New Federal Resources Can Support States’ Affordable and Supportive Housing Programs
Across the nation, COVID-19 has exacerbated the dual challenges of housing affordability and homelessness. As states address these issues, there are new federal resources available through the American Rescue Plan Act (ARPA) and proposed American Jobs Plan that states can deploy efficiently and equitably.
The economic impact from COVID-19 has left 30 to 40 million Americans at risk of eviction with a disproportionate impact on low-income communities of color. To avoid homelessness, many individuals and families have sought housing with friends and family, leading to crowding and increased coronavirus transmission. The pandemic has also greatly impacted individuals currently experiencing homelessness and living in congregate shelters. In New York City, the age-adjusted mortality rate from COVID-19 among sheltered people experiencing homelessness was 50 percent higher than the rest of the population’s cumulative rate as of February 2021.
The National Academy for State Health Policy (NASHP) is launching its Second Health and Housing Institute. The goal of the institute is to help states break down inter-agency silos and strengthen services and supports to help low-income and vulnerable populations become and remain successfully housed. Permanent supportive housing programs require affordable housing and housing-related services financed by Medicaid. Importantly, the new institute will focus on state deployment and execution of newly available federal resources.
With the passage of ARPA and the proposed American Jobs Plan, the following are new programs, policy, and funding opportunities:
Eviction Prevention and Affordable Housing:
- In late March, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky extended the temporary halt in residential evictions until June 30, 2021. Under the eviction moratorium, individuals must declare their inability to pay rent due to the loss of income or employment to avoid eviction.
- ARPA allocated $21.5 billion for the Emergency Rental Assistance Program (ERAP). ERAP funds will be released by early May 2021 to support eligible households in which one or more individuals are experiencing unemployment or housing instability. Financial assistance is limited to 18 months.
- $100 million in grants to organizations approved by the Department of Housing and Urban Development (HUD) that provide housing counseling services to households experiencing housing instability. Housing counseling includes information on renting, mortgage defaults, foreclosures, and credit issues.
- $5 billion allocated in ARPA for emergency housing vouchers. Vouchers serve as emergency rental assistance and voucher renewals for people experiencing homelessness, at risk of homelessness, experiencing housing instability, or fleeing intimate partner violence.
Supportive Housing and Homelessness Assistance:
- $5 billion in federal funding to states for the Homelessness Assistance and Supportive Services Program. This funding will be distributed to states to acquire and develop properties for supportive housing programs, tenant-based rental assistance, and supportive services, including housing counseling and homeless prevention services. Funding can also be used for the supportive housing workforce and service providers.
Home- and Community-Based Services:
- President Biden’s proposed American Jobs Plan includes $400 billion to strengthen home- and community-based services for seniors and people with disabilities. This funding will also raise wages for home health care workers and support the Money Follows the Person program to provide services for individuals in communities rather than nursing homes. Both home-and community-based services and the Money Follows the Person program are essential components of supportive housing.
These newly available resources provide states with opportunities to support, expand, and develop programs for those experiencing homelessness, housing instability, and populations that benefit from supportive housing. States will play an important role in determining how resources are distributed equitably to communities that have historically been denied federal housing resources and those most in need. In addition, some funding will go directly to local governments, public housing authorities and HUD-approved nonprofits. States can work collaboratively with these partners on shared agendas around housing stability and homelessness to strengthen health outcomes.
Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author 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. The author would also like to thank the Corporation for Supportive Housing for their analysis of the American Rescue Plan Act.
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
Medicaid Agencies Cultivate Partnerships and Deploy Data to Bolster COVID-19 Vaccination Efforts
COVID-19 vaccine distribution has accelerated across states as the Biden Administration updates its vaccine goal to 200 million doses by April 23, 2021 and many states are opening eligibility to all adults by early April. The National Academy for State Health Policy (NASHP) recently spoke with several state Medicaid officials to learn more about how their agencies – and specifically their Medicaid managed care organizations (MCOs) – are leveraging partnerships and data to advance their vaccination efforts.
Leadership and communication across state agencies are enabling optimal coordination.
States’ COVID-19 vaccination efforts are primary led by their departments of health (DOHs), but nearly every other state agency plays a role in helping to raise awareness with the constituencies they serve or by aiding with vaccine logistics and administration – often both. To reduce confusion, agencies must work in lockstep, agreeing on policies while using similar messaging and data sources to promote accurate information about the vaccine. In the case of Medicaid, state officials work not only to convey vaccine updates from their state DOH to Medicaid enrollees, but also to the health plans and providers they work with. Medicaid agencies have revised call center scripts, website content, and other resources so they are in line with the latest language put forth by their DOHs.
To improve coordination, Medicaid agency officials participate in, and sometimes lead, weekly meetings with state and county officials to update them about the latest vaccine progress. They have also worked with state and county officials to identify and share data about Medicaid enrollees to enable improved targeting of high-risk, and/or priority populations for outreach by state and local authorities. Medicaid agencies have also shared data about provider networks to aid vaccine administration efforts. Specifically, data has been used to recruit providers who are already actively engaged in serving certain populations as part of direct vaccination efforts, including as vaccine administrators at mobile vaccination sites.
Empowering Medicaid health plans encourages innovative vaccination promotion strategies.
Along with collaborating with state and local agencies, Medicaid agencies have also cultivated stronger relationships with their MCOs and other participating health plans to promote vaccinations. Several states’ officials report meeting with their health plans on a biweekly or weekly basis to share the latest updates on vaccination policy, as well as to strategize about best practices to encourage vaccination. United by a mutual goal of encouraging members toward health and away from catastrophic illness, the vaccination effort provides a unique opportunity for Medicaid to work in partnership with its health plans and encourages innovative approaches to improve vaccination rates. Some innovative strategies include:
- Distributing educational material about how to schedule appointments and appointment reminders;
- Enabling plans and plan representatives to schedule appointments on behalf of enrollees;
- Active post-vaccination outreach to assess vaccine side effects;
- Communication to family members and care takers about vaccine eligibility and access; and
- Development of training modules for care managers to address vaccine hesitancy.
Several officials especially noted the challenge of ensuring transportation to and from vaccination sites. To mitigate these issues, states have employed various methods of moderating this barrier – from providing access to free transportation services to mandating that health plans cover transportation to and from vaccination sites. One state had a policy to reimburse enrollees for miles traveled, while another worked with carriers to set a rate for transit services that included a “wait time” between arrival at and departure from the vaccination site.
Access to state data is critical to health plan participation in vaccination efforts.
Beyond sharing strategies to encourage outreach and access to vaccination sites, Medicaid agencies have played a key role in sharing critical data about Medicaid enrollees directly with MCOs or other participating carriers.
Medicaid agencies have unique access to state data sources, including Medicaid enrollment and claims data and vaccination data from public health data repositories, which is otherwise not available to private companies or other agencies. Access to this data not only positions a state Medicaid agency to take an active role in identifying enrollees to target for vaccination outreach, but it also enables it to perform analytics across data sources. For example, some states are cross-walking vaccine registry data with Medicaid data to identify Medicaid recipients who have scheduled vaccination appointments or who have been vaccinated. This ability to crosswalk data from vaccine registries is especially important, as many vaccines are scheduled and administered without an insurance claim, leaving health plans without any information about the vaccination status of their enrollees. However, armed with Medicaid data and analytics, health plans are able to conduct direct follow-up with their members. In several cases, states report active participation from health plans that are using data to encourage vaccination, including among high-risk individuals. Others go further and connect enrollees with case managers who may be able to assist with arranging transit to and from appointments or scheduling follow-ups for the second vaccine dose.
Capacity to conduct complex analytics may be limited based on states systems’ ability to extract and share data across agencies, and outdated claims processing systems may affect the timeliness of available data. Meanwhile, vaccination databases are in the midst of being brought to scale in tandem with escalating vaccination efforts, and data may not yet be fully accessible or up to date in state systems. State agencies are rapidly working to improve data capacity, including efforts to enable direct connections between carriers and providers to data sources or analytic information. One state also reported efforts to access data from border states, to ensure it had updated vaccination information even for those that may get vaccinated outside of the state.
States have and continue to rapidly adapt in response to the ever-evolving pandemic. As vaccine capacity increases, they will continue to build on their growing resources and infrastructure to address changing needs and circumstances. As they do, NASHP will report on the development of new policies and promising practices from those at the forefront of addressing the COVID-19 crisis.
How States Use Federal Medicaid Authorities to Finance Housing-Related Services
To address the housing needs of their Medicaid enrollees, states can leverage a variety of federal Medicaid authorities to deliver housing-related support services to individuals with disabilities and chronic conditions. This report explores the various federal waivers states used to increase supportive housing and reduce their Medicaid costs.
Background
Housing is an essential social determinant of health. Evidence shows a strong association between access to safe, affordable, and stable housing and positive health outcomes. Housing with supportive services, known as permanent supportive housing, supports individuals with complex medical needs and reduces emergency department use. Supportive housing also helps individuals remain stably housed over the long term.
There is also a strong return on investment for states that implement permanent supportive housing programs. By investing in supportive housing, states and localities can reduce health care, homeless shelter, and corrections costs. For example, Oregon reported a 12 percent savings in Medicaid expenditures one year after moving 1,625 individuals into affordable housing with support services. Many states support housing’s role in health by funding housing-related services in their Medicaid programs.
NASHP recently finished its three-year Health and Housing Institute with state officials from Illinois, Louisiana, New York, Oregon and Texas. The institute’s goal was to break down agency silos within states and strengthen services and supports that assist low-income and populations with complex conditions in becoming and remaining successfully and stably housed. Maximizing policy levers and authorities available through the Medicaid program was critical to increasing housing-related services and tenancy supports.
Priority Populations
States are currently engaged in supportive housing initiatives for people with disabilities, mental health diagnoses, substance use disorder (SUD), multiple chronic conditions, and those experiencing or at-risk of homelessness.
States are also focused on deinstitutionalization due to mandates set by the 1999 Supreme Court case, Olmstead, Commissioner, Georgia Department of Human Resources et al. vs. L.C.. The case stated that institutionalization of individuals with disabilities who can be served in the community is unjustified segregation. Research indicates that community-based settings are more cost effective, less restrictive, and provide better outcomes for individuals with disabilities than institutions. As a result, the Centers for Medicare & Medicaid Services (CMS) has issued guidance, known as the Olmstead Letters, to help states identify services that support deinstitutionalization.
