Eligibility Levels for Pregnancy-Related Coverage in Medicaid and CHIP
Eligibility Levels for Pregnancy-Related Coverage in Medicaid and CHIP
Through Coordination and Investment, Arizona Substantially Increases Access to School-Based Behavioral Health Services
By leveraging federal Medicaid funding and state investment while simultaneously clarifying complex billing procedures and enhancing engagement with providers, Arizona has made remarkable progress in increasing student access to critical school-based behavioral health services.
Arizona’s efforts to improve school behavioral health services began in 2018 when its state legislature allocated $3 million from the state’s general fund to expand these services. The state’s Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of Education (DOE) used $1 million of this funding to provide schools with mental health training, and the remaining $2 million was matched with federal Medicaid funds, resulting in a total $10 million in Medicaid funding to increase the number of behavioral health providers in schools.
To obtain Medicaid reimbursement for school-based services under the Medicaid School-Based Claiming (MSBC) program, Arizona’s local education agencies (LEAs) use two school-based claiming programs, the Direct Service Claiming (DSC) program and the Medicaid Administrative Claiming (MAC) program. LEAs seek Medicaid reimbursement through the DSC program to cover the cost of providing medical and behavioral health services to Medicaid-eligible students with an Individualized Education Program (IEP). The MAC program provides LEAs with reimbursement for administrative outreach services for Medicaid that are conducted in school settings. The state contracts with a third-party administrator, Public Consulting Group (PCG), to process Medicaid school-based claims.
In addition to claims processed through the MSBC program for students with IEPs, Medicaid services delivered by behavioral health providers contracted through one of AHCCCS’ managed care organizations can be reimbursed by Medicaid regardless of whether the student has an IEP.
Challenges and Solutions
Improving partnerships and coordination between schools and providers: While Arizona provided school behavioral health services before 2018, the additional state funding helped prioritize these services and facilitated the development of new relationships between behavioral health providers and schools. State officials reported that prior to the initiative to promote school-based behavioral health services, there were some challenges related to establishing relationships between schools and providers.
For example, some school administrators were skeptical if they could bill for school-based services or were concerned about the logistics of providing appropriate space to conduct behavioral health services without interrupting usual school activities. Many of these issues have been addressed through extensive and ongoing training sessions with both school administrators and provider groups. State officials also credited the cross-sector workgroup meetings that are held on a regular basis with helping improve interagency relationships.
Another key factor in Arizona’s success was incentivizing partnerships between schools and behavioral health provider agencies to create a differential adjusted payment for behavioral health providers. The enhanced payment became effective in October 2019, and provides a 1 percent rate increase for providers that have a memorandum of understanding with three or more schools to provide behavioral health services, and a 3 percent rate increase for providers that are autism Centers of Excellence.
State officials at AHCCCS also are in the process of improving data sharing with the DOE. By matching school identifier numbers on claims for services provided on a school campus, or as the result of a referral from an educational entity, the state will be able to obtain a better understanding of where and which services are delivered. Improving these data-matching processes will also provide information about where students are being referred for additional services and help identify where future focus should be directed within the state to enhance school-based behavioral health services.
Another key partnership to support students’ behavioral health needs is AHCCCS’ collaboration with the Arizona DOE on several grants, including Project Aware, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Project AWARE works with three school districts to provide suicide prevention and behavioral health resources.
Addressing lack of behavioral health providers and service delivery challenges: Arizona state officials identified the lack of behavioral health providers, particularly in rural regions, as an issue faced by many states. However, Arizona officials are pleased and encouraged by the number of providers who are participating in the state’s expansion of school-based behavioral health services. One factor that likely incentivized greater provider engagement was the implementation of the differential adjusted payment, although state officials indicated that there had already been a growing interest among behavioral health providers to develop new school partnerships to reach more students due to the statewide focus on the issue.
School districts in Arizona have also developed creative solutions to connect their students to behavioral health services. One school district in Arizona responded to provider shortages and space limitations by setting up a dedicated mobile unit in the school parking lot for behavioral health services. Prior to bringing in the mobile clinic, providers did not have financial incentives to travel to the school because it was difficult to secure an appropriate office during the school day. With the mobile unit, the district can provide consistency for their providers as well as a private space for students to receive behavioral health care. However, because the care is not technically provided in the school building, the district needed to work with the state Medicaid agency to find a way to appropriately bill under school-based behavioral health services.
