Care Coordination

Care coordination refers to efforts by Medicaid programs to ensure that children and adolescents get the right care at the right time in the right setting by creating a bridge across multiple systems that serve children and families. States have implemented or are designing a variety of integrated health care delivery systems and medical or health home models that include children. This section contains details on these initiatives and other care coordination programs that serve children. These include separate care coordination entities, managed care contracting strategies, and multi-faceted interventions to improve how clinical and psycho-social care is care coordinated for children. This section includes information on state efforts to integrate care.


Patient 1st:
The Alabama Medicaid Agency operates the Patient 1st program, which creates a medical home for Medicaid recipients by linking them with a primary medical provider (PMP). Participating PMPs receive a monthly care management PMPM for coordinating care for Medicaid recipients in their practices. Each PMP provides and arranges for each recipient’s health care needs, and is required to provide EPSDT preventive care screenings to Medicaid eligible children. PMPs serving this population who do not provide EPSDT services are required to sign an agreement with another provider to provide EPSDT services.
Patient Care Networks
Alabama has enhanced the Patient 1st  primary care case management program by creating regional  Patient Care Networks. These nonprofit organizations supplement provider capacity for care coordination by assuming responsibility for “implementing a plan of care … for each [Medicaid] participant that includes coordination of care through collaboration with the member, family, primary care physicians, specialists, community resources, and pharmacists.”
A Section 2703 Health Homes state plan amendment approved in 2013 allowed Alabama to incorporate additional comprehensive care management services into the Patient Care Networks for Medicaid beneficiaries with two or more of the following conditions: asthma, diabetes, heart disease, cardiovascular disease, chronic obstructive pulmonary disease, cancer, HIV, mental health conditions, substance abuse disorder, sickle cell anemia, or organ transplant.
Alabama is currently building off of the Patient Care Network concept by planning the launch of Regional Care Organizations (RCOs). RCOs will be risk-bearing organizations that are responsible not only for providing comprehensive Medicaid benefits (including EPSDT services) and securing medical homes for all enrolled Medicaid beneficiaries in a region, but also for coordinating care across settings.
Care Coordination
The Alabama Medicaid Agency partnered with the Department of Public Health to initiate an EPSDT care coordination service for private and public providers. The program assists provider offices with identifying, contacting, coordinating, and providing follow up for children who are behind on EPSDT screenings and immunizations. Care coordinators are also available to assist with transportation services using Alabama’s Medicaid Non-Emergency Transportation (NET) program.
Alaska, through its contractor Qualis Health, provides case management services designed for patients with serious illness, injuries, and some chronic conditions. These services are available to children with disabilities and children covered by Alaska’s Children with Complex Medical Conditions Waiver. Upon receiving a referral for case management services, a Qualis Health nurse manager works with the patient and family on a number of things related to health care needs including working with the patient, family and medical providers to develop a coordinated care plan. Additionally, these managers also help coordinate the services provided by all professionals involved.
The coordination of EPSDT services – including dental, behavioral, and other need – for Medicaid children is also a primary goal of the practices participating in the T-CHIC initiative.
Arizona Medicaid’s Medical Policy Manual outlines care coordination responsibilities of Medicaid participating primary care physicians, including:
  • “Referring members to providers or hospitals within the Contractor network, as appropriate, and if necessary, referring members to out-of-network specialty providers
  • Coordinating with the Contractor in prior authorization procedures for members
  • Conducting follow-up (including maintaining records of services provided) for referral services that are rendered to their assigned members by other providers, specialty providers and/or hospitals
  • Coordinating the medical care of the AHCCCS members assigned to them, including at a minimum:
    • Oversight of drug regimens to prevent negative interactive effects
    • Follow-up for all emergency services
    • Coordination of inpatient care
    • Coordination of services provided on a referral basis, and
    • Assurance that care rendered by specialty providers is appropriate and consistent with each member’s health care needs.”
The manual also outlines care coordination responsibilities for contractors delivering Children’s Rehabilitative Services (CRS):
“The CRS Contractor must establish a process to ensure coordination of care for members that includes:
  • Coordination of CRS member health care needs through a Service Plan,
  • Collaboration with providers, communities, agencies, service systems, members, and families,
  • Provide service coordination, and communication, designed to manage the transition of care for a member who no longer meets CRS eligibility requirements or makes the decision to transition to another AHCCCS Contractor after the age of 21 years.
  • Appropriate notification of pending discharge from the CRS program as described in Policy 520 of this Chapter.”
Arizona’s Medicaid agency and the Arizona Early Intervention Program jointly developed a process for coordinating EPSDT and early intervention services. These guidelines outline procedures for coordinating care when concerns about a Medicaid-enrolled child’s development are identified by either a primary care physician or by the Arizona Early Intervention Program.
Arizona also released a Request for Information in December 2013 to seek input for an integrated health care service delivery system to provide physical and behavioral health care services to maximize care coordination statewide.
Arkansas Medicaid and the Arkansas Foundation for Medical Care partnered in the Assuring Better Child Health and Development project to improve care coordination and linkages to services. Specifically, these two groups worked to improve the link between primary care and Early Intervention (First Connections – Arkansas Infant and Toddler Program). The state developed a standardized provider feedback and consent form that allows physicians to refer to and receive feedback from providers of Early Intervention services, with feedback on referrals to Early Intervention. Primary care providers can use this form to connect children to services including speech therapy, occupational therapy, and social work services, among others.
Arkansas also has an initiative called the Health Care Payment Improvement Initiative: Building a Healthier Future for all Arkansans. This initiative aims to move the Arkansas health system from a payment model that rewards volume to one that rewards quality and outcomes, and that aligns financial incentives for how care is delivered. The initiative is multi-payer and focuses heavily on Medicaid. The central payment and delivery system transformations of this initiative are Episodes of Care and Patient Centered Medical Homes, and the Health Home; all of which require increased levels of care coordination.
California California received approval for a Bridge to Reform Section 1115 Demonstration Waiver in 2010. In 2011, under authority provided in the Bridge to Reform waiver, the state launched five pilot projects intended to better coordinate care for children with special health care needs. The projects were designed to support development of medical homes and accountable care organizations that could provide children with whole person care and reduce fragmentation of service delivery.
Through the Colorado Medical Home Initiative, the state supported a  “systems-building effort to promote quality health care for all children in Colorado.”  Medical home standards for providers serving children in Medicaid or CHIP were developed through a partnership between state agencies in Colorado.
The state has since transitioned its Accountable Care Collaborative model. Seven Regional Care Coordination Organizations are now responsible for providing medical management, care coordination among providers and services, and support to providers, and are accountable for quality and cost through utilization-based incentive payments and a shared savings program.
In 2012, Connecticut introduced a patient-centered medical home (PCMH) initiative within their redesigned HUSKY Health program. Under this initiative, