Medicaid Managed Care – Page 4 – The National Academy for State Health Policy

How Governors Addressed Health Care in their 2020 State of the State Addresses

February 13, 2020/in Policy Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Social Determinants of Health, State Insurance Marketplaces, State Rx Legislative Action, Work Requirements /by Sarah Lanford and Anita Cardwell

NASHP Joins Lewin Group to Provide Integrated Care for Kids Model Support

February 10, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Karen VanLandeghem

The Centers for Medicare & Medicaid Services (CMS) has awarded the Lewin Group and its partners, which includes the National Academy for State Health Policy (NASHP), a seven-year contract to support implementation and monitoring for CMS’ Integrated Care for Kids (InCK) Model.

Launched in January 2020, this model is part of CMS’s strategy to fight the opioid crisis and address its impact on vulnerable Medicaid and the Children’s Health Insurance Program (CHIP)-covered children and their caregivers. The InCK Model aims to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable payment models to coordinate physical and behavioral health care with services to address health-related needs. InCK funding will provide Connecticut, Illinois (2 awards), New Jersey, New York, North Carolina, Ohio, and Oregon with the flexibility to design interventions for their local communities that align health care delivery with child welfare support, educational systems, housing and nutrition services, mobile crisis response services, maternal and child health systems, and other relevant service systems. By bringing together medical, behavioral, and community-based services, InCK strives to reduce fragmentation in service delivery and expand access to care for children and youth.

The Lewin Group, NASHP, and the other team members will support implementation of the InCK Model through technical assistance, program monitoring, measuring awardees’ progress on critical program milestones and outcomes measures, data collection and analysis, and critical feedback loops to support awardees’ work toward their goals.

“The Lewin Group is excited to contribute to this innovative approach that breaks new ground in the delivery of child- and family-centered care and the development of pediatric alternative payment models. We look forward to working with CMS to positively impact of the health of the next generation,” said Lisa Alecxih, Lewin Chief Capabilities Officer.

“NASHP is delighted to partner with the Lewin Group to support this innovative CMS InCK model,” said Trish Riley, NASHP’s executive director. “We bring to this work our decades of expertise in state health care delivery system design, cross-sector partnerships, payment reform, and the unique needs of children and their families.”

The Lewin Group is an established leader in health care and human services policy research, analytics and consulting at the federal and state level.

CMS Requests Input to Better Coordinate Care for Children with Complex Conditions from Out-of-State Providers

February 10, 2020/in Policy Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, EPSDT, Health Equity, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Social Determinants of Health /by Kate Honsberger

The Centers for Medicare & Medicaid Services (CMS) recently released a request for information (RFI) for input from states, providers, health systems, and families to better coordinate care from out-of-state providers for children with complex health conditions enrolled in Medicaid. The deadline to submit comments is March 23, 2020.

States have long addressed issues of access to care, provider availability, service delivery system design, and public insurance reimbursement for children with medical complexity (CMC). This RFI addresses considerations for CMC who may require specialized treatment or therapy that is not offered by in-state providers and therefore need services in other states, complicating the ability of states to coordinate and deliver care effectively.

Coordinating care for enrollees from out-of-state providers can also present an administrative burden for state officials who are required to screen and enroll these providers in their Medicaid programs in order to provide payment for services. This RFI is part of a requirement from the Medicaid Services Investment and Accountability Act of 2019 which calls for the secretary of the Department of Health and Human Services to issue guidance to states on this topic.

CMS is seeking input from states and stakeholders who have experience with specific aspects of coordinating care from out-of-state providers, including:

Sate initiatives that have promoted and/or improved the coordination of services and supports provided by out-of-state providers to children with CMC;
Administrative, fiscal, and regulatory barriers that states, providers, and enrollees and their families experience that prevent children with CMC from receiving care, such as community and social support services, from out-of-state providers in a timely fashion, as well as examples of successful approaches to reducing those barriers;
Measures that have been or can be employed by states, providers, health systems, and hospitals to reduce barriers to coordinating care for children with CMC when receiving care from out-of-state providers; and
Best practices for developing appropriate and reasonable contract terms and payment rates for out-of-state providers in both Medicaid fee-for-service and managed care systems.

For a full list of requested information please review the RFI. CMS will review input from states and stakeholders and issue guidance by October 2020. The new guidance will include:

Best practices for using out-of-state providers to provide care to children with CMC;
Coordinating care provided by out-of-state providers to children with CMC, including services provided in emergency and non-emergency situations;
Reducing barriers that prevent children with CMC from receiving care from out-of-state providers in a timely fashion; and
Processes for screening and enrolling out-of-state providers, including efforts to streamline these processes or reduce the burden of these processes on out-of-state providers.

The National Academy for State Health Policy (NASHP) encourages states to submit relevant information to shape future guidance.

The RFI was posted on January 21, 2020 and comments are due March 23, 2020.

View the CMS RFI for instructions on how to submit comments. NASHP will share the release of any future CMS guidance on this topic as part of its ongoing work in the area of children with medical complexity.

To review NASHP resources related to children with medical complexity and children and youth with special health care needs, please visit its resource page.

New York Recommends Pediatric Preventive Care Improvements in its First 1,000 Days on Medicaid Report

December 16, 2019/in Policy New York Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Elinor Higgins

By age three, a child’s brain has grown to 80 percent of its adult size and experiences during the first 1,000 days are critical to healthy brain development and social, emotional, cognitive, language, and physical development. Preventive measures taken in the first few years of life can have a significant and lasting impact on a child’s future health outcomes and overall success. New York is honing strategies to support healthy development during the first 1,000 days through primary care and trauma prevention strategies.

In October 2019, New York released recommendations from its Final Report of the First 1,000 Days Preventive Pediatric Care Clinical Advisory Group as part of the First 1,000 Days on Medicaid redesign initiative, which was launched in July 2017. It recognizes the critical role that Medicaid can play in the early life of children to help set them up for future success. The initiative also aims to work collaboratively with education programs and other sectors to deliver better results for children in New York.

Later in 2017, a group of stakeholders from different sectors and agencies, including education, child welfare, community-based organizations, public health, and mental health, convened to produce a plan for 10 proposed activities to be part of this initiative. Their first goal was to create a Preventive Pediatric Care Clinical Advisory Group that would develop a framework model for how to organize pediatric care in order to implement the Bright Futures guidelines. The framework model would identify barriers, possible incentives, and new system approaches to deliver the most effective care possible during well-child visits.

The advisory group included members from several child- and family-serving sectors that frequently partner with pediatric primary care, such as education, Early Intervention, and child welfare, and the group also sought feedback and participation from family representatives and community groups. The report, produced in October for the New York Medicaid program, details the group’s Model of Pediatric Population Health, which aims to build on the patient-centered medical home model with higher standards of care and care coordination. The focus of the model is on practice transformation to address the social determinants of health related to poverty, racism, and other environmental influences, and it integrates behavioral health care with traditional clinical care. The model lays out three tiers for integrating behavioral health:

Tier 1: Services received by all children:
- Screening: Age-appropriate screenings for child development, maternal depression, and adverse childhood experiences (ACEs), social-emotional development, social determinants of health, and interpersonal violence
- Culturally sensitive anticipatory guidance focused on social-emotional/family health (e.g., Reach Out and Read, Vroom, lactation counseling, parent access for questions)
- Information about community resources (e.g., Head Start)

Tier 2: Services received when a child or parent has an identified need: (Examples include developmental delay, housing or concrete services need, trauma, or maternal anxiety)
- Short-term counseling by early childhood mental health-trained professionals
- Care coordination by staff knowledgeable about early childhood services to facilitate connection with community resources
- Follow up and escalation to Tier 3 if needed
- Care delivered in a collaborative care model by the primary care provider, with support from mental health professionals either in the practice or remotely via tele-health

Tier 3: Services received when a more complex need is identified for a child or parent
Therapeutic intervention (e.g., dyadic therapy, parental mental health and substance use treatment) in the practice
- Referral to community-based mental health services when needed
- Case management (with early childhood skills) for all needs, including navigation across services

The report recognizes that there will be an increased need for behavioral health staff if the three-tier model is to be implemented successfully. The group envisions that half of the Tier 1 and Tier 2 services could be reimbursed under Medicaid based on diagnoses and fee-for-service payments, but that a capitated payment model might be more effective. For Tier 3 services, the report recommends a parallel to the value-based payment model used to fund collaborative care for adults through Medicaid. Capitated payments through value-based contracts between Medicaid managed care organizations and pediatric practices have been suggested by stakeholders as a potential path for a child-focused, population-based arrangement.

The goal of this model is to achieve health equity for all children and families by addressing systemic disparities, fostering trust between families and medical providers, promoting community linkages, and providing two-generational, trauma-informed, culturally competent, and integrated primary and behavioral health care.

