Special Populations and Services – The National Academy for State Health Policy

How States Address Social Determinants of Oral Health in Managed Care Contracts

Medicaid Agencies Cultivate Partnerships and Deploy Data to Bolster COVID-19 Vaccination Efforts

March 29, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Health IT/Data, Medicaid Managed Care, Population Health, Program Design, Quality and Measurement, Social Determinants of Health, Special Populations and Services, Vaccines /by Christina Cousart

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.

View state-by-state vaccination eligibility plans at: State Plans for Vaccinating their Populations against COVID-19.

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.

Michigan Medicaid Addresses Social Determinants of Oral Health through Dental and Medical Contracts

January 15, 2021/in Medicaid Managed Care Michigan Blogs, Featured News Home Child Oral Health, CHIP, Consumer Affordability, Cost, Payment, and Delivery Reform, EPSDT, Health Coverage and Access, Health Equity, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Social Determinants of Health, Special Populations and Services, Workforce Capacity /by Ariella Levisohn

Inequities in dental care are prevalent across the United States, with significant disparities based on age, race, ethnicity, and socioeconomic status. Economic factors, such as ability to pay for dental insurance, and social factors such as food insecurity and access to nutritious food options also play a large role in oral health outcomes.

In Michigan, state Medicaid medical and dental managed care contracts now include requirements to address social determinants of health (SDOH) among enrollees. Examples of these requirements include:

Incorporating oral health into community health workers’ training curriculum;
Collaborating with community-based organizations (CBOs);
Collecting data on enrollees’ SDOH and using it to target outreach and educational activities; and
Implementing quality assurance and improvement projects that promote equitable access to oral health care.

Michigan’s Medicaid medical and dental managed care contracts demonstrate a proactive approach to identifying and addressing SDOH among Medicaid enrollees. While budget shortages resulting from the COVID-19 pandemic may make it more difficult for states to take on additional initiatives, addressing SDOH in Medicaid contracts can decrease costs and improve oral health outcomes. States that want to encourage dental plans to take on a larger role in promoting equitable access to care and addressing SDOH could adopt initiatives similar to Michigan’s.

These types of Medicaid contractual requirements are important first steps in improving SDOH among enrollees, while strengthening monitoring and enforcement requirements are also critical tools when adequate funding and personnel are available.

Why Focus on Oral Health and SDOH?

SDOH are the conditions in the places where individuals live, learn, and work that may affect their health risks and outcomes. They include factors such as food access, housing stability, educational attainment, poverty, health literacy, and transportation, among others. Social determinants dictate an individual’s access to health care and quality of care, which directly affect physical and oral health and exacerbate health disparities. For example:

Low-income children are twice as likely to have dental caries (tooth decay) than children from higher-income homes; and
Individuals who are poor or have less than a high school education have edentulism (toothlessness) at a rate three-times higher than those with higher incomes or more education.

Increasingly, Medicaid medical and dental managed care organizations are implementing initiatives designed to address SDOH among their members in order to improve oral health and promote health equity.

While all states cover dental care for Medicaid-enrolled children under age 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits. However, optional adult benefits, such as dental care, may be affected by state efforts to meet continued budget challenges arising from the COVID-19 pandemic. Dental disease, though, not only adversely affects oral health but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Preventive dental care has the potential to improve overall health and well-being and reduce costs.

How Michigan Addresses Oral Health and SDOH

In NASHP’s recent 50-state scan of Medicaid managed care medical and dental contracts, Michigan was one of only three states (out of 19 reviewed) to consistently and directly reference SDOH in their Medicaid dental plan contracts.* Additionally, Michigan’s Medicaid medical managed care organization (MCO) contract includes detailed requirements for addressing SDOH, many of which align with the dental plan’s language and promotes coordination between physical and oral health care. While written contractual requirements do not guarantee that medical and dental plans are actively engaged in implementing SDOH-related initiatives – especially in the absence of funding to monitor these programs – Michigan’s contracts offer valuable examples of potential ways to address SDOH that other states could adopt as a first step.

Michigan Delivery System Overview

Michigan Medicaid uses a managed care system to deliver medical and dental care, and the Medicaid dental benefit is carved out and administered by various dental plans contracted by the state. Michigan Medicaid covers limited dental services for adults, including dental check-ups, teeth cleaning, X-rays, fillings, tooth extractions, and dentures. Additionally, the state offers an enhanced dental benefit for Medicaid-eligible pregnant women that includes emergency dental treatment and some oral surgeries. Michigan also administers the Healthy Kids Dental program, which covers comprehensive oral health care for children under age 21 enrolled in Medicaid.

Dental Contract Language

Michigan stands out because of the state’s frequent and direct mentions of SDOH throughout its Healthy Kids Dental (HKD) model contract. The HKD contract reflects a broad range of required initiatives related to SDOH, including:

Collaboration with community organizations;
Data use to target interventions and assess population-wide social needs, and
Implementation of quality assurance and improvement projects that reduce barriers to oral health care.

