Appendix 2

Materials for Connecticut Leadership Workshop

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

Children with special health care needs (CSHCN) are defined as children under 21 who have or are at risk
for a chronic physical, developmental, behavioral, or emotional condition, and require health and related
services of a type or amount beyond that which is required by children generally^.7 Such children may
have a variety of conditions, but all have a need for specialized health care services, care plans, and care
coordination. CSHCN account for an estimated 76 percent of total Medicaid expenditures for children,
even though they represent less than 25-30 percent of the population.⁸ While Husky A and B -- Medicaid
and State Children’s Health Insurance Program -- offer generous child health benefits, opportunities exist
to maximize existing financing and services, contract mechanisms can help the State in purchasing
services for CSHCN.

Financing Services for CSHCN

• Maximize Medicaid and Title V financing. Data indicate that 80 percent of CSHCN in
  Connecticut are eligible for Medicaid benefits. These data also reveal that Title V Maternal and Child
  Health Block Grant funds have been used to pay for Medicaid-covered services to Medicaid-eligible
  children. With this knowledge, Connecticut is poised to redesign its approach to financing services
  for CSHCN. Working together, Medicaid and Public Health can better ensure that eligible children
  are enrolled in Husky plans and that managed care organizations (MCOs) are prepared to identify and
  deliver covered services to enrollees who are CSHCN. Remedying this problem will make Title V
  funding available for additional CSHCN who are uninsured or underinsured and not eligible for
  Medicaid.
• Set appropriate, risk-adjusted rates. In a letter to State Medicaid Directors dated October 5,
  1998, HCFA (now the Center for Medicare and Medicaid Services-CMS) suggested that “States
  should consider … developing rates of payment to MCOs, prior to enrollment of persons with special
  health care needs that assure adequate payment… (and) providing appropriate financial incentives to
  providers and MCOs to encourage appropriate delivery of care to persons with special health care
  needs. Such approaches also must recognize that serving individuals with special health care needs
  takes more time and resources than with healthier patients"⁹ In Connecticut, the Department of
  Public Health, the Papanicou Center at the University Connecticut, and others have discussed
  strategies for revising billing codes and setting enhanced capitation rates.
• Assure continued access to a full range of Medicaid/EPSDT benefits. Connecticut has done
  a good job of contracting for a broad range of services to which children are entitled under Husky A
  and B. In recent months, however, the State has considered options for reducing benefits through a
  Federal waiver option. For CSHCN, this is a particular burden.

Providers and Networks for CSHCN

• Apply the “medical home” project model within managed care plans. This model was
  developed by the Title V agency and is ready for replication, with documentation, CPT codes, and
  procedures already tested. The success of the pilot projects to refine the medical home model in
  Connecticut and other States has been documented. In the Connecticut approach, CSHCN are
  identified using a screening tool and severity index. Providers, serving as the child’s medical home,
  “flag” the child’s chart, and a nurse manager is assigned to provide care coordination and case
  management. Care coordination is the “lynchpin” of this effort.
  
  Currently, mechanisms to pay for pediatric medical home case management under Medicaid managed
  care are not fully developed. Such mechanisms need to be articulated in the managed care contract,
  and plans may need operational advice. While Federal law does not define “care coordination,”
  administrative or targeted case management may be used. Defining the appropriate billing codes and
  setting the reimbursement rates (and strategy) under Medicaid is the next step. Given the relatively
  high percentage of Connecticut’s CSHCN enrolled in Husky A and B managed care plans, any new
  mechanisms should be articulated in managed care contracts between the State and Medicaid MCOs.
  
  
• 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.
  
  
• Give families better information about provider choices. As suggested in the GWU
  purchasing specifications for CSHCN, State contract language might require MCOs to offer
  information about: a) the pediatric professionals participating in Contractor’s provider network who
  are willing to serve as primary care providers for children with special health care needs; and b)
  pediatric specialists not participating in Contractor’s provider network to whom enrolled children
  with special health care needs are referred.
  

Selected Connecticut Initiatives and Research Projects on CSHCN

• A Medicaid Managed Care Model Demonstration project is designed to test the ability of Connecticut
  to monitor the quality of the new children's behavioral health system and of the services that will be
  provided to children and families under Connecticut Community KidCare. (Mark Schaefer, Ph.D.)
  