Medicaid and Housing-Related Services
Medicaid provides services for individuals with low incomes as well as specific populations, including those with intellectual, developmental, and physical disabilities. People who are homeless or at risk of homelessness generally qualify for Medicaid, especially in states with expanded programs for low-income adults. There is also increased national attention and resources for supportive housing for people with SUD. In November 2020, the Secretary of Health and Human Services released a report on housing-related services and supports under state Medicaid programs as a part of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This report identifies federal authorities to provide housing-related services to people with SUD.
While Medicaid cannot pay for housing development or rent, with the exception of security deposits in some states, it can support services for enrollees to find and sustain housing. These services, defined by each state, can include:
- Education and training on the role, rights, and responsibilities of the tenant and landlord;
- Early detection and intervention for behaviors that may jeopardize housing, such as late rental payment and lease violations;
- Assistance with the housing recertification process; and
- Coordination with services and service providers for primary care, SUD treatment, mental health providers, and vocational and employment support.
Medicaid authorities allow states to test approaches to program financing and delivery by waiving Medicaid statutory requirements, and amending existing state plans. The following explores how states use Medicaid Section 1115 Demonstration waivers, 1915(b) Managed Care Authorities, 1915(c) Home- and Community-Based Services (HCBS) waivers, 1915(i) HCBS state plan amendments, the 1915(k) Community First Choice Option, and Health Homes to finance housing-related services.
Federal Medicaid Authorities for Housing-Related Services
Section 1115 demonstration waivers allow for “experimental, pilot, or demonstration projects that are found by the Secretary to be likely to assist in promoting the objectives of the Medicaid program.” Section 1115 demonstrations allow states to test innovative models and address social determinants of health and are considered to be more flexible than other federal Medicaid authorities. Section 1115 waivers also allow states to target services for population groups and within specific geographies.
Section 1115 waivers must be budget neutral to the federal government, meaning the federal contribution cannot exceed the amount without the demonstration initiative. Savings generated from the demonstration can also be invested in other innovations, such as coverage expansions in state Medicaid programs. States are also required to conduct monitoring and evaluation of their 1115 demonstrations, findings that can be useful to other states looking into implementing similar demonstration waivers. Most 1115 waivers are approved for a five-year period and can then be renewed for up to three to five years.
Trends across housing-related 1115 waivers show that states target different groups, but primarily focus on individuals with high emergency department use, SUDs, and serious mental illness (SMI).
- Virginia recently added eviction prevention and housing transitional services for individuals with serious behavioral and physical health needs at risk of homelessness through a 1115 demonstration waiver. These services include:
- Individual housing and pre-tenancy services: Includes a housing assessment, financial literacy education, application assistance, an individualized housing support plan, and identification of resources to obtain housing.
- Individual housing and tenancy-sustaining services: Updating individual housing support plans as needed, assisting in securing independent living supports, educating about roles and responsibilities of tenants and landlords, making home modifications, linking to community resources, and providing annual pest eradication treatment as needed.
- Community transition services: Provides up to $5,000 per member per lifetime to help individuals obtain an independent community-based living setting. Allowable expenses include security deposits, home furnishings, and home modifications.
1915(b) Managed Care Authority
A section 1915(b) waiver is one avenue for states to implement a managed care program among other provisions. This waiver allows states to waive requirements for comparability, statewide access, and freedom of choice and it can be approved for two years. Savings achieved through managed care can be used to provide housing-related services.
As identified by the SUPPORT Act report, few states leverage the 1915(b) authority for housing-related services.
- In Colorado, the state’s Community Mental Health Services Program includes Assertive Community Treatment (ACT). ACT teams, staffed by licensed clinicians and peer specialists, provide 24/7 individualized services to adults with a serious mental health diagnosis including housing assistance.
1915(c) Home- and Community-Based Services (HCBS) Waivers
Section 1915(c) HCBS waivers are designed to provide services in community-based settings rather than institutional settings. These waivers must provide services that cost less than services offered in institutions, protect individuals’ health and welfare, have adequate and reasonable provider standards, and are individualized and person-centered.
States can operate multiple HCBS waivers and define target groups by age or diagnoses and choose the maximum number of enrollees allowed. HCBS services can be offered to individuals earning up to 300 percent of the federal poverty level (FPL). HCBS waivers can cover housing, pre-tenancy services, tenancy-sustaining services and transition services. States primarily use 1915(c) waivers to cover individuals with disabilities – not individuals at risk of homelessness, with chronic conditions, or SUD. This is due to the waivers’ requirement that individuals meet an institutional level of care for services. Some states, including Louisiana, operate different waivers for children and adults.
Louisiana currently operates four 1915(c) HCBS waivers:
- Children’s Choice Waiver: Covers housing stabilization and transition services for individuals with autism, intellectual disabilities (ID) and developmental disabilities (DD) for ages 0-20.
- New Opportunities Waiver: Provides housing stabilization, transition services, and $3,000 per member per lifetime maximum for security deposits and essential home furnishings.
- Residential Options Waiver: Covers in-home caregiving, community living supports, one-time transitional services, housing stabilization, and transition services for individuals of all ages with autism, ID and DD.
- Supports Waiver: Promotes housing stabilization and transition services for individuals of all ages with autism, ID, and DD.
1915(i) State Plan Home- and Community-Based Services
The 1915(i) state plan authority is similar to 1915(c), but allows states to provide HCBS services through a State Plan Amendment (SPA), rather than a waiver. States cannot limit the number of individuals eligible or geography for services and beneficiaries qualify through needs-based criteria, rather than institutional criteria used for the 1915(c). States can use age, disability status, diagnosis and/or Medicaid eligibility group to target their benefit for individuals earning below 150 percent of FPL.