Collaboration with Community Organizations

One way dental plans can help address SDOH-related needs is by working with community-based organizations (CBOs). CBOs play an important role in connecting individuals to social services and helping people access health-related social needs, such as healthy food, transportation services, and educational materials that promote health literacy.

Michigan requires dental plans administering the HKD program to “collaborate with community-based organizations to facilitate the provision of enrollee oral health education services to ensure the entire spectrum of social determinants of oral health are addressed, e.g., housing, healthy diet and physical activity.” Michigan also encourages contractors to “build relationships with community partners that will engage in integrated care and promote good oral health practices.”

Through dynamic and active partnerships with CBOs, dental plans can more easily refer individuals to social and community services to help address members’ needs. Additionally, these partnerships with CBOs allow the state to expand its reach to more Medicaid-eligible children through educational initiatives.

Dental plans can also encourage members to work with CBOs and other public health programs by implementing their own educational programs. Michigan lists community-based public health resources on its website, and requires dental plan contractors to institute educational, public relations, and social media programs to increase awareness of available resources, such as CBOs, that can help reduce the impact of social determinants of oral health.

Data Collection, Tracking, and Reporting

While coordinating with social and community resources is an important step in improving health equity, having strong mechanisms in place to collect and track community data is critical to ensure social determinants are addressed. Michigan stands out in its commitment to require that medical and dental plans collect SDOH-related data.

Michigan requires HKD contractors to collect data on SDOH and utilize enrollment files, claims, encounter data, and utilization management data to improve community collaboration and address oral health disparities. The state specifies that the dental plan must “use social determinants of oral health data provided by [the Michigan Department of Health and Human Services] to analyze member-level data to direct the contractor’s efforts of targeted interventions, outreach, enrollee education and health promotion.” Additionally, the dental plan must report on the effectiveness of its population health management programs, including measures identifying the number of enrollees experiencing a “disparate level of social needs,” such as limited transportation access and housing instability.

Michigan’s data utilization requirements range from addressing individuals’ health-related needs to analyzing population-wide equity issues. Plans are required to gather and utilize this information for finetuning their services, such as care management and referrals. However, given that requirements for health plans to collect SDOH-related data are fairly new, and the state has little funding available for this work, the state’s role in monitoring whether data collection is occurring is currently limited. With adequate funding and personnel, states can take a more active role in tracking and data analysis to better understand the social needs of the population and effectively target SDOH-related interventions.

Quality Assurance and Performance Improvement

Michigan is committed to not only reporting on the effectiveness of SDOH-related initiatives, but also working to improve existing systems to better address inequities in oral health. The HKD contract requires the dental plan to have a Quality Assurance and Performance Improvement (QAPI) plan that includes a description of how the contractor will, “develop system interventions to address the underlying factors of disparate utilization, health-related behaviors, and oral health outcomes, including, but not limited to, how they relate to utilization of dental emergency services,” and “ensure the equitable distribution of dental services to contractor’s entire population, including members of racial/ethnic minorities, those whose primary language is not English, those in rural areas, and those with disabilities.”

SDOH can contribute to variances in utilization of dental services and poor oral health outcomes, with factors such as geographic location and language proficiency playing an important role in driving health care access. In addition to using data to better understand the impact of social factors on members’ oral health and population utilization trends, Michigan requires contractors to continue to find new ways to reach all populations and reduce the effects of SDOH on oral health outcomes.

Medical Contract Language

Much of the language related to SDOH included in the Healthy Kids Dental contract is consistent with the language in Michigan’s Medicaid medical MCO contract, which covers adults and children. Both the HKD and MCO contracts require the plan to collaborate with CBOs to provide physical and oral health education and address SDOH, implement community education campaigns to improve public knowledge of community-based resources, report on the effectiveness of SDOH-related population health management initiatives, and promote equitable access to care using Quality Assurance and Performance Improvement (QAPI) projects.

However, the medical contract also offers additional opportunities for investment in SDOH that states could consider implementing in dental contracts. For example, Michigan requires medical MCO contractors to participate in the Medicaid Health Equity Project, which is a statewide effort to address racial and ethnic disparities. Through this project, Medicaid health plans collect and report on data across multiple quality measures, including access to preventive and ambulatory health services. The state then uses data stratification by race and ethnicity to determine how racial and ethnic discrimination affect each quality measure, with the goal of addressing any disparities.

Additionally, the medical contract requires health plans to enter into agreements with CBOs to coordinate “population health improvement strategies,” which address social determinants such as physical environment and socioeconomic status. These agreements with CBOs must include information on data sharing, each partner’s role in care coordination, reporting requirements, and plans for coordinating service delivery with primary care providers.

What are Key Considerations and Next Steps?