• Connecticut was one State in the Medical Home Learning Collaborative for Children with Special
  Health Care Needs (a 15-month project ending in January 2004) to implement the Medical Home
  Model to improve care for children with special health care needs. Care coordination, parent
  involvement, and coding/reimbursement were some of the hot topics. Over 30 clinical practice sites
  from twelve States, along with their State Title V Agencies, participated in this project. (National
  Initiative for Child Health Quality NICHQ) The goal of the Best Clinical and Administrative
  Practices Workgroup on Improving Managed Care for Children with Special Needs was to develop
  and pilot strategies to improve the quality of care for children with special needs enrolled in Medicaid
  and SCHIP. Connecticut was represented on the workgroup, consisting of key Medicaid health plans
  leaders. Plans focused on creating a "Medical Home," cultural competency, risk adjustment, and
  consumer relations (Center for Health Care Strategies)

II. Promoting Early Childhood Development in Medicaid Managed Care

Currently, promoting early childhood social-emotional development is a focus of attention in Connecticut.
Medicaid managed care offers specific opportunities. Medicaid managed care contracts typically include
prevention and early intervention through EPSDT, as well as treatment. States can work with MCOs to
improve care, using their power as purchasers to ensure that important services are properly provided.

Benefits and Services to Promote Early Childhood Development

• Use the GWU purchasing specifications on child development to develop contract language that
  clearly communicates policies on developmental services to managed care plans. While
  Medicaid has over 30 benefit categories, no category is labeled "child development services.” The
  GWU purchasing specifications identify a range of covered services linked to child development.
• Improve and clarify the description of developmental assessment under EPSDT. For example, a
  State may distinguish a routine developmental screening conducted as part of an EPSDT screen from
  a developmental exam or diagnostic assessment conducted by a medical social worker, public health
  nurse, or developmental pediatrician. States also could encourage or mandate use of professionally
  recommended objective screening tools appropriate for young children.
• Clarify State Medicaid guidance on screening, assessment, and treatment related to early
  childhood mental health development. The State might clarify benefits covered, better define
  developmental screening and assessment, put protocols into place for developmental services, and
  define a set of providers qualified to receive reimbursement. Such guidance might distinguish
  treatment services for children with diagnoses from those to promote healthy mental development.
  This is particularly important where Medicaid mental health services are “carved out.”
• Encourage pediatric provider sites to promote healthy development. State Medicaid agencies
  could reimburse primary pediatric practitioners for providing preventive mental health care and
  development services (see Bright Futures). Medicaid might also pay for developmental services
  provided by social workers and child psychologists co-located in pediatric practices.
• Develop protocols and guidelines for more effective screening and referral of mothers and
  young children. Families affected by depression, domestic violence, substance abuse, and related
  conditions can benefit from early interventions carried out by physicians, psychologists, and
  psychiatrists. States might clarify coverage of parent-child (or family) services for young children.

Financing Services to Promote Early Childhood Development

• Clarify rules on Medicaid payment for services delivered through other public programs, such
  as the Individuals with Disabilities Education Act (IDEA) Part C Early Intervention, children’s
  mental health, child welfare, and Head Start. Many State Medicaid contracts require MCOs to sign
  memoranda of understanding with public agencies.
• Clarify and adopt billing codes appropriate to early childhood development. Some States have
  found that billing codes tailored to young children’s conditions (e.g., using DC:0-3)¹⁰ helped to
  reduce unnecessary spending, minimize fraud, and maximize early intervention.
• Consider the potential impact for children of a behavioral health carve out. If behavioral health
  services were carved-out of HUSKY A by amendment to the 1915(b) waiver, it could lead to different
  definitions of EPSDT ‘medical necessity’ for children in mandatory versus optional groups. Coverage
  of transportation assistance, case management, and certain “wrap-around” support services might be
  different (reduced) for the optional group. Children at-risk, but without a diagnosis, may be affected.

⁷ McPherson et al. A New Definition of Children with Special Health Care Needs. Pediatrics. 1998;102:137-140.
⁸ Oehlmann ML. Improving Managed Care for Children with Special Needs: A Best Clinical and Administrative
Practices Toolkit. Princeton, NJ: Center for Health Care Strategies, 2004.
⁹ GWU Purchasing Specifications.
¹⁰ Zero to Three. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early
Childhood (DC:0-3) (1994) and DC:0-3 Casebook. Washington, DC: Zero to Three Publications, 1997.