Appendix 1
Materials for Pennsylvania
Leadership Workshop
This document was prepared
for a Leadership Workshop on Managed Care and Child Health to be held on
March 18, 2004 in Harrisburg, Pennsylvania. The workshop is based on work
by the Center for Health Services Research and Policy at The George Washington
University (GWU), and conducted with support from the Health Resources and
Services Administration’s (HRSA’s) Maternal and Child Health
Bureau (MCHB) and the Managed Care and Health Services Financing Technical
Assistance Center (MCTAC). Senior policy makers and professionals attending
the workshop will discuss approaches to ensure that health plan enrollees
receive the highest quality pediatric care. This information was designed
to provide a framework for discussion, offering options for solutions to
concerns shared by State agencies, managed care organizations, and consumer
advocates. These documents have not been endorsed by Federal or State officials.
Prepared by Kay Johnson, Johnson Group Consulting; and Jeff Levi, Center
for Health Services Research and Policy under contract with HRSA. |
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.
This document was prepared
as follow-up to a Leadership Workshop on Managed Care and Child Health held
on March 18,
2004 in Harrisburg, Pennsylvania. The more than 35 senior policy makers
and professionals attending the workshop
discussed approaches to assure that children enrolled in Medicaid and SCHIP
health plans receive the highest quality care.
These documents have not been endorsed by Federal or State officials. The
workshop was based on work by the Center for
Health Services Research and Policy at The George Washington University
(GWU), and conducted with support from the
Health Resources and Services Administration’s (HRSA’s) Maternal
and Child Health Bureau (MCHB). |
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)
- 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.
- 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.
- 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.
- 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.
- 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.
- Improve methods
and timeliness for electronic eligibility verifications. (Department
of
Public Welfare) Such methods are important for verifying both eligibility
and for plan
enrollment.
- 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.
- 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.
- 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)
- 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)
- 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)
- Consider a case
management carve out.
- 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)
- 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)
- Monitor network
capacity for CSHCN. (Department of Insurance)
- Consider special
issues related to adolescent health, including confidentiality,
individual cards, and services in transition to adult years. (Title V)
- Conduct MCO
focus studies related to services for CSHCN. (MCOs and Title V)
- 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)
- 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)
- 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)
- 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)
- 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)
- 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.
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