Clarifying qualifying services and billing procedures: The state’s increased focus on the provision of behavioral health services in schools also helped to improve the accuracy of billing code processes. When efforts to expand school-based behavioral health services were initially launched, state officials at AHCCCS actively worked to address some of the existing misunderstandings about the allowability for those services to be provided at a school campus outside of the MSBC program. State officials recognized that due to errors in coding related to where services are provided, some school-based behavioral health services were not being correctly captured, resulting in the state not having a clear picture of the scope of services being provided to students.
To address these issues, AHCCCS coordinated and led many informational learning sessions throughout the state for both educators and provider agencies, including trainings about billing procedures. Once providers learned how to assign the correct place of service code, state officials reported a notable increase in the quantity of behavioral health services provided. State officials attributed the increase not only to the coding improvements that more accurately captured completed work, but also due to new services provided as a result of the state’s overall emphasis and investment in school behavioral health services.
Like many states, Arizona uses a Random Moment Time Study (RMTS) to assess the amount of time providers spend engaged in Medicaid-reimbursable activities. Each LEA has a RMTS coordinator who facilitates the administration of the program. As the third-party administrator, PCG manages the overall RMTS process, and provides program-specific introductory trainings for new coordinators and LEAs as well as recurring trainings to provide program updates and address areas of concern. AHCCCS coordinates with PCG to improve the RMTS process, and at present, AHCCCS consistently meets RMTS compliance standards, despite having to transition to virtual trainings during the COVID-19 pandemic.
Effect of COVID-19: The transition to mobile learning due to COVID-19-related school closures has presented an opportunity for schools to provide behavioral health services through virtual platforms. State officials report there has been a reduction in the number of claims that use place-of-service codes, which indicate when services are provided at an educational institution, most likely due to the decrease in the number of students attending school in person because of the pandemic. However, officials indicated that they have observed a dramatic increase in the amount of behavioral health services currently delivered through telehealth as more students have had to operate within a remote learning environment.
For districts without local providers, the ability to work with students without travel has helped connect more children to care. According to one Arizona state official, many behavioral health providers have gone above and beyond to connect with children whose need for care has been exacerbated by stress and isolation resulting from the pandemic.
State officials said there is anecdotal evidence that the pandemic has caused an increase in the number of parents expressing concern that their children are exhibiting depression and/or suicidal tendencies. However, officials also noted they have observed a greater willingness among parents to discuss issues concerning mental health, which could result in parents more actively advocating to ensure that schools continue to offer behavioral health services.
Overall Success
Since the start of the state’s efforts to expand behavioral health services in schools in 2018, officials report progress has been remarkably successful throughout 2019 and into early 2020, and there has been a substantial increase in the number of students who have received behavioral health services from an educational entity or institution. While declines in the number of youth suicides cannot be directly correlated with the state’s expansion of behavioral health services — and data from the effect of the pandemic is not yet available — there was a 41 percent decrease in youth suicides from 2018 through 2019.
State officials report their efforts have been so successful that in 2020 the state legislature passed SB 1523, which established and allocated $8 million to a new Children’s Behavioral Health Services Fund that will further enhance school-based behavioral health services. The fund will be administered by AHCCCS and provides behavioral health services to students who are not Medicaid-eligible but are uninsured or under-insured and who receive a referral for services from an educational institution.
In reflecting on lessons from Arizona’s expansion of school-based behavioral health services that might be used by other states, officials explained that determining how to handle nuanced billing situations, such as telehealth and the state’s mobile unit, was an important factor in ensuring that all provided services were accurately captured and reimbursed. They commented, “If Arizona can do it, anyone can do it — we are ranked 51st in [the nation for] education funding, and we have the poorest counselor-to-student ratio in the nation…that said, we have this great state Medicaid agency, and we’ve been able to figure out how to reach more kids with the dollars given to us. And so, if Arizona can figure out how to do this sort of work and get these partners on school campuses, then any other state can do this.”