Addressing SDOH is critical to improving oral health, overall health, and health equity. Increasingly, Medicaid dental plans across the country are collecting data on community needs and implementing initiatives to reduce barriers to oral health care. In a recent 50-state scan of Medicaid managed care contracts, NASHP found that out of 19 dental contracts and 38 medical contracts reviewed nationally, 13 and 37, respectively, require the plan to coordinate with community services. Efforts to address SDOH are also underway, though they tend to be further along on the medical side than the dental side. This provides an opportunity for states to apply medical contracts’ language in their dental contracts, or work with health plans to link existing SDOH-related programs with the dental system.

In response to budget shortfalls resulting from the COVID-19 pandemic, Michigan’s Medicaid program now faces potential rate changes, particularly for dental payments. However, program staff report they see opportunities to establish shared performance metrics between Medicaid MCOs and dental plans in the future. The state is considering ways to standardize and refine SDOH-related data collection and analysis, especially related to dental care. Michigan health officials noted the necessity of first ensuring data was valid and reliable before using it to drive decisions or implement capitation withhold incentive programs. The state is also discussing leveraging Michigan’s health information exchange to transmit standardized SDOH screening information to plans and providers.

Through the Healthy Kids Dental and Medical MCO contract, Michigan has demonstrated a strong commitment to addressing social determinants of oral health. The contracts present an opportunity for states to adopt similar language in order to encourage dental plans to coordinate with CBOs, effectively collect and use SDOH-related data, and implement performance improvement projects aimed at reducing disparities.

* NASHP scanned Michigan’s Healthy Kids Dental model contract and the Michigan Medicaid Medical MCO sample contract.

Acknowledgements: This fact sheet was made possible by the DentaQuest Partnership LLC. The author would like to especially thank Trenae Simpson for her guidance and assistance, and state officials in Michigan for their helpful feedback. The information, content, and conclusions are those of the author’s and should not be construed as the official position or policy of the DentaQuest Partnership LLC.

Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives

December 17, 2020/in Medicaid Managed Care Illinois, Louisiana, New York, Oregon, Texas Featured News Home, Reports Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health, Special Populations and Services /by Allie Atkeson, Ariella Levisohn and Jill Rosenthal

How States Address Social Determinants of Oral Health in Dental and Medical Medicaid Managed Care Contracts

November 2, 2020/in Medicaid Managed Care Blogs, Featured News Home Child Oral Health, CHIP, CHIP, Chronic Disease Prevention and Management, Essential Health Benefits, Health Coverage and Access, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Social Determinants of Health, Special Populations and Services /by Ariella Levisohn, Allie Atkeson and Carrie Hanlon

Inequities in oral health and health outcomes are driven by upstream factors, including diet, education, transportation, and access to care. A growing number of states are working to improve the oral and physical health of Medicaid enrollees and reduce costs by addressing these social determinants of health in their managed care contracts.

Recently, states have used Medicaid managed care contracts and value-based purchasing agreements to address the education, food, and transportation needs of their enrollees. However, less is known about how states leverage their purchasing clout to improve dental care or address social determinants of health (SDOH) directly in dental contracts.

To learn how state Medicaid programs include social determinants of health in their dental and medical Medicaid managed care contracts, view this interactive map.

A 50-state review by the National Academy for State Health Policy (NASHP) of Medicaid dental and medical managed care contracts, requests for proposals, and other similar documents publicly available through September 2020, identified how states address social determinants of oral health. Dental contracts were reviewed for a comprehensive list of social determinants and medical contracts were analyzed for references to care coordination, community resources, food access, social determinants of health screening, and coordination with dental contractors. In total, NASHP scanned dental contracts in 19 states and medical contracts in 38 states.

Of the dental contracts, nine referenced coordination between dental plans and medical plans and 13 referenced coordination with social and community services. Other common references in dental contracts included equity/cultural competence, education, and transportation (each referenced in 10 state contracts).

All but one of the 38 medical contracts referenced coordination with social and community services. Thirty-three states referenced food in their medical contracts, 25 referenced adverse experiences (such as domestic violence and child abuse), and 15 referenced care coordination between dental and medical care. Three states (Florida, Michigan, and Virginia) referred to food in both their dental and medical contracts, while only one (Virginia) referenced adverse experiences in both contracts.

State Medicaid Program Delivery of Dental Care

While Medicaid covers some form of adult dental care in 47 states and Washington, DC, and all states cover dental care for children under 21 as part of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits.

States have different options for delivering dental care. Some states with managed care use a carve-in model, where the dental benefit is integrated into medical managed care programs. With a carved-in benefit, managed care organizations (MCOs) may administer the dental benefit or subcontract the dental benefit to another vendor. In carve-out dental programs, states contract with a dental MCO or dental benefits manager (DBM). Alternatively, states with Medicaid managed care medical delivery systems may have fee-for-service dental systems.

Medicaid dental and medical contracts illustrate how states can consider social determinants affecting oral health and overall health through:

Screening, referral tracking, and follow-up;
Educational initiatives;
Staffing and training requirements;
Data sharing and technology;
Coordination between dental and medical systems; and
Performance improvement.