The advisory group also produced a list of recommendations about committing to the Pediatric Population Health model through activities like investment in its core programs, including sustaining the HealthySteps model and sites funded by the NYS Office of Mental Health HealthySteps pilot, and the documentation of progress and outcomes for children as different aspects of the model are piloted. The other planned activities included in the First 1,000 Days on Medicaid initiative include a focus on early literacy, home visiting, development of data systems for cross-sector referrals, and a peer family navigators pilot program.

New York is not the only state focusing on the first few years of a child’s life as a critical period for improving health outcomes across the lifespan. Rhode Island’s First 1,000 Days of RIte Care, the state Medicaid program, aims to improve rates of developmental screening and coordination between pediatric care with family home visiting and Early Intervention. California’s Medicaid program, MediCal, is collaborating with the state’s Office of the Surgeon General to address ACEs with trauma screenings and provider training on trauma-informed care. As states continue to look for ways to improve health at all ages, early childhood is a period where increased coordination across sectors and agencies can lead to preventive strategies that have a lasting impact.

This blog is supported by the David and Lucille Packard Foundation. To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.

Infographic: State Team-Based Care Strategies for Medicaid-Eligible Women

December 2, 2019/in Policy District Of Columbia, Minnesota, Montana Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration /by Eddy Fernandez

For more information, please click the program titles and read NASHP’s State Medicaid Quality Measurement Activities for Women’s Health.

Acknowledgement: Thank you to the officials in Washington, DC, Montana, and Minnesota for reviewing their respective highlighted strategies. This infographic is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

States Increase Access to Oral Health Services and Support Overall Health

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

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

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

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

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

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

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

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

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

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

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

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

Introduction

Key Terms

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

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

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

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

Medicaid SUD Coverage and Benefits for Pregnant Women

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

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

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

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

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

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

Examples of State Medicaid Coverage and Quality Improvement Strategies

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

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

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

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

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

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

Leverage waivers to expand coverage and access to SUD treatment.

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

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

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

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

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

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

Conclusion

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

Notes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Using Data, Incentives, and Innovation, Three States Work to Improve Maternal Vaccination Rates

November 4, 2019/in Policy California, Colorado, Wisconsin Blogs, Featured News Home Chronic Disease Prevention and Management, Health Coverage and Access, Health IT/Data, Immunization, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Social Determinants of Health /by Ariella Levisohn

Despite the health benefits of immunizing pregnant women against influenza and pertussis (whooping cough) and protecting them and their infants from these life-threatening diseases, only half of pregnant women are vaccinated against both diseases and only one-third receive both the influenza and pertussis vaccines during pregnancy.

Three states are trying a number of innovative approaches to increase vaccination rates among pregnant women by providing incentives to health plans, increasing access to vaccinations through pharmacies, and using data to identify and target populations, regions, and providers with substandard influenza and Tdap (which protects against pertussis) vaccination rates.

Evidence shows pregnant women are at increased risk of developing complications from certain preventable diseases and can also risk passing those diseases on to their children. Following immunization, data shows that both mothers and infants are less likely to be hospitalized from complications. When a woman is vaccinated during pregnancy, she develops antibodies that are transmitted to her child before birth, which can then protect the infant during the first few months after birth. The US Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or planning to become pregnant get the flu vaccine and the Tdap vaccine during each pregnancy.

Low Immunization Rates Persist

Despite the CDC’s guidelines, many women do not receive the influenza and pertussis vaccines during pregnancy. According to the CDC’s recent report, Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States, published in Morbidity and Mortality Weekly Report (MMWR), current rates of maternal immunization for influenza and Tdap are 53.7 percent and 54.9 percent, respectively. Only one-third of pregnant women received both the influenza and Tdap vaccines, and the rates are even lower for African-American pregnant women. The report noted that provider recommendations to patients can improve maternal immunization rates – when providers offered vaccinations or provided a referral to pregnant women, 65.7 and 70.5 percent received the flu and Tdap vaccine, respectively. Based on this data, the CDC recommends that providers begin discussing vaccinations with pregnant patients early and continue the conversation during each visit.

Overall, women enrolled in public insurance programs were less likely to be vaccinated during pregnancy than women with private insurance, due in part to access barriers. State Medicaid agencies, which cover 43 percent of all births across the United States and up to 60 percent of births in some states, can use innovative approaches to identify pregnant women in need of vaccinations, gather data to identify strategies and targeted approaches, and encourage providers to increase vaccination rates to improve health and save on costs.

The 2019 MMWR data are especially notable in light of the Healthy People 2020 goal to increase the number of pregnant women vaccinated against influenza to 80 percent. While most states remain far from that goal, California, Colorado, and Wisconsin are working to improve maternal vaccination rates for both their Medicaid populations and privately insured women.