The National Academy for State Health Policy (NASHP) would like to thank state officials from Arizona for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Eight States Join NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy to Address Maternal Mortality
The National Academy for State Health Policy (NASHP) has announced a new, two-year policy academy kicking off in April for state health officials interested in building state capacity to address maternal mortality for Medicaid-eligible pregnant and parenting women, with the goal of improving access to quality care.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the Maternal and Child Health Bureau within the Health Resources and Services Administration, NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy will engage eight state teams (GA, ID, IL, IA, LA, PA, SD, and VA). The teams include representatives from state Medicaid agencies, public health agencies, and other state stakeholders (e.g., mental health/substance use agencies, child welfare agencies, provider groups, Medicaid managed care plans, and others.)
Through this policy academy, states will identify, develop, and implement policy changes or develop specific plans for policy changes to improve maternal health outcomes, with a specific focus on improving racial disparities in maternal mortality.
The United States has seen a steady rise in maternal mortality over the past few years and has the worst maternal mortality rate among developed nations. Additionally, there are stark racial disparities in pregnancy-related deaths. American Indian/Alaska Native and Black women are two- to three- times more likely to die from pregnancy-related causes than non-Latinx (non-Hispanic) White women. States are grappling with a number of factors in their efforts to improve access to quality care for this population and strengthen the systems serving them.
Over the course of the two-year project, NASHP will provide technical assistance to states, identify barriers, and share promising practices for improving maternal health outcomes to help states achieve their policy goals.
State Health Policy Resources to Promote Black Maternal Health and Equity
Each year approximately 700 women die in the United States as a result of pregnancy or related complications, and Black women are three- to five-times more likely to die in childbirth than White women. In honor of the fourth Black Maternal Health week, April 11-17, 2021, sponsored by the Black Mamas Matter Alliance, the National Academy for State Health Policy (NASHP), is showcasing recent state health policy resources to help improve Black maternal health.
NASHP Blogs
- New Jersey Medicaid Implements New Policies to Improve Maternal Health, March 2021
- How New York Is Safeguarding Pregnant Women during the COVID-19 Pandemic, November 2020
- State Strategies to Address the Black Maternal Health Crisis, October 2020
- Eight States Join NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy to Address Maternal Mortality, April 2021
NASHP Report
- Four State Strategies to Employ Doulas to Improve Maternal Health and Birth Outcomes in Medicaid, July 2020
Interactive Maps and Charts
- State Maternal Mortality Review Committee Membership and Recommendations, February 2021
- State Medicaid Policies for Maternal Depression Screening During Well-Child Visits, April 2020
- View Each State’s Efforts to Extend Medicaid Coverage to Postpartum Women, March 2020
Infographic
State Team-Based Care Strategies for Medicaid-Eligible Women, December 2019
Michigan’s Caring for Students Program Leverages Medicaid Funding to Expand School Behavioral Health Services
Despite a federal rule change that allows states to bill Medicaid for school-based physical and behavioral health services provided to all Medicaid-enrolled students, many states struggle to overcome the persistent and complex billing challenges associated with receiving Medicaid reimbursement for delivery of these critical services.
To access additional Medicaid funds to expand school-based behavioral health services, Michigan established the Caring 4 Students (C4S) program, which strengthens partnerships between its Medicaid agency, providers, and educational entities and streamlines Medicaid billing policies and procedures. This case study explores how Michigan overcame some of the challenges states face when seeking Medicaid reimbursement for school-based behavioral health services. It also describes how Michigan retooled the C4S program during the pandemic to ensure the services continued to reach students through telehealth.
Introduction
The majority of children who receive behavioral health care access these services in school settings. According to the School-Based Health Alliance, 70 percent of children who receive mental health services access them at school.[1] As an increasing number of children experience worsening behavioral health due to the pandemic,[2] the need for these support services is even greater. Also, with the pandemic forcing many schools to offer reduced in-person teaching or fully remote learning, they have had to adapt and provide more behavioral health services through telehealth.
