Appendix 1

Materials for Pennsylvania Leadership Workshop

1. Assuring Continuity in Benefits and Coverage for Children with Publicly Subsidized Health Coverage

The 120,000 children served under the Pennsylvania SCHIP program and the more than 900,000 children
enrolled in eligible for Medicaid are often thought of as discrete populations. Yet, we know that lowincome
working families frequently change income and employment status in ways that affect their
eligibility for publicly subsidized health coverage. For States with separate SCHIP programs, ensuring
linkages with Medicaid eligibility, providers, and MCOs is important to assure access to needed health
services.

Bridges between Medicaid and SCHIP Eligibility

• Specify coordination and patient information transfer procedures contractors must
  follow. What are the MCO obligations when a child enrolls or disenrolls from Medicaid or SCHIP?
  For example, are notices to the eligibility agency or prompt, efficient record transfers required?
• Clarify definitions under SCHIP eligibility to aid SCHIP and Medicaid enrollment. A
  study of non-Medicaid SCHIP programs found that more than a dozen States (including
  Pennsylvania) had ambiguous or unclear language to define a family, attribute income, set income
  adjustments for size of family, and specify income standards and methodologies under SCHIP.¹ The
  Pennsylvania Renewal Workgroup is discussing such definitions.

Assuring Continuity of Care between Medicaid and SCHIP

• Offer parallel benefit categories. For example, a GWU study of non-Medicaid SCHIP programs
  found that several States (including Pennsylvania) did not define case management services or
  services for children with special health needs.²
• Require that a course of treatment be continued/completed during transitions. For
  children under a course of treatment at the time of Medicaid or SCHIP enrollment or disenrollment,
  require that the contractor continue to furnish needed services until that course of treatment is
  completed or until the child is enrolled in a successor MCO.
• Offer presumptive eligibility for children. Building on the policy precedent set for pregnant
  women, States have this option under Federal law. Presumptive eligibility can improve child health
  coverage levels and be of benefit to community health clinics, WIC nutrition sites, and other public
  providers. Implementation of the proposed pilot program is the first step toward success.

Appropriate Provider Networks for Children with Publicly Subsidized Coverage

• Monitor involvement of “traditional” providers in MCO networks: A “traditional”
  provider has experience serving a substantial number of uninsured low-income children, including: 1)
  Federally qualified health centers (FQHCs), 2) rural health clinics, 3) city or county health
  departments operating clinics, 4) other maternal and child health clinics receiving funds under Title
  V, 5) providers funded under the Ryan White Comprehensive AIDS Research and Education Act, and
  6) family planning clinics receiving funds under Title X. A GWU study found, for example, that
  several States (including Pennsylvania) did not define relationships with FQHCs under their SCHIP
  managed care contracts.³
• Give access to out-of-network providers in certain circumstances: For example, prohibit
  contractors’ restrictions on children’s access to emergency services, public health services, or health
  care at school-based health centers. Another option is to require that contractors give access to out-of
  network providers for children in migratory or seasonal agricultural worker families, in homeless
  families, and/or in foster care. Special attention should be given to MCO contracts under SCHIP.

2. Services for Special Needs Children in Medicaid/SCHIP Managed Care

Children with special health needs, including those with mental/behavioral health
needs

Children with special health care needs (CSHCN) are defined in as “children under 21 who have or are at
risk for a chronic physical, developmental, or behavioral, or emotional condition, and require health and
related services of a type or amount beyond that which is required by children generally."⁴ Such children
may have a variety of conditions, but all have a need for specialized health care services, care plans, and
care coordination.

Benefits and Services for CSHCN

• Clarify how services will be provided. States may contract for the full range of services to
  which children beneficiaries are entitled under Medicaid. Additionally, the State “carves out”
  services under contracts for behavioral health. Measuring and enforcing the adequacy of provider
  networks is an ongoing role of the State’s management of these contracts. Alternatively, States may
  contract with MCOs for the provision of some services and “carve out” others. Carved-out services,
  in turn, may be covered on a fee-for-service basis or through a risk contract with another MCO, or
  both. Clarity is key.
• Elect to cover care coordination services. States may choose to place care coordination under
  MCO contracts or to provide them on a fee-for-service basis through other State or local agencies or
  private organizations. While Federal Medicaid law does not define “care coordination,” either
  administrative or targeted case management may be used.
• Use care plans. Such plans assist families, providers, plans, and purchasers. States may require
  contractors to ensure that a primary care provider develop and maintain a care plan for CSHCN.
• Require linkage to IFSP or IEP under special education. Contractors should understand and
  comply with their obligations under an Individualized Family Service Plan (an IFSP under IDEA Part
  C Early Intervention) or Individual Education Program (an IEP under IDEA Part B Special
  Education) requirements for enrolled children. Defining the related roles and responsibilities of an
  MCO in Medicaid/SCHIP contracts facilitates cooperation.