Social Determinants of Health in Dental and Medical Medicaid Contracts

Almost all states scanned have some requirement for plans to refer members to community resources and social services. NASHP focused specifically on requirements that are applicable to the general population, rather than individuals designated as high risk or high needs. States use a variety of strategies to encourage investment in SDOH.

Screening for SDOH Needs

Sixteen states use routine screenings for certain social determinants, including employment status and access to food and transportation. The scan of 14 medical contracts and two dental contracts indicate that states are more likely to require medical plans to conduct needs assessments, often within a specified time frame after enrollment, than dental plans. States may also require medical plans to use this data to appropriately target interventions to meet enrollees’ needs.

While dental plans do not necessarily have the same explicit requirement to conduct a screening, some states do ask their dental plans to use SDOH data to target their educational and outreach activities.

Michigan’s dental plan is required to use social determinants of oral health data from the state in order to target interventions, outreach, and education efforts.
Nevada’s dental contract requires the contractor to complete a community-based needs assessment to inform their health promotion and educational activities, including ensuring that any interventions are culturally appropriate and meet the needs of the target population.

Referral Tracking and Follow-up

While screening is an important first step in identifying members’ social needs, it also raises a question of how states use the data to address social determinants. NASHP found that in almost every state with publicly available contracts, Medicaid agencies partner with community-based organizations to meet the social needs of enrollees. For example, plans may facilitate referrals to these community agencies based on information collected through SDOH screenings. States can use tracking, follow-up, and reporting requirements to ensure that referrals to community resources and organizations are effective and successful. Contractors can support these efforts by documenting “closed-looped” referrals that ensure that an enrollee is successfully connected with a community-based organization to address other health and social needs.

In Louisiana, the Dental Benefit Program Manager is required to connect enrollees with community-based service providers and document referrals and referral outcomes in enrollees’ dental records.

Dental contracts are less likely to require or encourage the plan to monitor referral follow-up. However, dental plans could adopt some of the medical MCOs’ language in order to track the status of referrals, strengthen care coordination between insurance plans and community resources, and ensure individuals are receiving adequate social services that meet their evolving needs. For example, New Hampshire requires MCOs to track the effectiveness of community-based providers and resources, and Oregon requires reporting on referrals to culturally diverse social and support services.

Educational Initiatives

Healthy People 2020 identified health literacy as a component of SDOH, noting that individuals’ ability to access and understand relevant health information affects their health and health outcomes. To help improve health literacy, many states require managed care plans to implement educational initiatives. For dental plans, this includes educating members about the importance of oral health or launching community oral health initiatives designed to help eliminate barriers to dental services and improve population oral health.

In both Nevada and Texas, the dental contractor must develop and implement programs designed to educate members about nutrition, the importance of oral health, and the relationship between oral health and overall health.
Florida’s dental plan includes incentives for participation in health education classes. Examples of incentives members can receive that support healthy child development include clothes, food, books, safety devices, publications, and memberships in health and education clubs.
In its response to Nebraska’s request for proposals (RFP), dental contractor MCNA referenced a program it implemented in Texas that uses the fotonovela (a comic book-style communication popular in the Latinx community) to distribute health information materials to children of migrant farm workers.

Staffing and Training Requirements

Plans may also be responsible for training their employees to better meet members’ needs. In their contracts, states can prioritize the type of training that a plan’s staff receive.

Nebraska’s dental contract requires all staff to be trained on how social determinants (including food, housing, education, violence, and physical and sexual abuse) affect members’ health and wellness. Staff also receive training on how to find community resources and make referrals.

Both medical and dental plans also employ staff members who are responsible for care coordination, addressing social determinants, and improving access to care for historically marginalized populations.

Nebraska’s dental contract requires the plan to employ a tribal network liaison to coordinate and expand dental services to Native Americans and connect them to community resources. Arizonaand New Mexico both require medical MCOs to employ someone to coordinate services with Native Americans.

Examples of other medical plans’ required staff positions include a community liaison in Illinois, who connects enrollees with community-based services, and a service coordination director in Kansas, who oversees quality improvement initiatives related to SDOH. Dental contractors could potentially leverage medical MCO positions and their expertise to streamline care experiences for enrollees across medical and dental systems.

Coordination between Dental and Medical Systems

To better integrate dental and medical care, dental and medical managed care use staff members to connect physical health and oral health services across contracts. These staff members also connect Medicaid enrollees to community services to meet social needs.

In its dental contract, Tennessee requires a coordinator to work with the medical MCO and develop a system to exchange data with the MCO.
Florida requires MCOs to have a liaison for their prepaid dental health plan to help integrate medical care, behavioral health, and long-term benefits with the dental plan.
Iowa requires the dental contractor to send a care facilitation plan to the state with information on how the plan will facilitate coordination between dental and medical plans and providers.