While states can fund school-based behavioral health services in a variety of ways, a number of states have leveraged federal Medicaid dollars to help fund behavioral health services for students with Medicaid coverage. In federal fiscal year 2016, estimated Medicaid spending for both school-based and administrative services totaled $4.5 billion.[3]
Historically, schools were restricted in their ability to receive federal Medicaid reimbursement for physical and behavioral health services provided to Medicaid-enrolled students. The “free care rule” prohibited schools from seeking Medicaid payments for services provided to Medicaid-enrolled students if the services were provided for free to all students, such as no-cost health screenings. While the rule contained an exception for services identified in Medicaid-enrolled students’ Individuals Education Plans (IEPs), it limited schools’ ability to obtain Medicaid reimbursement for services provided to students with Medicaid coverage who did not have IEPs. However, as a result of the “free care rule” policy reversal in 2014, states have the opportunity to bill Medicaid for physical and behavioral health services delivered to all Medicaid-enrolled students, including students without IEPs.
Despite the rule change, some schools still face challenges in obtaining Medicaid reimbursement for services provided to Medicaid enrollees, either due to state-level policy barriers or other issues, such as the administrative complexity of the billing process. School staff often may not have the expertise or resources to implement Medicaid billing procedures, and often need assistance and training from state education and Medicaid agencies.[4] Also, some states with budgets impacted by the pandemic may be limited in their ability to invest in an expansion of services.
Development of C4S
To help increase students’ access to behavioral health services, in 2019 Michigan capitalized on the flexibility provided by the reversal of the free care rule by creating the C4S program through a state plan amendment (SPA) that leverages the Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) benefit. Through the C4S program, Michigan schools can now receive Medicaid reimbursement for services delivered to Medicaid-eligible students if they are covered under EPSDT, delivered within a provider’s scope of practice, and billed in accordance with state Medicaid billing procedures.[5]
In addition to federal Medicaid dollars, implementation of the C4S program was bolstered by state funding,[6] which included a $16.5 million allocation by the state legislature in the fall of 2018 to provide direct medical services to students that must be billed to Medicaid whenever possible. State officials subsequently acted quickly to submit a Medicaid SPA by December 2018, and after approval by federal officials, the state launched the C4S program in October 2019.
Interagency Coordination
Nearly all 587 school districts in Michigan fall under the authority of an intermediate school district (ISD), which conducts various administrative functions for the schools. Michigan has 56 ISDs, as well as two independent school districts, and the ISD system structure allows all schools, regardless of how small they are, to participate in the C4S program because the reimbursement claims are administered by the ISDs. The state considers the ISDs to be the main provider entities within the C4S program, as clinicians participating in the program report their services under each ISD’s provider identifier number.
State officials characterize the C4S program as a three-legged stool – consisting of Medicaid, the ISDs and the Michigan Department of Education (MDE) – all closely coordinating together to support the behavioral health needs of students. Even prior to the reversal of the free care rule, Michigan ISDs worked closely with the state Medicaid agency to provide IEP services for Medicaid-enrolled students. The strong relationship between Medicaid and the ISDs can be credited, in part, to a payment agreement that provides ISDs with 60 percent of federal Medicaid reimbursement for school-based services. To provide schools the support needed to manage the service expansion through C4S, ISDs receive 95 percent of the federal share for services covered under the program and the state Medicaid agency receives the remaining five percent to cover administrative costs.
Challenges and Solutions
Lack of behavioral health providers: In addition to expanding the scope of Medicaid reimbursable health and behavioral health services, the C4S program also expanded the type of providers who can claim reimbursement for delivering services to Medicaid-enrolled students. While funding from the legislature allowed the state to hire new mental health staff, the C4S program still needed additional providers because similar to many states, Michigan was already facing shortages within its mental health workforce.
In response, Michigan’s Medicaid officials employed a creative approach to ensure there were enough providers to support the expansion of school behavioral health services. Recognizing the potential of utilizing other categories of providers, such as physician assistants, nurse practitioners, behavior analysts, and marriage and family therapists, state officials incorporated them and others into the list of allowable providers. Including these additional provider types expanded the behavioral health workforce pool and helped the state address the lack of providers, particularly in rural areas of the state.