California’s Medi-Cal Strategies

In California, pregnant women covered by Medi-Cal, the state’s Medicaid plan, see providers who are less likely to stock or recommend the Tdap vaccine. Women on Medi-Cal receive prenatal Tdap immunizations at much lower rates than privately insured women, and infants born to mothers with Medi-Cal coverage are twice as likely to contract pertussis compared to privately insured infants. California is using a number of strategies to improve maternal immunization rates for women on Medi-Cal, including setting expectations for contracted health plans, monitoring and providing incentives, and addressing barriers at the clinician and patient level:

Medi-Cal managed care contracts require health plans to ensure the timely provision of all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations for members, and report data to the California Immunization Registry (CAIR). Medi-Cal managed care contracts also require that contracted health plans monitor their primary care provider sites for the provision of preventive services, including all ACIP-recommended immunizations for adults and children.

California’s 2019-2020 budget includes funding for incentive payments in the managed care delivery system for timely prenatal care as well as for prenatal providers who administer the Tdap vaccine to pregnant members. Some of California’s Medi-Cal managed care health plans are also trying to lower the financial barriers to providing vaccines by allowing providers to directly bill the health plan outside of capitation rates, providing free Tdap starter doses to clinics, and encouraging group purchasing of vaccines.

Medi-Cal encourages its health plans to follow up on potential quality of care issues when cases of pertussis in infants born to unvaccinated mothers are identified through public health department notification.

California pharmacists are authorized to provide immunizations without a physician’s order. Most major chain pharmacies in California offer Tdap immunizations as part of their vaccine portfolio. All routinely recommended adult vaccines are covered by Medicaid without prior authorization (in both fee-for-service and managed care plans) when given in a provider’s office or in a pharmacy. Recent state regulations require pharmacists to notify providers of immunizations administered and to enter all doses into the California Immunization Registry, making it possible for providers to know whether vaccine referrals to pharmacies are successful.

Colorado and Wisconsin’s Use of Data

One of the challenges to improving maternal immunization rates is obtaining and monitoring data, especially as many states do not require providers to report immunizations to their Immunization Information Systems (IIS). Quality data, though, is needed by states working to tailor their strategies for improving immunization uptake to the areas of highest need and to monitor trends. Specifically, the Centers for Medicare & Medicaid Services identifies data linking of Medicaid eligibity and claims data with vital statistics data as a critical mechanism for surveillance, programmatic monitoring, and evaluation of maternal immunization.

Colorado is using data matching to determine the rates of maternal immunization in each county. Colorado has successfully matched 96 percent of patient medical record numbers with Colorado Immunization Information System (CIIS) records. The CIIS data matching has allowed the state to map immunization rates by provider and region and identify gaps in maternal immunization uptake. Colorado is now using this data to determine the areas of highest need in the state to inform and guide outreach programs. Currently, Colorado is also piloting text and email reminders to encourage patients to get vaccinated.

Wisconsin is also using data matching to obtain baseline immunization rates. Wisconsin matched 96 percent of women who gave birth in 2018, as recorded by the Vital Records Office, with data from the Wisconsin Immunization Registry. Like Colorado, Wisconsin used this data to create data maps to identify influenza and Tdap vaccination levels in each region of the state. Wisconsin was also able to track vaccination rates by age, race, type of insurance, and quality of prenatal care. Next steps for the state include monitoring these trends, identifying areas of highest need, and using the data to improve maternal immunization rates.

In addition to partnering with state public health departments and their immunization programs, state Medicaid agencies can partner with providers to ensure vaccines are stocked and to promote vaccine recommendations for pregnant women so they become routine. For example, the American College of Obstetricians and Gynecologists has released a number of resources designed to support health care providers in increasing maternal vaccination rates, including the Maternal Immunization Tool Kit, strategies for immunization implementation, and a guide to starting an office-based immunization program. The American Academy of Pediatrics also offers recommendations on cost-saving measures for the purchase and administration of immunizations. Finally, the CDC has compiled a toolkit for prenatal care providers that includes resources for provider and patient vaccination education.

In addition to these resources, other states can learn from the work California, Colorado, and Wisconsin have done to identify gaps and improve vaccination rates among pregnant women covered by state Medicaid programs.

Acknowledgements:
The National Academy for State Health Policy (NASHP) would like to thank Abby Klemp at the Wisconsin Department of Health Services, Sarah Royce at the California Department of Public Health, and Karen Mark at the California Department of Health Care Services for their time and insight. NASHP would also like to thank the US Centers for Disease Control and Prevention for their assistance with this blog and for funding this project.