The 1915(i) state plan option is considered to be more broad than the 1915(c) option, however states may struggle to create targeted service programs due to eligibility requirements. States can use risk of homelessness as a needs-based criteria, however eligibility must include other levels of functionality, such as behavior, cognitive abilities and medical risk factors.
- North Dakota’s 1915(i) state plan amendment (SPA) was recently approved to provide community transitional services and housing support services to individuals with a mental health or SUD or disability. Services include benefit application, lease applications, one-time expenses for furnishings and modifications, financial literacy training and education on the roles of landlords and tenants.
1915(k) Community First Choice (CFC) Option
The CFC state plan option was established by the Affordable Care Act (ACA and allows states to provide person-centered home- and community-based attendant services and supports. States receive a 6 percent increase to their Federal Medical Assistance Percentage (FMAP) for this option. States cannot cap the number of individuals participating and cannot target special populations. Eligible individuals must:
- Be eligible for Medicaid under the state plan;
- Meet an institutional level of care;
- If not entitled to nursing facility services, have an income below 150 percent FPL; and
- Enroll voluntarily.
Under the option, states can finance transition costs such as security deposits and home furnishings and other expenditures that support and individual’s independence.
- Oregon and Maryland cover these housing-related services in their CFC programs.
Section 2703 of the ACA allows states to develop health homes for Medicaid enrollees with chronic conditions. States can implement a health home through an SPA. Health home services are eligible for a 90 percent-enhanced FMAP for the first two years of the SPA. Health home services include these six core services;
- Comprehensive case management;
- Care coordination;
- Health promotion;
- Comprehensive transitional care and follow-up;
- Individual and family support; and
- Referral to community and social services.
Health homes do not expire like waivers and SPAs. As of December 2020, 21 states and Washington, DC were operating 37 health home models. Six states terminated their SPAs and are no longer offering health home services.
- California’s health home program provides housing transition and tenancy-sustaining services for individual with chronic conditions, mental illness, or chronic homelessness as defined by its SPA. Multi-disciplinary care teams must include a housing navigator to “…foster relationships with housing agencies and permanent housing providers, including supportive housing providers; partner with housing agencies and providers to offer the member permanent, independent housing options, including supportive housing; connect and assist the member to get available permanent housing; coordinate with member in the most easily accessible setting.”
State Examples
Conclusion
To address the housing needs of their Medicaid enrollees, states can leverage a variety of federal Medicaid authorities. These authorities allow states to target housing-related services for individuals with disabilities, SUD, SMI, and other chronic conditions. Research from supportive housing programs in Seattle, Santa Clara, CA, and New York City show that supportive housing programs help individuals achieve sustained housing.
It is also expected that there may be a shift in the approval of Medicaid authorities under a new Administration. Section 1115 waiver demonstrations generally reflect priorities identified by leadership at CMS. Under the Trump administration, 1115 waivers could be used to support work requirements and payments for individuals in institutions for mental disease, despite the deinstitutionalization priority recommended under Olmstead.
The Biden administration, supportive of the ACA and Medicaid expansion, is expected to support continued flexibility for states through 1115 waivers without block grants or work requirements. This additional flexibility could include coverage expansions and additional services, such as housing supports.
While these authorities allow for the financing of services for specific individuals, states cite the ability to work across health and housing sectors and data sharing as other important tools for supportive housing. The National Academy for State Health Policy (NASHP) will begin a second health and housing institute this spring to support additional states in strengthening their services and supports that assist low-income and vulnerable populations in becoming and remaining successfully and stably housed.
For more information about NASHP’s health and housing efforts, visit its Housing and Health Resources for States center or contact Allie Atkeson.
Acknowledgement: This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author 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.
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.
How States Improve Housing Stability through Medicaid Managed Care Contracts
In 2019, more than 500,000 individuals experienced homelessness and nearly 20 million renters spent 30 percent or more of their income on housing. These numbers are increasing as the COVID-19 pandemic exacerbates housing insecurity for people of color and low-wage workers. To improve housing stability – a critical social determinant of health (SDOH) – states are using Medicaid managed care contracts to encourage health plans to support members’ housing-related needs and promote coordination between housing providers and health plans.
Background
Housing status is a key social determinant of health. Many individuals experiencing homelessness suffer from diabetes, heart disease, and HIV/AIDS at rates that are up to six times higher than the general population, and are at increased risk for contracting COVID-19. Rates of mental illness and substance use disorders are also significantly higher among individuals experiencing homelessness.
Many individuals experiencing or at risk of homelessness qualify for Medicaid. Medicaid can be a valuable resource for helping individuals facing housing insecurity, and research shows that investing in housing can save states money and improve health. One study found that hospitalization, emergency room use, and total expenditures for individuals experiencing homelessness in Massachusetts were 3.8-times higher than for the average Medicaid recipient.
Increasingly, state Medicaid agencies are focusing on addressing housing-related needs of their enrollees through their managed care contracts.
How States Use Medicaid Managed Care Contracts to Address Housing Needs
While Medicaid managed care contract language varies significantly between states, there are some similarities in states’ approaches to addressing Medicaid enrollees’ housing needs, including these managed care organization (MCO) contractual requirements:
- Screen enrollees for housing-related needs;
- Hire designated housing coordinators; and
- Ensure the coordination of care between housing providers or agencies and Medicaid programs.