Overall complexity of reimbursement process: State Medicaid agency officials indicated that some school districts were initially hesitant to participate in the C4S program because they were concerned about the potential administrative burden that might be involved with implementing the Medicaid reimbursement process. These concerns have been addressed by establishing strong communication channels among the three entities (Medicaid, ISDs, and MDE) to clarify processes and procedures and provide ample opportunities for staff training sessions.
Given the complexity of the reimbursement process, the state Medicaid agency works particularly closely with the ISDs to provide them with answers to specific questions. Training on implementing the reimbursement processes occurs frequently, both at an annual conference and on a regular basis because of the frequency of staff turnover in the schools and consequently the need to train new employees about the procedures and how to account for time spent providing services.
One key aspect of the Medicaid reimbursement model is that the state uses a process that is based on paying for part of the salary of a particular staff position, rather than reimbursing for the actual services themselves. Given that providers do not spend all of their time engaging in reimbursable activities, in order to determine the amount of their salaries that can be reimbursed by Medicaid, state officials must estimate the portion of time they spent on providing medically eligible services to Medicaid-enrolled children. To do this, each month state officials ask for responses to a Random Moment Time Study (RMTS), which is a federally approved method to assess how providers spend their time. The RMTS data is incorporated into an algorithm containing a number of other factors, and this calculation forms the basis of the Medicaid reimbursement model.
State officials reported there are still some challenges associated with helping providers understand how to evaluate their time spent providing services when they respond to requests for RMTS data, due to some providers’ lack of familiarity with the RMTS process as well as the accelerated pace of implementation of the C4S program. However, state officials indicated that they expect these issues can be addressed with additional training.
Provider and general reimbursement issues: One challenge the state encountered during the initial stages of C4S implementation was due to an existing rule within MDE, which stipulated that if a provider’s salary was partially funded by general education dollars that individual was not permitted to work with special education students. State Medicaid officials worked with MDE to eliminate that rule, and this has resulted in the ability to more effectively and efficiently allocate providers’ time and allow them to serve more students.
Another key to the state’s success in increasing Medicaid reimbursement for behavioral health services provided in the schools was to address the reimbursement rate applied to school psychologists. There are four different pools of staff providers serving students — direct services staff, personal care services staff, targeted case management staff, and administrative and outreach staff. Prior to implementation of C4S, the school psychologists were categorized as part of the administrative outreach pool, resulting in a low Medicaid reimbursement rate. State officials were able to work with the Centers for Medicare & Medicaid Services (CMS) to change that designation so they were instead recognized as part of the direct service staff pool, which significantly increased their reimbursement rates.
Michigan state officials also anticipated a potential administrative challenge related to provider reimbursement. If the state used two separate Medicaid state plans to implement the program — one for special education students and another for general education students — this would create reimbursement complications because it would silo providers into serving only one student population group. By instead submitting a SPA for the C4S program that added in coverage of the general education students, this allowed providers to serve both groups of students. The state also worked closely with CMS on the overall reimbursement methodology to maximize the program’s potential for leveraging federal Medicaid funds, which included keeping the students with IEPs separate from the general education students in the state’s calculations because of their differing Medicaid eligibility rates.
Transition to online school services due to COVID-19: Michigan officials had to quickly adjust policies and processes in response to the statewide shift to online learning in the spring of 2020 due to the COVID-19 pandemic. State officials had heard anecdotally about an increased need among students for behavioral health services due to stresses associated with the pandemic, and they anticipate that this demand may continue to grow. Recognizing the need to increase access to behavioral health services for students who may be in crisis, the state waived the requirement that a plan of care must be in place, allowing schools to bill Medicaid up to 30 days without an existing plan of care.
State officials quickly broadened their telehealth policies to include an audio-only provision, and while that will most likely be discontinued when the pandemic ends, they indicated that they plan to sustain many other telehealth provisions post-pandemic.
Also, while telehealth services were implemented fairly rapidly, state officials reported that changing the billing processes was not as easy. School closures caused nearly all RMTS moments to show no reimbursable activity, because providers were not providing medical or behavioral health services during the initial stages of the closure. State officials explained that while this did result in a notable loss in reimbursement, the enhanced Federal Medical Assistance Percentage (FMAP) provided by the Families First Coronavirus Response Act would help cover much of this decrease. Also, CMS allowed the state to use an average of RMTS responses from the last two quarters for their RMTS when schools were closed, because of the significant declines in time spent providing care, and state officials indicated that federal approval to do this helped significantly.
