Appendix 2
Materials for Connecticut
Leadership Workshop
This document was prepared for
a Leadership Workshop on Managed Care and Child Health to be held on June
2, 2004 in Hartford, Connecticut. 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. |
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.
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