States working to address housing insecurity and homelessness among Medicaid enrollees, or states that already require plans to focus on SDOH more broadly but wish to tailor initiatives specifically towards improving housing status, can adopt some of the contractual language and initiatives described below.
Screening for Housing Insecurity
According to NASHP’s scan of states’ Medicaid managed care contracts, 16 states (of 38 with publicly available contracts or requests for proposals) require contractors to conduct routine screenings for certain SDOH. Of the 16 states, 14 require their managed care plans to screen members about their housing needs during these assessments. These screenings can occur at any interval from annually to quarterly, with some states specifying that individuals who qualify as high-needs members should be screened more frequently. In New Hampshire, community mental health programs that contract with the state’s Medicaid program are required to conduct quarterly assessments and document all members’ housing status. In Pennsylvania, providers must complete an SDOH assessment that focuses on housing security, among other things, at least annually and more often depending on the individual’s risk level.
While some states require health plans to screen all enrollees, others only require screenings for certain populations. For example, Minnesota’s Medicaid MCO requires outreach and screening for members who have been to the emergency department for services three or more times within four consecutive months. In Alabama, the maternity psychosocial assessment includes questions related to homelessness.
Screening for housing status in order to identify members experiencing housing insecurity or homelessness is an important first step in addressing housing needs. However, in the absence of mechanisms to connect individuals to community resources that can help them find appropriate housing assistance, the impact of SDOH screenings is limited.
Hiring Housing Coordinators
According to NASHP’s analysis, seven state Medicaid MCOs identify a designated, full-time employee exclusively responsible for addressing enrollees’ housing needs – Arizona, Kansas, Louisiana, New Hampshire, New Jersey, New Mexico, and North Carolina. Other states, including Delaware and Pennsylvania, require their plans to hire more broadly defined care coordinators or SDOH specialists. They work on housing as part of their jobs, but are also responsible for addressing other member needs, such as employment, transportation, and education.
Through its contract with Kansas Medicaid, United Healthcare employs a housing navigator, a position added in 2016. The housing navigator develops partnerships statewide to identify resources for providing housing supports – including vouchers, prevention services, public housing, and homeless service agencies – and to help members locate housing. United Healthcare’s housing navigator has assisted more than 200 Medicaid members with housing needs.
The Louisiana MCO contract requires the plan to hire a permanent supportive housing program liaison who works with the Louisiana Department of Health to help implement the PSH program deliverables, which include providing affordable housing and tenancy supports. While hiring housing navigators or specialists requires MCOs to invest financial resources, onboarding navigators to help connect members directly to housing services and supports has been shown to be one effective way to address Medicaid enrollees housing-related needs, especially those identified during SDOH screenings.
Partnering with Housing Providers and Agencies
State housing agencies and local housing providers are also valuable resources for improving both the health and housing needs of individuals. Rather than building new systems, managed care plans can address housing insecurity among members by partnering with existing housing services and working to eliminate siloes between health and housing agencies.
For example, in New Mexico, health plans are required to contract with a federally qualified health center that specializes in providing health care for populations experiencing homelessness. Similarly, in New York, health plans are required to coordinate care with Health Care for the Homeless providers. In Oregon, Coordinated Care Organizations – the state’s Medicaid accountable care organizations – have contracted with community-based organizations to provide housing supports and helped develop a medical respite program to house individuals experiencing homelessness following an inpatient hospital stay.
Some state Medicaid contracts also identify opportunities for MCOs to support housing initiatives run by state or federal housing agencies. In Texas, the Medicaid MCO service coordinator must work with staff from their Section 811 Project Rental Assistance program, a federal program that helps provide supportive housing for individuals with disabilities, to coordinate care for Texans receiving Section 811 services and those leaving nursing facilities. This helps integrate health and housing services for individuals previously identified as having housing needs. In Louisiana, the state housing authority and the Department of Health co-manage the permanent supportive housing (PSH) program. The Louisiana MCO contract outlines a number of ways that MCOs are required to support the PSH program, including:
- Provide outreach to members who qualify for PSH;
- Help members apply for PSH;
- Ensure timely prior authorization for PSH tenancy and pre-tenancy supports;
- Refer members approved for PSH to relevant providers; and
- Work with PSH program management to ensure an adequate and qualified network of PSH program staff and service providers.
The MCO is also required to contract directly with housing providers approved by the state to provide tenancy and pre-tenancy supports to members participating in the PSH program. One analysis of Louisiana Medicaid recipients pre- and post-PSH showed a 26 percent reduction in emergency room visits, a 12 percent reduction in hospitalizations, and an increased use of behavioral health services among participants. Through partnerships with PSH programs, MCOs can improve integration of health and housing services for members and expand the reach of housing programs by helping to identify Medicaid enrollees in need of housing and connect them directly to resources.
Creative Financing
State Medicaid managed care contracts employ creative ways to use Medicaid funding to support efforts to address housing insecurity among enrollees. Although Medicaid cannot directly fund housing, there are many other strategies to effectively invest in housing services. Oregon’s Coordinated Care Organizations (CCOs) are required to spend a portion of their profits or reserves on health-related services, and specifically on housing supports. Starting January 2021, CCOs are also required to submit annual spending plans to the state, which include the CCO’s spending priorities related to addressing SDOH and health equity, and how they align with the state’s housing-related priorities. In Kansas, the state’s MCO request for proposal calls for alternative payment strategies to incentivize warm handoff transitions for individuals moving from institutions into community-based programs and services.