The state is also seeking to ensure equitable access to behavioral health services by focusing on addressing issues for students who lack access to devices that can be used for telehealth services. State officials recently submitted a SPA to federal officials to obtain reimbursement for providing students in need of devices with access to iPads and computers that would be owned and managed by the schools. They indicated that if the proposal is approved, they plan to continue reimbursing for devices beyond the pandemic period.
Overall successes: The C4S program has not only achieved one of its overall goals of increasing students’ access to behavioral health services, it has also helped bring in needed additional funds to the schools. There had already been some psychologists in the schools, but it was not until implementation of C4S that Michigan was able to obtain Medicaid reimbursement for any qualifying services provided. Also, despite needing to navigate the challenges associated with the pandemic, state officials considered it a success that there has been an approximate 6 percent increase in the amount of federal Medicaid reimbursement being directed to schools through the C4S program.
The Future of C4S
State officials said they anticipate that C4S’ initial successes will continue and that the program will likely expand further, as not all ISDs were able to implement the program fully during its initial stages. As school hiring begins to increase post-pandemic and as providers and ISDs become more familiar with navigating the RMTS responses and overall reimbursement process, state officials indicated they expect the program to grow steadily in the coming months.
Notes
The National Academy for State Health Policy (NASHP) would like to thank state officials from Michigan for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.
[1] Mental Health webpage on the School-Based Health Alliance webpage, https://www.sbh4all.org/school-health-care/health-and-learning/mental-health/.
[2] Stephen W. Patrick et al, “Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey. Pediatrics October 2020, 146(4). https://pediatrics.aappublications.org/content/146/4/e2020016824
[3] Medicaid and CHIP Payment and Access Commission (MACPAC), “Medicaid in Schools.” April 2018. https://www.macpac.gov/wp-content/uploads/2018/04/Medicaid-in-Schools.pdf
[4] Heather Clapp Padgette, Candace Webb, Phyllis Jordan, “How Medicaid and CHIP Can Support Student Success through Schools.” Georgetown University Center for Children and Families, April 2019. https://ccf.georgetown.edu/2019/04/24/how-medicaid-and-chip-can-support-student-success-through-schools/
[5] While the C4S program serves all students, the state can only receive Medicaid reimbursement for services provided to Medicaid-eligible children. Also, the C4S program also expands school nursing services, but this case study focuses on the program’s behavioral health services.
[6] Also, the non-federal share of Medicaid spending for school-based services is provided by schools through certified public expenditures.
Recent State Actions to Address Declining Children’s Insurance Coverage Rates
Since reaching an all-time low in 2016, the rate of uninsured children has climbed from 4.7 percent in 2016 to 5.7 percent in 2019. In response, several state legislatures are considering bills designed to improve children’s coverage options and promote child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP).
Program and Enrollment Expansions
One of the most notable efforts to expand children’s coverage was included in New Jersey Gov. Phil Murphy’s fiscal year 2022 budget, which establishes the Cover All Kids initiative to provide coverage to all uninsured children. At an estimated cost of $20 million, it is forecasted to cover 88,000 children by expanding Medicaid eligibility thresholds and extending coverage to children currently ineligible due to immigration status.
The Cover All Kids program aligns with initiatives previously proposed by New Jersey advocates and legislators to ensure all children have coverage. The governor’s proposed budget also directs the Department of Human Services to eliminate premiums and the waiting list for children enrolled in CHIP and provides funds for an enhanced outreach campaign to increase Medicaid and CHIP child enrollment.
In Utah, lawmakers considered two children’s coverage bills during this session. In 2019, Utah had the third-highest increase in the rate of uninsured children and the highest rate of uninsured Latinx children in the country. In response to these troubling statistics, the Utah Legislature passed HB262, which creates the Children’s Health Care Coverage program. This program directs the Utah Department of Health, Department of Workforce Services, and the state Board of Education to develop a program to promote health insurance coverage for children when they enroll in school and when they apply for free and reduced lunch.
