Services;
- Susanna Snyder, Maternal Child Health Policy Specialist, Health Programs Office, Colorado Department of Health Care Policy and Financing; and
- Dr. Kaylin Klie, Physician, Denver Health; Assistant Professor, University of Colorado Department of Family Medicine

Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.

SUPPORT for Families and Communities Act: New Funding and Flexibility for States to Address Substance Use Disorder

October 23, 2018/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by Kitty Purington

Last week, Congress sent the SUPPORT for Patients and Communities Act, a wide-ranging bill that seeks to address the country’s opioid crisis across a number of policy areas, to the President for his signature. The act contains numerous provisions that affect how state Medicaid agencies structure and administer services and supports for individuals with opioid and other substance use disorders (SUD).
Medication-assisted treatment (MAT) emerges as a central strategy, and the act gives states some flexibility to expand SUD service delivery using Institutes for Mental Disease (IMDs). A number of provisions also address the impact of SUD on pregnant women, infants, children, and youth. The table below highlights some of the act’s key provisions affecting state Medicaid programs.

Requires states to cover children in foster care up to age 26 and to suspend eligibility for juvenile justice-involved youth (Sec. 1001, 1002)	By calendar year 2023, states must provide former foster care youth with Medicaid coverage up to age 26, regardless of what state they lived in when they aged out of the foster care system. Currently, Medicaid must cover youth up to age 26 within the state the youth aged out of foster care, and states have the option to cover youth who age out of another state’s foster care system. For youth engaged in the criminal justice system, the act requires states to suspend, rather than terminate, Medicaid coverage while these youth are incarcerated, and to restore their Medicaid coverage upon their release, without completing a new application, unless they no longer meet eligibility requirements.
Creates a demonstration program to expand SUD treatment (Sec. 1003)	The act creates a new demonstration program to improve capacity for SUD treatment services, with a particular focus on MAT, neonatal abstinence disorder, pregnant and post-partum women, and adolescents. Ten states will receive planning grants, and of those states, five will be selected to receive enhanced federal match for SUD treatment and recovery services.
Additional requirements for Medicaid drug utilization review (Sec. 1004)	By October, 2019, states will be required to have safety edits and automated review processes in place to avoid prescription abuse, monitor and report on antipsychotic medication prescribing to children, and identify fraud and abuse by Medicaid enrollees, providers, and pharmacies.
Extends SUD health home enhanced match to 10 quarters (Sec. 1006)	For health home state plan amendments approved on or after Oct. 1, 2018, the act extends enhanced Federal Medical Assistance Percentages (FMAP) funding to states from eight quarters to ten.
Requires MAT to be included in state plans (Sec. 1006)	From Oct. 1, 2020 to Sept. 30, 2025, states will be required to include MAT services in their state plans. States may certify that implementing the provision is not feasible due to a shortage of qualified providers or facilities to provide MAT.
Changes in Institutions for Mental Disease coverage (Sections 1012, 1013, 5052)	Permits states to pay for services delivered outside of an IMD to pregnant/postpartum while they are receiving SUD treatment in an IMD facility. Creates a temporary state plan amendment option period (Oct. 1, 2019 to Sept. 30, 2023) that permits payment for IMDs for up to 30 days within any 12-month period for Medicaid beneficiaries. Maintenance of effort is required by states for both IMD and outpatient SUD services. States must demonstrate that they have a full continuum of SUD services available. Clarifies that states may pay capitation rates to managed care plans for enrollees receiving treatment in an IMD.
Clarifies payment for treatment at residential pediatric recovery centers (Sec 1007)	Permits states to pay for inpatient or outpatient services, including counseling for parents, at residential pediatric recovery centers that treat infants with neonatal abstinence syndrome.
Strengthens prescription drug monitoring programs (Sec. 1944)	Starting October 2021 , states must require Medicaid providers to check patients’ prescription drug history before prescribing controlled substances. The act allows for enhanced FMAP to states for expenditures to design, develop, or implement a prescription drug monitoring program that meet the act’s requirements.
Changes Medicaid managed care medical loss ratio (Sec. 4001)	Permits states to receive an enhanced share of remittances from Medicaid managed care plans that do not meet the minimum medical loss ratio of 85 percent.
Mandates reporting on adult behavioral health measures (Sec. 5001)	Beginning with the state report for 2024, states will be required to report on all behavioral health measures included in the adult core measure set.
Extends mental health parity to Children’s Health Insurance Programs (CHIP)	Requires all state CHIP programs to include coverage of mental health services, including behavioral health treatment. The provision explicitly notes that the requirement for these comprehensive services applies to both children and pregnant women regardless of the type of coverage (including separate CHIP programs) that a state has selected to operate.