In Massachusetts, the managed care contract mentions the Social Innovation Financing for Chronic Homelessness Population Program (SIF), a Pay For Success (PFS) initiative that finances PSH. Through the Community Support Program for People Experiencing Chronic Homelessness (CSPECH), Medicaid managed care entities fund support services for PSH tenants in the PFS program. As of October 2020, 860 members have enrolled in CSPECH. Together with the PFS program, CSPECH has improved housing retention, decreased emergency room stays, and saved millions in costs. While the current budget climate arising from the COVID-19 pandemic makes adopting new funding strategies difficult, investing health plan dollars in housing services can not only improve members’ housing status, but also decrease Medicaid spending down the line.
Pilot Programs
In addition to established methods, such as screening for housing needs and partnering with housing service providers, some states are using their managed care plans to launch new initiatives to address their Medicaid enrollees’ housing needs. In Florida, MCOs are participating in a voluntary pilot program to provide behavioral health services and supportive housing assistance directly to Medicaid enrollees who are homeless or at risk of homelessness and who also experiencing either serious mental illness or substance use disorder. The North Carolina managed care contract provides for an Enhanced Case Management Pilot program in up to four areas of the state. MCOs in each area work to determine the most effective, evidence-based interventions to address four priority domains, which include housing. The program also requires each program to evaluate the effect of the interventions on health care costs and outcomes. There is no “one-size-fits-all” approach to addressing housing, but piloting programs like these, or creative financing solutions like those mentioned above, can help MCOs determine which methods are best for reaching housing-insecure members in their state, while also improving health outcomes and decreasing costs.
Conclusion
As efforts to address SDOH become increasingly common among Medicaid managed care plans, many states are narrowing their focus to address housing insecurity and homelessness specifically. By working to identify enrollees’ housing needs and directly connect them to housing and supportive services, health plans can improve housing stability, which in turn improves health outcomes and decreases costs.
During the COVID-19 pandemic, states face budget challenges while their Medicaid managed care plans may experience financial gains from a decline in demand for physical health services. This leaves health plans in a unique position to invest new resources upfront in housing-related services. In 2020, many insurers reported large profits, in part due to the decline in non-COVID-19-related hospital admissions. Medical Loss Ratio rules, however, limit the amount insurers can keep for profit or overhead costs – health plans must either issue rebates or spend more on health-related services, which presents an opportunity to use these additional funds to address housing insecurity and homelessness among enrollees. And, by requiring health plans to indirectly invest in housing by hiring housing coordinators, partnering with existing housing agencies who are already immersed in the work, financing housing-related services, or by piloting new, creative solutions, states can take the lead in guiding Medicaid managed care plans’ work.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author 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.
Texas Improves Access to Routine Oral Health Services for Very Young Children
Though largely preventable, tooth decay (caries) is the most common chronic disease in US children, affecting approximately 23 percent of children ages 2 to 5.[1],[2] Texas’s First Dental Home and its enhanced bundled payment has increased access to preventive dental service and improved the oral health of Medicaid-enrolled children ages 6 to 35 months.
Providing children with access to routine oral health services has the potential to prevent dental caries, reduce emergency dental visits, and promote overall health, resulting in significant cost savings for states. States are required to provide dental services to Medicaid-enrolled children under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While it is recommended that all children receive an initial dental visit in their first year of life, less than 10 percent of Medicaid-enrolled children under age 3 receive preventive dental services.[3] This case study explores how Texas is improving oral health access for these very young children.
Importance of Oral Health in Very Young Children
Early childhood caries (ECC) is characterized by the presence of at least one decayed, missing, or filled primary tooth surface in a child younger than age 6.[4] Among children in this age group, nearly one-quarter have ECC,[5] with 10 percent untreated.[6]
In addition to causing pain and discomfort, dental caries, including ECC, can affect young children’s quality of life and overall development, including reduced intake of food, lower weight, and increased school absences.[7] High incidences of untreated dental caries are also associated with increased risk of hospitalizations and emergency dental visits, resulting in significant costs to state Medicaid programs.[8],[9] One report examining Medicaid-enrolled children under age 6 in Iowa found that children treated for ECC in a hospital or ambulatory setting accounted for 25 to 45 percent of total dental costs.[10]
Children who have their first preventive dental visit by age 1 are more likely to have subsequent preventive visits and lower dental-related costs.[11] Given the importance of early access to routine, preventive oral health services among young children, several leading national pediatric medical and dental organizations recommend that all children receive an initial dental visit during the first year of life.[12],[13],[14] Yet, only 9 percent of Medicaid-enrolled children under age 3 received a preventive dental service over a one-year period, compared to 84 percent of children in the same age group who received a well-child visit.[15],[16]
As states explore opportunities to improve access to oral health services, there is growing interest in strengthening routine access to oral health services among young children.