The Utah law also requires the state to:
- Conduct research on families who are eligible for Medicaid and CHIP to determine their awareness of coverage options;
- Analyze trends in disenrollment to identify barriers for coverage renewal; and
- Administer surveys to gather information about current enrollees’ experiences with the programs.
Findings from this research will be used to redesign the CHIP and children’s Medicaid enrollment websites and inform future outreach partnerships.
Another Utah bill, SB158, designed to address the state’s coverage crisis through the creation of a robust outreach program, focused on enrolling underserved populations, providing application assistance, and launching an advertising campaign to draw attention to coverage opportunities for children. In addition, the bill would have expanded public coverage to children whose family income fell below 200 percent of the federal poverty level (FPL). Despite senate approval, the bill did not pass.
Like Utah, Florida experienced a dramatic increase in childhood uninsured rates since 2016. The Center for Children and Families at Georgetown University’s Health Policy Institute 2020 report found that more than 55,000 Florida children had lost coverage between 2016 and 2019, representing the second-highest coverage drop in the nation during that period. Florida legislators are currently considering HB 201 and SB 1244, both of which would increase the eligibility threshold for their CHIP program from 200 percent of FPL incrementally by 20 percent each year beginning in the 2021-2022 fiscal year, until reaching 300 percent of FPL, which is expected in the 2026-2027 fiscal year.
In Maine, legislators are considering LD 372, a bill to expand access to CHIP. The bill includes provisions to:
- Expand income eligibility from 200 to 300 percent of FPL;
- Eliminate the waiting period for children whose families have lost employer-sponsored coverage;
- Extend coverage eligibility from age 19 to 20; and
- Eliminate premium payments for all enrollees.
Express-lane eligibility:
Last week, the Georgia Legislature passed HB 163, which directs the Department of Community Health to seek federal approval to establish express-lane-eligibility (ELE) for children whose families apply for the Supplemental Nutrition Assistance Program (SNAP). By implementing the ELE option, children will automatically be enrolled or renewed in Medicaid or the state’s CHIP program, PeachCare for Kids, based on the current information provided in their SNAP application. State child health advocates estimate that this could increase child enrollment in Medicaid in the state by 70,000. Currently, five states use SNAP data to determine eligibility for Medicaid and/or CHIP.
CHIP Buy-in Programs:
Legislators in Iowa and West Virginia are considering bills to create CHIP buy-in programs, which allow families with incomes above their state’s CHIP eligibility thresholds to purchase coverage.
Iowa’s SF220 would allow families to purchase CHIP coverage for children and young adults up to age 26 whose household income exceeds the maximum income eligibility threshold of 302 percent of FPL. Iowa’s CHIP-buy in plan differs from traditional CHIP buy-in programs as it would allow families to purchase CHIP coverage for their children as an alternative to qualified health plans on the exchange or plans on the individual market — which unlike CHIP are not tailored to children’s needs.
The CHIP coverage would be sold through the marketplace, allowing families to compare their coverage options, and could be paid for with premium tax credits for eligible enrollees. If passed, the state would need federal approval to implement the plan.
West Virginia’s HB2278 would establish a buy-in program for children’s whose families earn more than 300 percent of FPL and could afford to pay the cost of CHIP coverage in full.
Despite states continuing to grapple with managing the COVID-19 pandemic, many are still seeking to improve coverage for children in Medicaid and CHIP. The National Academy for State Health Policy continues to track states’ efforts to increase enrollment in children’s coverage in Medicaid and CHIP.
New Jersey Medicaid Implements New Policies to Improve Maternal Health
New Jersey, like many states, faces rising maternal mortality rates and racial disparities. A recent review of pregnancy-related deaths in the state from 2009 to 2013 found 46.2 percent of deaths occurred in Black women, compared to 26.9 percent in White women. With approximately 40 percent of New Jersey’s births covered by Medicaid, the governor’s office recently announced the following Medicaid initiatives to improve maternal health and reduce overall health care costs.