• Give attention to mental/behavioral health needs, because Medicaid populations generally
  have a higher prevalence of children with serious emotional disturbance than privately insured
  populations. Medicaid managed care contracts may include prevention and early intervention through
  EPSDT, as well as long-term treatment. For children, a family-focused/family-centered approach is
  the standard of care. The leadership of the Department of Public Welfare understands the importance
  of these issues and may help focus attention on the mental health needs among children and their
  families. The State determines how to finance this care.

Provider Networks for CSHCN

• Require Contractors to give families and caregivers of enrolled children the option of
  choosing the child’s primary care provider for their medical home, either (1) a primary
  care practitioner, or (2) a physician who is trained as a specialist in pediatrics, including pediatric
  medical subspecialists, pediatric surgical specialists, and child psychiatrists and psychologists.
  Regardless of the providers’ credentials, the medical home assists in early identification of special
  needs; provides ongoing primary care; and coordinates with a broad range of other specialty,
  ancillary, and related services.
• Require Contractors to provide information about their networks to newly enrolled
  CSHCN through an enrollee handbook, a provider directory, and other means.
• Require memoranda of understanding (MOU) between contracting MCOs and State
  agencies other than the purchaser that have responsibility for CSHCN. These include
  State: Title V CSHCN agencies, substance abuse and mental health agencies, educational agencies,
  child welfare agencies and/or developmental disabilities agencies.
• Define (and reflect in the contract) the benefit and payment relationships between
  contractor and the CSHCN program division. Some State Title V CSHCN Programs pay for
  or provide medical care directly to children with special health care needs; others furnish care
  coordination and referrals but do not pay for or provide medical care.

3. Strengthening Relationships to Improve Efficiency and Effectiveness

The efficiency and effectiveness of Medicaid/SCHIP managed care in Pennsylvania depends on wellfunctioning
State agency coordination and strong State-to-local relationships. While the State has delayed
further expansion of mandatory managed care enrollment, the mandatory HealthChoices program and the
voluntary managed care program continue. Moreover, the behavioral health program may yet be
modified. The impact of Medicaid managed care policies is particularly important in the case of
children’s health care. Children comprise more than half of Medicaid managed care consumers in
HealthChoices, (PA Office of Medical Assistance, 2003) a similar percentage of those enrolled in
voluntary arrangements, and all, of course, 100 percent of those enrolled in SCHIP managed care. The
Renewal Workgroup, Interagency Outreach Committee, Medical Assistance Advisory Committee,
Cultural Diversity Committee, and others are working to improve collaboration. Other entities (such as
Healthy Start, the Perinatal Partnership, and the Partnership for Children) provide opportunities to link to
local resources.

Relationships between Medicaid and the State Department of Health

The Pennsylvania Department of Public Welfare (DPW), Department of Health (DOH), and Department
of Insurance (DOI) have solid, ongoing professional relationships that reflect their shared interest in fiscal
accountability and good health for Pennsylvanians. As the health care system continues to evolve,
however, new mechanisms and operational approaches are needed to strengthen the system.

• Share information from Medicaid/SCHIP managed care performance measurement
  and data reporting. While certain summary data from MCOs are available, increasing the level of
  information shared could improve State health planning, services, and access. For example, a variety
  of public health databases (immunization, sexually transmitted diseases, children with special needs,
  birth defects) need information from MCOs to be accurate, timely, and complete.
• Develop an ongoing forum for discussion of public health and Medicaid managed care
  issues. Either within an existing body or a new workgroup, Pennsylvania could benefit from
  ongoing discussion of Medicaid/SCHIP managed care issues that have an impact on public health
  programs and services. Topics for discussion might include: patient education and utilization,
  provider education and cultural competence, and enhancement of provider networks. Entities
  (including but not limited to Healthy Start, the Perinatal Partnership, and the Partnership for Children)
  already exist and provide opportunities to link to community resources and public health providers.
• Work collaboratively to collect and utilize consumer and community input. Public health
  agencies are in regular contact with many Medicaid beneficiaries. Increased collaboration in
  assessment of consumer satisfaction, cultural competency, and unmet needs could benefit DPW,
  MCOs, and public health.

Relationships between Medicaid-Contracting MCOs and Local Health Agencies

Enrollment of large numbers of low-income children in MCOs and primary care case managers (PCCMs)
has important implications for State and local public health agencies.⁵ Well-functioning local
relationships are essential to protecting the public’s health.