Texas First Dental Home
Implemented in 2008 by the Texas Health and Human Services Commission (HHSC) – the state’s Medicaid program – to increase children’s access to preventive services under the EPSDT benefit, the First Dental Home (FDH) is a legislatively supported, Medicaid dental initiative designed to improve the oral health of Medicaid-enrolled children, ages 6-35 month, through the following actions:
- Initiate early preventive dental services (including for those children without erupted teeth);
- Provide communication and education to parents and caregivers promoting the importance of children’s oral health; and
- Establish dental homes for children beginning at 6 months of age or as early as possible upon enrollment in Medicaid. [17]
Children participating in FDHs are eligible for a maximum of 10 visits between 6 to 35 months of age, with at least 60 days between visits. This requirement allows for a child to begin FDH visits at six months of age with a recall schedule of every three months (for those children at moderate-to-high risk for developing severe ECC) until their third birthday.[18] In addition to completing an oral health questionnaire, a dental risk assessment questionnaire, and a comprehensive oral evaluation during the initial visit, FDH visits include:
- Texas Health Steps Caries Risk Assessment Tool;
- Dental prophylaxis;
- Oral hygiene instructions for the child’s primary caregiver;
- Application of topical fluoride varnish;
- Dental anticipatory guidance, including nutritional counseling and oral developmental milestones; and
- Establishment of a dental recall schedule.[19]
Due to the importance of caregiver participation and understanding of their children’s oral health, HHSC requires at least one parent or caregiver to be present with the child during the entire FDH visit.[20] An evaluation of FDH found that participation in the program increased caregivers’ oral health knowledge and some of their oral health practices to improve their children’s oral health.[21]
First Dental Home Bundled Reimbursement and Provider Enrollment
The Current Dental Terminology (CDT) code D0145 is used at an enhanced reimbursement rate of $142.07 for all FDH visits. For the purposes of FDH billing, D0145 is considered an all-inclusive (or bundled) code required for all diagnostic and preventive services rendered under FDH, including those not traditionally reimbursed for routine preventive services, such as oral hygiene instruction and nutritional counseling.[22],[23] Dentists cannot bill for any other exam, prophy, or fluoride codes for a FDH visit.[24]
Eligible providers (e.g., pediatric and general dentists) must become FDH providers to claim reimbursement using the enhanced bundled CDT code. In addition to being trained and certified by the Texas Health Steps Program, the state’s EPSDT program, dentists must have a National Provider Indicator number (NPI) and an individual Texas Provider Indicator (TPI) number of each practice location.[25] Within the first 12 months of the program’s implementation, 815 dentists became FDH providers, 674 of whom billed for services.[26]
Texas is a state with dental benefits carved-out of its medical managed care program to three dental maintenance organizations (DMOs). Collectively, these DMOs help to manage the dental care needs of the state’s Medicaid members, including participation in FDH. Under this arrangement, HHSC outlines FDH-specific contract requirements, which stipulate that each DMO must:
- Implement a process to detect under-utilization of FDH services;
- Verify a providers’ qualifications to submit claims for FDH services; and
- Publish provider directories and note which providers are FDH providers.
In addition to these contract requirements, HHSC has a dental Pay-for-Quality (P4Q) program to further strengthen oral health utilization. Under Texas’s dental P4Q program, 1.5 percent of each DMO’s capitation is at risk of recoupment for specific performance measures (e.g., the percentage of enrolled children who receive a comprehensive or periodic oral evaluation in a reporting year) if a DMO’s performance declines beyond a defined threshold. Conversely, if a DMO’s performance improves beyond the threshold, the DMO can earn incentive payments.[27] To help bolster its performance, at least one DMO implemented value-added services for members participating in FDH, including a free dental care kit and gift card upon completion of a FDH visit.[28] As a result of limited data due to COVID-19 from which to assess quality measures, HHSC has temporarily suspended its dental P4Q program, including performance measures under FDH.[29]
Texas’s multipronged efforts to increase access to preventive oral health services for Medicaid enrolled children 6 to 35 months of age under the EPSDT benefit have resulted in increased utilization, even exceeding the rate of dental care use among commercially insured children in some years.[30],[31] Based on available dental performance measures collected by HHSC, participation in FDH has steadily increased with approximately 71 percent of children 6 to 35 months of age receiving at least one FDH visit in FY 19.[32] Based on claims data collected from 2005-2011, there was an estimated cost savings of $12.9 million (or $269.01 per member per year) among children 3 to 6 years of age receiving routine preventive dental services. The savings per member is driven, in part, by reductions in oral health utilization and treatment expenditures.[33] The goal of FDH services is to aid in the additional reduction of treatment expenditures.[34]
Due to the impact of COVID-19 on access to preventive services,[35] utilization of FDH was down 90 percent at the start of the public health emergency. By summer 2020, use of FDH services was at 80 percent compared to the previous year, with access rates slowly returning to normal.
Conclusion
To improve the oral health of Medicaid-enrolled children ages 6 to 35 months, Texas’s First Dental Home successfully implemented an enhanced bundled payment, caregiver engagement strategies, and provider-specific requirements to increase access to preventive oral health services for very young children under the EPSDT benefit. Texas’s approach is one that other state Medicaid programs can adapt as they explore strategies to improve the oral health of very young children and promote access to an initial dental visit during the first year of life.
Acknowledgements: This case study 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. The 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.