Medicaid Coverage of Doula Care: Legislation passed in 2019 enabled Medicaid coverage of doula services in the state. A doula is a trained professional who provides continuous physical, emotional, and informational support to the birthing parent throughout the perinatal period. Doula care has been shown to reduce cesarean rates, improve birth experiences, and improve birth outcomes. Once doulas receive the community-based doula training from an approved program, they are able to enroll as fee-for-service providers and with Medicaid managed care organizations.
New Jersey has designated two levels of doula care eligible for reimbursement, standard and enhanced care.
- Services for standard care include up to eight perinatal visits and attendance during labor and delivery with a reimbursement rate of $800.08.
- Enhanced care is for members age 19 or younger and services include 12 perinatal visits and attendance during labor and delivery with a reimbursement of $1,066.
- Additionally, for both levels of care there is an $100 incentive for postpartum, follow-up visits.
In order to receive the incentive payment, doulas must provide a postpartum service visit within six weeks of delivery and use the code 99199 HD U8 for billing. An obstetric clinician follow-up visit must occur within six weeks of delivery to receive the incentive payment but is not required for doulas to receive reimbursement for other services. Doulas serving Medicaid enrollees must be trained to provide culturally competent care that supports the diversity of the members and assist members with community-based services to improve health outcomes. Currently, Minnesota and Oregon cover doula services for all Medicaid recipients and New York has a pilot program running in two counties. Additionally, as directed by their state legislatures, Virginia and Washington State have submitted reports and studies on implementation of Medicaid reimbursement.
Increased Payments to Certified Nurse Midwives: In an effort to increase access to quality maternity services, New Jersey Medicaid has also increased the reimbursement rate of certified nurse midwives (CNMs) to be equivalent to 95 percent of the current rate for physicians who provide prenatal, labor and delivery, and postpartum services. A CNM is an advanced practice registered nurse (with a master’s degree in nursing) who specializes in the care of women throughout their life course, including pregnancy, childbirth, and the postpartum period. According to the most recent Pregnancy Risk Assessment Monitoring System (PRAMS) data, 33.1 percent of Black, non-Hispanic mothers in New Jersey reported receiving late or no prenatal care, compared to 14.6 percent of White, non-Hispanic mothers. The increase in reimbursement rates for CNMs is designed to build a larger network of midwives and increase access to quality pregnancy-related care for mothers and babies in New Jersey. As of 2013, approximately 34 states and Washington, DC, reimburse CNMs at 90 to 100 percent of the rate of earned by practicing physicians.
Medicaid Will Not Pay for Non-Medically Necessary, Early-Elective Deliveries (EED): In 2019, New Jersey passed a law that no provider will be approved for reimbursement by Medicaid for a non-medically indicated, early-elective delivery performed at a hospital on a pregnant woman earlier than the 39th week of gestation. Scheduled cesarean sections or medical inductions performed prior to 39 weeks carry risks for both mother and baby. Overall, New Jersey’s rate of surgical births (cesareans) is 30.3 percent. The benefits of non-surgical birth include shorter hospital stays, reduced infection rates, lower blood clot risk, and fewer infants born with difficulty breathing. Currently, 20 states have reduced or eliminated payment for procedures (EEDs, elective inductions, and non-medically necessary cesarean sections) that do not follow clinical guidelines. The new Medicaid policy in New Jersey supports education campaigns and hospital initiatives that are already in place to lower non-medically necessary EEDs. The new policy will not affect mothers who have medical indications for early delivery.
Providers Required to Complete the Perinatal Risk Assessment (PRA) Forms: In 2019, the state passed a law requiring Medicaid providers to complete PRAs during the first prenatal visit for all Medicaid enrollees. The tool is used to identify demographic, medical, and psychosocial factors that can help determine case management plans for pregnancies. The PRA form has been updated to included assessment of alcohol and drug use and COVID-19-related challenges. The state will use the data collected from the PRAs to analyze and identify risk factors among pregnant Medicaid enrollees in the state.
State Medicaid programs have the opportunity to implement policy changes, similar to New Jersey’s, that support improving maternal and infant health outcomes. Given current budget challenges in states, funding can be challenging, but these policy changes can result in cost savings by lowering cesarean rates, decreasing length of stays in hospitals, and improving overall birth outcomes. The National Academy for State Health Policy (NASHP) will continue to track state maternal and child health policies.
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. 