How States Use the National Standards for CYSHCN in their Health Care Systems

October 28, 2019/in Policy Charts, Featured News Home, Maps Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement, Quality and Measurement /by NASHP Staff

States Feature Strategies to Better Integrate Care for Dual-Eligible Beneficiaries

October 21, 2019/in Policy Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Long-Term Care, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement /by Kitty Purington

Dual Eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare and medical assistance from a state Medicaid plan. States cover some Medicare costs, depending on the state and the individual’s eligibility.

Many states already leverage Dual Eligible Special Needs Plans (D-SNPs ) to better manage care for individuals enrolled in both Medicare and state Medicaid programs. Recent changes to federal regulation, stemming the Bipartisan Budget Act of 2018, are expected to make D-SNPs more attractive for states seeking to better integrate care for this population.

The National Academy for State Health Policy (NASHP), with support from The SCAN Foundation, convened state policymakers at its recent annual conference to explore these new opportunities, highlight Medicare/Medicaid integration efforts in leading states, and explore what internal state capacity is needed to successfully address the needs of dual-eligible beneficiaries across programs.

The session, Maximizing Medicare: New Opportunities to Support State Policy Goals, featured examples of successful D-SNP models in Minnesota and Arizona, and highlighted lessons learned from states, detailing what internal expertise is needed to support these programs.

Individuals covered by both Medicare and Medicaid present unique challenges for state policymakers. This population often has higher health care costs and poorer outcomes, including higher rates of chronic conditions and behavioral health diagnoses. For states, creating well-integrated and coordinated systems of care for this high-needs population can be hampered by the complex interplay of these two programs.

The Bipartisan Budget Act of 2018 permanently authorized D-SNPs, and final regulations require D-SNPs to coordinate Medicaid benefits for duals and assist them in navigating appeals. The new rule also requires D-SNPs – in some circumstances – to provide an integrated appeals process and discharge planning for some high-need members. All D-SNPs must meet certain minimum integration criteria by 2021.

Both Minnesota and Arizona have experienced improved integration of care for duals through use of D-SNPs. Both states leveraged the contracting requirements of the Medicare Improvements for Patients and Providers Act to align administration and improve consumer experience. Wisconsin has structured its program to provide a more integrated experience at every step, including one set of enrollment materials, aligned enrollment dates, and care coordination for primary, acute, and long-term care services. Arizona’s D-SNP plans must be contracted “companion” plans with the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid agency. This and other contract features help encourage member enrollment in the same health plan for both Medicare and Medicaid services.

What internal capacity is needed to make these programs work? Presenters offered the following key takeaways:

Leadership is critical: Strong leadership is an important factor in providing more integrated care for duals. Leadership that understands the complexity of the population, and the need to mobilize specific resources and policies to address their unique issues and make long-term investment in these programs has been an ingredient for success in leading states.
Build and nurture strong managed care organization (MCO) partnerships: Collaborative relationships with Medicaid MCOs are also central to integrating care across programs. To avoid misalignment, presenters suggested working with MCOs to review detailed descriptions of the services to be coordinated by D-SNPs, including behavioral health and long-term services and supports, and discussing enrollment, marketing, and appeals policies with them to identify and resolve issues.
Engage stakeholders: Similarly, states found it helpful to regularly engage a range of stakeholders – providers, members, and advocates – to identify specific needs and areas of disconnect, and to allay consumer and provider concerns who may be impacted by policy changes.
Focus on staff capacity and ongoing training: States emphasized the need to have subject matter expertise within a state Medicaid agency. One presenter noted, “integration is a process and not an event,” long-term capacity is necessary to be able to analyze and respond to the changing state and federal regulatory landscape on an ongoing basis. Having designated staff and facilitating clear lines of communication across offices within Medicaid with an “open door policy” can also help identify and troubleshoot issues. Important areas of expertise include accessing and using Medicare data, understanding covered services and payment, and familiarity with state policy options to better integrate care.

Presenters encouraged policymakers to make full use of available resources to help them better understand the policy issues and needs of dual eligibles. The federal Medicare-Medicaid Coordination Office (MMCO) was noted as an excellent resource. MMCO leaders recently released a State Medicaid Director Letter detailing how states can improve care for dually-eligible beneficiaries. Additionally, the Integrated Care Resource Center website also provides a host of state-specific materials and learning opportunities.

Additional information and copies of slide presentations from NASHP’s 2019 conference is available on this Conference Presentation page.