• Require communicable disease reporting by contractors. PCCM arrangements present an
  opportunity for public health agencies to improve reporting of notifiable conditions. Low-income
  individuals are at greater risk than the general population to have communicable diseases (e.g., STDs,
  HIV/AIDS, and TB) and to be affected by other public health problems (e.g., lead poisoning).
• Assess the criteria for successful implementation of memoranda of understanding
  (MOUs) between providers and public health agencies. The function of an MOU is to clarify
  roles and responsibilities in meeting the health needs of Medicaid enrollees and the community as a
  whole.⁶ Effectively implemented MOUs help providers and payers.

Post-workshop Summary

1. Assuring Continuity in Benefits and Coverage for Children with Publicly Subsidized Health Coverage: Discussion Topics

Bridges between Medicaid and SCHIP Eligibility

• Specify coordination and patient information transfer procedures contractors must follow.
• Clarify definitions under SCHIP eligibility to aid SCHIP and Medicaid enrollment.

Assuring Continuity of Care between Medicaid and SCHIP

• Offer parallel benefit categories.
• Require that a course of treatment be continued during transitions between Medicaid or SCHIP
  enrollment or disenrollment.
• Offer presumptive eligibility for children.

Appropriate Provider Networks for Children with Publicly Subsidized Coverage

• Augment the number of available children’s dental and mental health providers.
• Monitor involvement of “traditional” providers in MCO networks.
• Give access to out-of-network providers in certain circumstances.

Possible actions or solutions discussed (and entity accepting responsibility for
continuing the dialogue or taking next steps)

1. Encourage local collaboration. (managed care organizations) In some regions of the State
   MCOs meet with providers and MCH local agencies to discuss challenges and design local
   solutions. This approach could be used voluntarily in other regions.
2. Identify gaps in provider networks. (Department of Insurance - DOI) Gaps in provider
   networks between Medicaid and SCHIP have been widely reported. DOI and DPW reported that
   such data are collected; however, this information is not applied across programs. The State could
   use geo-mapping (e.g. Colorado) or similar approaches to identify specific areas in need of
   improvement.
3. Require that SCHIP providers participate in Medicaid. A number of States have
   adopted such rules to reduce potential for discrimination against one group of publicly insured
   children.
4. Develop standardized documents/card for eligibility verification. (Cabinet on Children,
   Youth, and Families) Working across agencies, the Children’s Cabinet representatives could
   develop a more uniform document or card and require that it be the standard, acceptable means of
   verifying SCHIP or Medicaid eligibility.
5. Use presumptive eligibility for children or a similar State-designed method of
   assuring payment based on presumed eligibility. (Department of Public Welfare and Title
   V) Pennsylvania could adopt presumptive eligibility for children. Alternatively, the State might
   devise a mechanism to assure payment for visits made by children when Medicaid or SCHIP
   eligibility determinations are being finalized and/or children are in transitions between programs.
6. Improve methods and timeliness for electronic eligibility verifications. (Department of
   Public Welfare) Such methods are important for verifying both eligibility and for plan
   enrollment.
7. Strengthen and monitor mechanisms to ensure continuity of coverage and
   continuation of treatments. (Department of Public Welfare and Title V) An issue for
   providers and MCOs.
8. Adopt parallel benefit packages. (Pennsylvania Perinatal Partnership) Other States (e.g.,
   Connecticut, Kansas, and Wisconsin) have aimed to develop parallel benefit packages for their
   Medicaid and separate SCHIP plans. Pennsylvania could increase the similarity in covered
   benefits for these two programs.

2. Services for CSHCN in Medicaid/SCHIP Managed Care: Discussion Topics

Benefits and Services for CSHCN

• Clarify how services will be provided.
• Cover care coordination services.
• Use care plans.
• Require linkage to IFSP or IEP under special education.
• Give attention to mental/behavioral health needs.

Provider Networks for CSHCN

• Require contractors to assist families of CSHCN in choosing the child’s primary care provider for
  their medical home.
• Take steps to improve the supply of providers for CSHCN.
• Require memoranda of understanding (MOU) between contracting MCOs and State agencies other
  than the purchaser that have responsibility for CSHCN.

Possible actions or solutions discussed (and entity accepting responsibility for
continuing the dialogue or taking next steps)

Generally, more quality improvement activities and replication of best practices was called for in this
area. The discussion particularly focused on the following recommendations.