Data Sharing and Technology

Eleven states require some form of data sharing between dental and medical plans, or between plans and community organizations. Requirements for integrating different agencies’ social determinant data and sharing information across systems allow medical, dental, and social services to work together to coordinate care for members and encourage referrals and follow-up tracking.

In Tennessee, the dental benefits manager must facilitate data exchange with school-based health programs to coordinate any needed follow-up care.
Washington State tasks its dental contractors with using health information technology and health information exchanges to coordinate care between physical health, behavioral health, and social services and other community-based organizations.

Other states are creating their own online platform or mobile applications to improve access to social services for their Medicaid enrollees. These platforms are mentioned specifically in medical managed care plan contracts, but have the potential to be used by dental contractors as well.

Kansas developed a web-based, mobile-friendly application that connects service coordinators to community resources, such as food banks and pantries, housing, clothing, legal resources, and transportation.
Medicaid Prepaid Health Plans in North Carolina will use a telephonic, online, and interfaced IT platform to refer members to social services and track the outcomes of these referrals.

Performance Improvement

A number of states encourage both dental and medical plans to engage in performance improvement projects (PIPs) in order to address SDOH.

In Nevada, dental vendors are required to conduct both a clinical and non-clinical PIP every year. Non-clinical PIPs can focus on cultural competency and accessibility of services, among other SDOH.
Oregon Coordinated Care Organizations (CCOs) must implement PIPs that address at least four of eight designated focus areas, which include addressing SDOH and equity, and integrating primary care, behavioral health care, and/or oral health care.

Through these PIPs, state managed care plans (both dental and medical) can launch pilot interventions to improve health outcomes by addressing SDOH and reducing barriers to care.

Conclusion

Research shows that addressing individual social needs leads to better oral health outcomes. Despite having different levels of funding and varying Medicaid adult dental benefits, states across the country are finding ways to invest in SDOH. While not all states have started to include SDOH requirements in their dental contracts, these examples show potential opportunities for dental plans to integrate some of the medical plans’ language and guidance into their own work. To learn more about how state Medicaid programs include SDOH-related language in their dental and medical Medicaid managed care contracts, view this interactive map.

Acknowledgements: This blog and map were made possible by the DentaQuest Partnership LLC. The authors would like to especially thank Trenae Simpson for her guidance and assistance, and Trish Riley and Jill Rosenthal for their helpful feedback. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of the DentaQuest Partnership LLC.

State Medicaid Managed Care Program Design for Children and Youth with Special Health Care Needs

September 21, 2020/in Policy Maps Featured Policy Home, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Program Design, Special Populations and Services /by Veronnica Thompson and Kate Honsberger

States Are Increasing their Use of Medicaid Managed Care for Children and Youth with Special Health Care Needs

September 17, 2020/in Medicaid Managed Care Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Program Design, Special Populations and Services /by Olivia Randi and Kate Honsberger

A new, 50-state analysis of Medicaid managed care programs by the National Academy for State Health Policy (NASHP) shows that in the past three years, state Medicaid managed care (MMC) programs have:

Enrolled more children and youth with special health care needs (CYSHCN);
Provided more services to them through managed care; and
Launched more specialized initiatives serving CYSHCN in managed care.

These trends deviate from past approaches as, historically CYSHCN have often been exempt from MMC due to the complexity of their needs. CYSHCN represent nearly 20 percent of children younger than age 19 and have chronic and/or complex care needs that require physical and behavioral health care services beyond what children normally require.[1] As states become more proficient in developing MMC programs, they are increasingly incorporating CYSHCN into their program designs in an effort to improve quality and reduce costs.

NASHP has updated a 50-state chart and map, originally published in 2017, highlighting new developments in states’ MMC programs that serve CYSHCN.[2] The 2017 analysis found that 47 states use some form of MMC (risk-based, primary care case management, and prepaid health plans) to serve CYSHCN, a figure that remains true in 2020, with the same number of states and Washington, DC continuing to use MMC to serve some or all CYSHCN.

NASHP’s new analysis found a downward trend in traditional fee-for-service (FFS) models and a shift toward innovative delivery systems. Given that 47 percent of CYSHCN are covered by Medicaid, this analysis provides important insight into how states are designing services to meet the unique needs of CYSHCN.[3]

The use of managed care delivery systems is widespread, with states contracting with managed care organizations (MCOs), which are paid on a per-member, per-month basis, to provide services for people enrolled in Medicaid. Thirty-eight states use a risk-based model to serve CYSHCN, in which the MCO assumes the financial risk. Ten states use a primary care case management (PCCM) model in which states contract directly with primary care providers and pay them a case management fee for each enrollee’s care coordination, and three states have a prepaid health plan (PHP) through which health plans are paid per-member, per-month for a limited set of services.

In this new analysis, NASHP identified several key trends among the 47 states and Washington, DC that use MMC to serve CYSHCN, such as the use of specialized MMC plans, MMC enrollment policies for CYSHCN, behavioral health service delivery systems, and quality assessment standards for CYSHCN.