Notes
[1] “Hygiene-related Diseases, Dental Caries,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html [2] “Dental Caries in Primary Teeth,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2019. https://www.cdc.gov/oralhealth/publications/OHSR-2019-dental-caries-primary-teeth.html – :~:text=The prevalence of untreated tooth,-poor, and poor children. [3] “Utilization of Dental Services Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB9_DentalCare.pdf [4] “Statement on Early Childhood Caries,” American Dental Association, 2000. https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-early-childhood-caries [5] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, “Dental Caries in Primary Teeth,” [6] “Dental Caries and Sealant Prevalence in Adolescents in the United States, 2011-2011, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, March 2015. https://www.cdc.gov/nchs/products/databriefs/db191.htm#:~:text=Dental%20caries%20among%20children%20aged,31%25)%20aged%202%E2%80%938 [7]Sheiham, A., “Dental caries affects body weight, growth, and quality of life in pre-school children,” British Dental Journal, November 2006. https://www.nature.com/articles/4814259 – :~:text=First, untreated caries and associated,foods because eating is painful.&text=Second, severe caries can affect,irritability and disturbed sleeping habits [8] “The Importance of the Age One Dental Visit,” Pediatric Oral Health Research & Policy Center, 2019. https://www.aapd.org/globalassets/media/policy-center/year1visit.pdf [9] “Allareddy, V., et al., “Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization,” Journal of the American Dental Association, April 2014. https://pubmed.ncbi.nlm.nih.gov/24686965/ [10] “Kanellis, M., et al., “ Medicaid Costs Associated with the Hospitalization of Young Children for Restorative Dental Treatment under General Anesthesia,” Journal of Public Health Dentistry, May 2007. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1752-7325.2000.tb03288.x?sid=nlm%3Apubmed [11] Savage, M., et al., “Early Preventive Dental Visits: Effects of Subsequent Utilization and Costs,” Journal of the American Academy of Pediatrics, October 2004. https://pediatrics.aappublications.org/content/114/4/e418.long [12] “Recommendations for preventive pediatric health care,” Journal of the American Academy of Pediatrics, March 2000. https://pediatrics.aappublications.org/content/105/3/645 [13] American Dental Association, “Statement on Early Childhood Caries.” [14] “First Oral Health Assessment Policy,” American Association of Public Health Dentistry, May 4, 2004. https://www.aaphd.org/oral-health-assessment-policy [15] Centers for Medicare and Medicaid Services, “Utilization of Dental Services Among Medicaid Enrolled Children.” [16] “Utilization of Well-Child Care Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo/downloads/max_ib10_wellchild.pdf [17] “First Dental Home: Section 1: Overview of the First Dental Home Initiative,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_1.html [18] “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_3.html [19] “First Dental Home,” Texas Health and Human Services. https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/texas-health-steps/dental-providers/first-dental-home [20] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 1: Overview of the First Dental Home Initiative.” [21] Mccann, Ann., & Schneiderman, E., “Does the Texas First Dental Home Program Improve Parental Oral Care Knowledge and Practices,” Journal of Pediatric Dentistry, March 2017. https://www.researchgate.net/profile/Ann_Mccann/publication/319040790_Does_the_Texas_First_Dental_Home_Program_Improve_Parental_Oral_Care_Knowledge_and_Practices/links/5e496c8f299bf1cdb930f08e/Does-the-Texas-First-Dental-Home-Program-Improve-Parental-Oral-Care-Knowledge-and-Practices.pdf [22] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing.” [23] Use of CDT code D0145 in other state Medicaid programs is typically limited to an oral evaluation and counseling with the primary caregiver. [24] Texas Health and Human Services, “First Dental Home.” [25] Ibid. [26] “State of Texas Medicaid Dental Review,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2010. https://www.mchoralhealth.org/PDFs/CMSReview_TX.pdf [27] “Pay-for-Quality Program,” Texas Health and Human Services. https://hhs.texas.gov/about-hhs/process-improvement/improving-services-texans/medicaid-chip-quality-efficiency-improvement/pay-quality-p4q-program – :~:text=Medical Pay-for-Quality Program,performance on certain quality measures.&text=The redesigned medic. [28] “DentaQuest Provider Office Reference Manual: TX HHSC Dental Services,” DentaQuest, October 2020. https://dentaquest.com/getattachment/State-Plans/Regions/texas/Dentists-Page/Provider-Resources/TX_ORM.pdf/ [29] National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, “How States Can Promote Children’s Oral Health.” [30] Nasseh, K., et al., “ Dental Care Use among Children Varies Widely across States and between Medicaid and Commercial Plans with States,” Health Policy Institute Research Brief, 2014. https://www.semanticscholar.org/paper/Dental-Care-Use-among-Children-Varies-Widely-across-Nasseh-Aravamudhan/763bbe86700c42c0f4b8a5cec50772dc20cda1a7#references [31] Gupta, N., et al., “Medicaid Fee-for-Service Reimbursement Rates for Child and Adult Dental Care Services for all States, 2016,” American Dental Association, Health Policy Institute, 2017. https://www.ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_0417_1.pdf [32] “How States Can Promote Children’s Oral Health,” National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, October 2020. [33] Lee, I., et al., “Estimating the cost savings of preventive dental services delivered to Medicaid-enrolled children in six southeastern states,” Health Services Research, November 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153169/pdf/HESR-53-3592.pdf [34] The research study focuses on children outside the age range of those receiving services under the First Dental Home. The study also includes claims data that precede implementation of the First Dental Home. [35] “CMS Issues Urgent Call to Action Following Drastic Decline in Care for Children in Medicaid and Children’s Health Insurance Program Due to COVID-19 Pandemic,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, September 2020. https://www.cms.gov/newsroom/press-releases/cms-issues-urgent-call-action-following-drastic-decline-care-children-medicaid-and-childrens-health
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. 