1. Better use the Medicaid case management benefit that exists for all children under
   EPSDT in Pennsylvania, with particular attention to case management for CSHCN. (Department
   of Public Welfare and Title V)
2. Create demonstration projects on enhanced case management and wraparound
   services based on examples such as HIV waiver program and mental health system of care
   approaches. (Department of Public Welfare, Title V, and Perinatal Partnership)
3. Determine the best use for and the best practices of MCO special needs units. What
   can they do well and what is needed in addition to what such units can provide? (MCOs)
4. Consider a case management carve out.
5. Replicate the medical home project across the State, building on best practices from
   the 19 Pennsylvania American Academy of Pediatrics (AAP) demonstration
   projects. Funding needed to support replication. (AAP)
6. Consider Medicaid managed care payment adjustment according to patient acuity.
   DPW is investigating use of software to make such adjustments. The State should consider
   experience of other States with regard to CSHCN in managed care. (Department of Public
   Welfare and AAP)
7. Monitor network capacity for CSHCN. (Department of Insurance)
8. Consider special issues related to adolescent health, including confidentiality,
   individual cards, and services in transition to adult years. (Title V)
9. Conduct MCO focus studies related to services for CSHCN. (MCOs and Title V)
10. Use Title V CSHCN funding as “glue” to hold together various services, case
    management, and care coordination approaches, as well as to fill gaps. (Title V)

3. Strengthening Relationships to Improve Efficiency and Effectiveness: Discussion Topics

The efficiency and effectiveness of Medicaid/SCHIP managed care in Pennsylvania depends on wellfunctioning
State agency coordination and strong State-to-local relationships. While the State has delayed
further expansion of mandatory managed care enrollment, the mandatory HealthChoices program and the
voluntary managed care program continue. Moreover, the behavioral health program may be modified.
These managed care policies are particularly important in the case of children. Children comprise more
than half of Medicaid managed care consumers in HealthChoices, a similar percentage of those enrolled
in voluntary arrangements, and all of those enrolled in SCHIP managed care.

Relationships between Medicaid and the State Department of Health

• Share information from Medicaid/SCHIP managed care performance measurement and data
  reporting.
• Develop an ongoing forum for discussion of public health and Medicaid managed care issues.
• Work collaboratively to collect and utilize consumer and community input.

Relationships between Medicaid-Contracting MCOs and Local Health Agencies

• Require communicable disease reporting by contractors.
• Assess the criteria for successful implementation of memoranda of understanding (MOUs) between
  providers and public health agencies.

Possible actions or solutions discussed (and entity accepting responsibility for continuing the dialogue or taking next steps)

1. The Title V agency should work with the Departments of Insurance and Public Welfare to
   advance approaches and mechanisms for data sharing and engage in existing forums for
   discussing Medicaid and SCHIP managed care issues. Title V also should continue to identify
   issues of concern such as neonatal follow up, provider availability, and local public health
   financing for services delivered. (Title V)
2. Regional planning and discussion groups should engage all key stakeholders. Currently, some do
   not include SCHIP plans and others do not include Title V. Medicaid could help foster such
   involvement. (MCOs, Title V, and Perinatal Partnership)
3. While MOUs between public health agencies and MCOs exist in some areas of the State, more
   could be done to strengthen enforcement of MOU provisions, as well as to set up MOUs across
   Pennsylvania. (Department of Public Welfare, Title V, and Perinatal Partnership)
4. Another meeting should be convened to discuss mental/behavioral health issues, including
   prevention, early intervention, and treatment. (Department of Public Welfare, Title V, and
   Perinatal Partnership)
5. Providers, plans, and public agencies should investigate opportunities to adopt an electronic
   medical record system for children. (Pennsylvania AAP and MCOs)

¹ Rosenbaum, S., Markus, A. Policy Brief #4: State Eligibility Rules under Separate State SCHIP Programs—
Implications for Children's Access to Health Care. September 2002.
² Rosenbaum, S., Shaw, K., and Sonosky, C. SCHIP Policy Brief #3: Managed Care Purchasing Under SCHIP: A
Nationwide Analysis of Freestanding SCHIP Contracts. December 2001.
³ Rosenbaum, S., Shaw, K., and Sonosky, C. SCHIP Policy Brief #3: Managed Care Purchasing Under SCHIP: A
Nationwide Analysis of Freestanding SCHIP Contracts. December, 2001.
⁴ McPherson et al. A New Definition of Children with Special Health Care Needs. Pediatrics. 1998;102:137-140.
⁵ Rosenbaum S, et al. Negotiating the New Health System: A nationwide study of Medicaid Managed Care
Contracts. (3rd Edition) Washington, DC: The George Washington University, March 2000).
⁶References and more information at:
Department of Health Policy, George Washington University School of Public Health and Health Services
Research Activities, Department of Health Policy,George Washington University School of Public Health and Health Services.