MMC Contract Language for CYSHCN

Since 2017, six states have added a specific definition of CYSHCN to their managed care contracts – 29 states now clearly describe this population of children within their MMC program. Including a definition of CYSHCN in a managed care contract can support identification of CYSHCN and can be used to determine eligibility for specific services and supports. Some states align their definitions with the federal Maternal and Child Health Bureau, Health Resources and Services Administration definition, while others are based on specific health conditions or Medicaid enrollment categories (e.g., children enrolled in Medicaid through the aged, blind, and disabled eligibility category).[4]

More states are also evaluating the quality of care that MCOs provide to CYSHCN using measures that account for their unique needs, as compared to 2017. States are required by federal Medicaid regulations to develop a quality assessment and improvement strategy and to contract with an external organization to evaluate the quality of care provided by their MCOs. In addition to meeting these regulations, 39 states now include specific language in their contract regarding measuring quality of care provided to CYSHCN through MMC delivery systems, an increase of seven states since 2017.

MMC Enrollment Policies for CYSHCN

CYSHCN may be eligible for Medicaid coverage through specific pathways to coverage, including those who are eligible for Medicaid’s aged, blind, and disabled (ABD) category, those receiving Social Security Income (SSI), and those who are enrolled in foster care or who are receiving adoption assistance. Additional subcategories of CYSHCN who may be enrolled in Medicaid include American Indian/Alaskan Native (AI/AN) children, those enrolled in Medicaid home- and community-based service 1915(c) waiver programs, and those enrolled in state Title V CYSHCN programs. States are increasingly mandatorily and voluntarily enrolling these subpopulations into MMC. The majority of states continue to enroll children that are eligible for Medicaid through ABD, SSI and youth in foster care or receiving adoption assistance in managed care. Over the past three years, the number of states that enroll AI/AN children and those enrolled in 1915(c) waiver programs has increased by more than 10 for each subgroup. Together, these trends may point to an increased understanding among state Medicaid programs of the diverse needs among CYSHCN subgroups.

Specialized MMC Plans for CYSHCN

Several states have developed specialized managed care plans to meet the unique needs of CYSHCN or subgroups. These plans typically offer tailored benefits that are often not available through their standard MMC plan. The number of states that have specialized MMC plans for CYSHCN has nearly doubled over the last three years.

Thirteen states (DC, FL, GA, IL, IN, ND, TN, TX, UT, VA, WA, WI, and WV) operate 12 specialized health care plans to serve some or all CYSHCN, an increase of six states since 2017.
Nine states’ (DC, GA, IL, IN, TN, TX, WA, WI, and WV) specialized plans serve youth in foster care and/or receiving adoption assistance, representing over half of the specialized MMC plans. In 2017, only two such plans existed.
Six states (DC, IN, ND, TX, UT, and VA) have specialized plans that serve children who are eligible for Medicaid through the ABD category.
Five states (ND, TN, TX, VA, and WV) enroll children who are enrolled in 1915(c) waiver programs in their specialized plans.

Behavioral Health Service Delivery for CYSHCN

States have historically been more likely to carve behavioral health services out of their MMC plans and deliver these services through distinct behavioral health organizations (BHO) or through FFS arrangements. As more states are shifting to integrate behavioral health and primary care services, they are increasingly providing behavioral health services through their MCOs. As of 2020, 41 states provide behavioral health services through MMC, an increase of eight states since 2017. Six states continue to provide behavioral health services through carve-out FFS and BHO arrangements.

Table 1: States’ MMC Program Design: 2017 – 2020

The table below summarizes key trends across states’ Medicaid managed care programs that serve CYSHCN, such as increases in the number of states that enroll CYSHCN in MMC, offer specialized health care plans that serve CYSHCN, and integrate behavioral health services with primary care for CYSHCN. These and other insights can be found in NASHP’s updated 50-State Chart and Map.

Feature	Number of States – 2017	Trend	Number of States – 2020
Contract language
Contract provides a clear definition of CYSHCN	23	↑	29
Specific quality measures for CYSHCN	32	↑	39
Subpopulation enrollment in MMC (mandatory or voluntary for at least one plan)
Aged, blind, and disabled	40	↑	42
American Indian/Alaskan Native	22	↑	36
Foster care youth/adoption assistance	39	↑	46
Social Security Income (SSI)	20	↑	33
Title V CYSHCN	14	↑	17
1915(c)	14	↑	25
Specialized plans for CYSHCN*
Total states with specialized plans	7	↑	13
Includes aged, blind, and disabled	3	↑	6
Includes youth in foster care/adoption assistance	2	↑	9
Includes Social Security Income	2	↑	3
Includes CYSHCN	2	—-	2
Includes Title V CYSHCN	1	↓	0
Includes 1915(c)	2	↑	5
Behavioral health service delivery system for CYSHCN**
MCO provides behavioral health services	33	↑	41
Behavioral health services are carved-out into FFS	7	↓	6
Behavioral health services are carved-out of managed care and provided by a behavioral health organization	8	↓	6

*Specialized plans may include more than one subpopulation.

