Providing High-Quality Services to Children with Special Health Care Needs (CSHCN) Under Managed Care

Fully-Capitated Managed Care Arrangements

Serving Children with Special Health Care Needs

An alternative approach to serving CSHCN under managed care is for States to provide care for this population through fully-capitated managed care plans. This can be accomplished in one of two ways:

• By enrolling CSHCN in the same managed care plans as the general population of children.
• By developing distinct and specialized managed care systems to serve the population separately.

In this session, the panelists discussed the critical design issues to be addressed under either of these options to ensure the delivery of high-quality care.

Don Blanchon of Health Services for Children with Special Needs, Inc., discussed a managed care plan developed exclusively for children eligible for Supplemental Security Income (SSI) that is being used by the District of Columbia under a federal research and demonstration project. Some of the key features of this plan include:

• Extensive outreach to eligible families.
• Voluntary enrollment.
• Coordination of care.
• An open panel model.

According to Mr. Blanchon, the continuing challenges for this plan are educating families and providers about managed care and establishing formal relationships with public and private agencies that serve children.

Wendy Long, Medical Director of TennCare, provided an example of how Tennessee enrolled CSHCN along with other children in TennCare's fully capitated system. Although special training was provided to Managed Care Organizations (MCOs) staff, there were still a number of implementation challenges, including difficulties determining medical necessity and access standards for specialty services, and slow acceptance of a greater quality assurance role on the part of Title V CSHCN program staff. Initial analyses of quality monitoring results indicate that TennCare is saving money while increasing rates of insurance coverage in Tennessee.

In order to serve CSHCN in the State of Michigan, according to Ron Uken, the former Chief of Michigan Children's Special Health Care Services, the objective is to enter into long-term contracted partnerships with a limited number of MCOs in order to develop specialized, high-quality delivery systems, while sharing financial risk. The State has issued an Request for Proposals (RFP) for a proposed system that will feature voluntary enrollment and family-centered care coordination in a variety of delivery settings including offices, schools and hospitals. The State CSHCN program will be also acquiring new oversight responsibilities, such as quality assurance, contract management and organizing and training staff.

Reference

State of Michigan, Department of Management and Budget (DMB), Request for Proposal. Children's Specialty and Children's Comprehensive Health Care. Pages i-xi, 17-103.

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