Name of Practice: Enrollment of Children with Special Health Care Needs into Medicaid Managed Care (RI0602) Category: Children with Special Health Care Needs Abstract: The State of Rhode Island has sought to reduce the high rates of emergency department utilization and hospital admissions, as well as lengthy periods of stay, for Medicaid-eligible children with special health care needs. The State has enhanced requirements in its managed care contract pertaining to this population, arranged for health screenings to identify conditions needing treatment as early as possible, encouraged its managed care plan to expand its network of specialty providers, and intensified monitoring of plan performance. An analysis of Medicaid claims data found that both the rate of emergency department visits and the hospitalization rate for Medicaid beneficiaries under the age of 21 receiving Supplemental Security Income declined between State fiscal year (SFY) 2002 and SFY 2005. The State determined that this initiative reduced Medicaid expenditures by $1,440,506 per month during State fiscal year 2006. The Problem The State of Rhode Island noted that Medicaid-eligible children with special health care needs tend to have particularly high rates of emergency department utilization and hospital admissions, as well as lengthy periods of stay. The State reasoned that improving access to, and coordination of, appropriate services for Medicaid-eligible children with special health care needs would help avoid the need for emergency services, prevent unnecessary admissions, and facilitate timely discharge to the home with appropriate community supports. This intervention would also increase the level of consumer satisfaction, improve health outcomes for Medicaid-eligible children with special health care needs, and help contain the growth of costs associated with Medicaid-eligible children with special health care needs. Discussion of Approach Since 2003, the State of Rhode Island has enabled children with special health care needs (CSHCN) to enroll voluntarily in the Neighborhood Health Plan of Rhode Island, a managed care organization participating in the State's RiteCare section 1115 demonstration project. These children may have behavioral health disorders, development disabilities, and/or physical conditions that render them medically fragile. They are enrolled in Medicaid based on eligibility for Supplemental Security Income benefits, a need for an institutional level of care, or receipt of an adoption subsidy. The intent of the State's initiative is to provide such children with access to an organized, coordinated system of care with a broad network of acute, primary, specialty, and behavioral health providers. The State has incorporated additional requirements in its contract with Neighborhood Health Plan of Rhode Island, including access standards, to assure children with special health care needs can obtain necessary, high-quality services. Each child receives an initial health screening upon enrollment to identify service and care coordination needs. The State has sought to assure transparency in the establishment of this program by inviting parents, providers, advocates, and other agencies to participate in open forums. Neighborhood Health Plan of Rhode Island has worked to serve this population by expanding its network of specialty providers, by forming an advisory group of family members and advocates, and by establishing a dedicated care management unit for CSHCN. The State monitors plan performance through face-to-face meetings and the receipt of standard reports. The State monitors the timeliness of initial screens, the adequacy of the plan's provider network and its ability to retain providers, and efforts to move children from institutional to home and community-based care. Contract penalties can be assessed for contract requirements not met by the plan. Results Initial results indicate that voluntary enrollment of CSHCN in a designated managed care plan has enhanced the access of CSHCN to primary care providers and behavioral health care while moderating the utilization of inpatient hospital services and the costs of medical care for this population. A 2005 survey indicated that 96 percent of CSHCN enrolled in this plan reported being satisfied or very satisfied with their health care coverage, while 92 percent reported being satisfied or very satisfied with their care coordination. An analysis of data from the Medicaid Management Information System (MMIS)/Medicaid Research Files (MRF) found that the rate of emergency department visits for Medicaid beneficiaries under the age of 21 receiving Supplemental Security Income declined from 689.5 visits per 1,000 eligibles in SFY 2002 to 520.1 visits per 1,000 eligibles in SFY 2005. The hospitalization rate for the same group declined from 165.9 hospitalizations per 1,000 eligibles in SFY 2002 to 150.9 hospitalizations per 1,000 eligibles in SFY 2005. The State determined that reduced Medicaid expenditures by $1,440,506 per month during State fiscal year 2006 based on a comparison of monthly costs for CSHCN who chose to enroll into the program versus children with similar needs who chose not to enroll. Further Information Contact: Deborah Florio
Administrator
Department of Human Services
Center for Child and Family Health
Medicaid Division
600 New London Avenue
Cranston, R.I. 02920
(401) 462-0140
e-mail: dflorio@dhs.ri.gov Nancy Hermiz
Neighborhood Health Plan of Rhode Island
299 Promenade Street
Providence, Rhode Island 02098
(401) 459-6041
e-mail: whermiz@nhpri.org Links: www.dhs.ri.gov, select "Children and Families" and then "Children with Special Health Care Needs" This Profile has been posted to the CMS Medicaid/SCHIP Quality website for informational purposes only and does not convey CMS endorsement of the practice itself. The descriptive information supplied and the results reported in this Profile have been supplied by sources familiar with the practice but have not been independently validated by CMS.
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