**Some states use more than one approach to provide behavioral health services.

Notes

[1] Children with Special Health Care Needs.” Maternal and Child Health Bureau, December 17, 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs.

[2] See NASHP’s 2017 chart and map here: https://www.oldsite.nashp.org/state-medicaid-managed-care-program-design-for-children-and-youth-with-special-health-care-needs/

[3] MaryBeth Musumeci and Priya Chidambaram, How Do Medicaid/CHIP Children with Special Health Care Needs Differ from Those with Private Insurance? (Menlo Park, CA: Kaiser Family Foundation, June 2019). https://www.kff.org/medicaid/issue-brief/how-do-medicaid-chip-children-with-special-health-care-needs-differ-from-those-with-private-insurance/

[4] Children with Special Health Care Needs.” Maternal and Child Health Bureau, December 17, 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs

Six States’ Strategies to Providing Home Health Services to Children Enrolled in Medicaid

July 6, 2020/in Medicaid Managed Care Connecticut, Delaware, Iowa, Maryland, Ohio, Washington Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Community Health Workers, COVID-19, Health Coverage and Access, Health Equity, Integrated Care for Children, Long-Term Care, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health, Special Populations and Services, Workforce Capacity /by Olivia Randi and Kate Honsberger

To improve the quality of services for children and youth with special health care needs (CYSHCN) and reduce health care costs, states are implementing strategies to improve access to home health services. Of particular importance as states confront COVID-19-related budget challenges, home health services can help to avoid costly emergency department use, hospitalizations, and institutional care.

The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit mandates coverage of all medically necessary services for children under age 21 who are enrolled in Medicaid. However, states vary in their definitions of medical necessity, prior authorization processes, and approaches to home health service delivery.

Prior to National Academy for State Health Policy’s (NASHP) analysis, there was limited information available on home health services for CYSHCN, and few studies had analyzed states’ approaches to delivering these services.

In its new report, State Approaches to Providing Home Health Services to Children with Medical Complexity Enrolled in Medicaid, NASHP examines six states’ (WA, OH, IA, MD, DL, CT) strategies to support access to home health services for CYSHCN. These include addressing provider capacity, advancing the person-centered medical home model, streamlining prior authorization processes, collaborating with Title V Maternal and Child Health Services Block Grant Programs for CYSHCN, and promoting stakeholder collaboration.

Home health services are provided in a person’s residence and include:

Nursing services;
Home aide services provided by a home care agency;
Medical supplies and equipment for use in home-based settings; and
Physical and occupational therapy, or speech pathology and audiology services.

Through analysis of these states’ home health service delivery systems, NASHP identified several key insights that other state health policymakers can leverage in their own systems to improve service delivery and reduce costs. A shortage of home health providers was the primary challenge that states faced in delivering these services to CYSHCN, which states have addressed through training programs and by increasing or modifying reimbursement policies.

Partnerships across agencies and families were recognized as key to developing informed strategies to improve home health services for CYSHCN. States have leveraged these partnerships, as well as implemented technologies and streamlined processes, to deliver more coordinated, cost-effective home health services.

Prioritize efforts to address provider shortages. To address the lack of home health provider capacity, several states have focused on developing, enhancing, and raising awareness of training programs to increase the supply of home health agency staff. States have also modified their reimbursement policies, including increasing their reimbursement rates for home health providers, and proposing a structured fee schedule to streamline the reimbursement process for home health agencies. Ohio, for example, allows for reimbursement of family caregivers for providing services for children enrolled in its Medicaid waivers in an effort to increase home health service provider capacity.
Leverage the benefits of cross-sector and stakeholder collaboration. Partnering with a variety of state agencies, including Title V CYSHCN programs, provider groups, families, and other key stakeholders helps build the infrastructure necessary to deliver comprehensive home health services to CYSHCN. Stakeholder groups in Ohio, Maryland, and Delaware were crucial to developing strategies to improve access to home health services for CYSHCN. Two of these states also referenced the importance of family engagement to inform the work of the stakeholder group. In Ohio and Iowa, Medicaid agencies, providers, and Title V CYSHCN programs have formed collaborations to improve care coordination and access to home health services for CYSHCN.
Adjust service delivery models to increase capacity. The medical home is a primary care service delivery model that emphasizes coordinated care through a team-based approach. Connecticut and Delaware, have looked to this model to encourage providers to improve care coordination for CYSHCN, including home health services. States have also looked to streamline their prior authorization processes to reduce administrative challenges for CYSHCN to access home health services. Delaware and Iowa are implementing changes to simplify this process through a “flag” in their data system and by developing a standardized prior authorization form for all managed care plans, respectively.

Other key insights from this analysis include seeking regular feedback from families, strengthening oversight, and customizing fee-for-services and managed care approaches. States interested in improving children’s access to home health services through Medicaid may benefit from the approaches implemented by the six states highlighted in this issue brief. For a list of NASHP’s reports, blogs, and other resources related to improving care for CYSHCN, please click here.

Serving Children and Youth with Special Health Care Needs in Medicaid Managed Care: Targeted Contract Language

March 12, 2020/in Medicaid Managed Care Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Featured Policy Home, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Program Design, Quality and Measurement, Special Populations and Services /by Kate Honsberger, Anna Matilde “Tilly” Tanga and Karen VanLandeghem

Virginia Advances Integrated Care for Pregnant and Parenting Women with Substance Use Disorder

December 16, 2019/in Medicaid Managed Care Virginia Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Special Populations and Services /by Melissa Caminiti and Ashley Harrell

To tackle the opioid epidemic, which has been the leading cause of unnatural deaths since 2013, Virginia recently developed an integrated physical and behavioral health continuum of care, which spans multiple treatment settings and includes case management and peer recovery support. The initiative, combined with increased access to naloxone and other efforts, has helped reduce fatal overdoses by 3.3 percent between 2017 and 2018.

In March 2016, with support from Virginia Gov. Terry McAuliffe, the Virginia General Assembly passed appropriations mandating transformation of the SUD Medicaid benefit entitled the Addiction and Recovery Treatment Services program or ARTS, which was implemented on April 1, 2017. Early results from Virginia’s ARTS program indicate success in increasing access to care for Medicaid-eligible pregnant women with SUD and opioid use disorder (OUD).

Data obtained from pre-ARTS implementation (covering April 2016-March 2017) compared to post-ARTS implementation (April 2017-March 2018) indicate that the percent of Medicaid-enrolled pregnant women with SUD who received treatment increased from 2 percent to 21 percent, while the rate of pregnant women with OUD who received treatment increased from 4 percent to 31 percent. In addition to increasing treatment rates, the number and types of treatment providers and treatment programs available to pregnant women with SUD and OUD also increased significantly in the post-ARTS implementation period.

Ashley Harrell, senior program advisor with Virginia’s Department of Medical Assistance Services (DMAS), recently shared the goals and highlights of the program with the Maternal and Child Health Policy Innovation Program (MCH PIP) Policy Academy, hosted by the National Academy for State Health Policy (NASHP). The academy, made up of eight cross-sector state teams, focuses on the mental health needs of pregnant and parenting women, particularly those with or at risk of substance use disorder (SUD). The ARTS program has six major goals:

Expand the short-term SUD inpatient detox benefit to all Medicaid/FAMIS enrollees (FAMIS is Virginia’s health insurance program for uninsured children);
Expand short-term SUD residential treatment to all Medicaid enrollees;
Increase reimbursement for existing Medicaid/FAMIS SUD treatment services;
Add peer support services for individuals with SUD and/or mental health conditions;
Require SUD care coordinators for DMAS-contracted managed care plans; and
Organize provider education, training, and recruitment activities.

The Virginia state Medicaid agency has made additional policy changes to improve access to care for pregnant enrollees with SUD. Some of these changes include:

Allowing and encouraging same-day billing of medical and behavioral health services;
Requiring access to medication-assisted treatment (MAT) along the addiction care continuum; and
Removal of prior authorization requirements for up to 24 mg/day of Suboxone film for in-network buprenorphine-waivered practitioners.

Additionally, the Virginia Medicaid MEDALLION 4.0 has an embedded High-Risk Maternity Program that includes comprehensive care management and family planning services to women with SUD. MEDALLION 4.0 is a statewide, fully capitated, risk-based, mandatory managed care program for Medicaid and Family Access to Medical Insurance Security (FAMIS) members that operates under the authority of a §1915(b) waiver. MEDALLION 4.0 covers pregnant women, infants and children and provides acute and primary health care services, prescription drug coverage, and behavioral health services for their members.

Harrell’s presentation spurred much discussion among academy participants, who quickly shared their concerns about access to care, integration of services, health equity, and the long-term health outcomes of women, children, and families affected by SUD.

Over the next two years, NASHP academy participants will continue to learn from each other and from subject matter policy experts as they strive to develop, support, and advance state-level policy innovations for pregnant and parenting women with or at risk for SUD and/or mental health conditions. Understanding state innovations is key to identifying new strategies to leverage change. As one policy academy participant observed during the meeting, “No one [state] has all the answers, but we have a lot of resources in each other.”

For more information on the academy, read NASHP’s blog, New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD. For more information about the Virginia ARTS program, visit the Virginia DMAS ARTS website or email questions about the ARTS program to sud@dmas.virginia.gov.

State Medicaid Managed Care Program Design for Children and Youth with Special Health Care Needs

States Are Increasing their Use of Medicaid Managed Care for Children and Youth with Special Health Care Needs

Serving Children and Youth with Special Health Care Needs in Medicaid Managed Care: Targeted Contract Language

Virginia Advances Integrated Care for Pregnant and Parenting Women with Substance Use Disorder

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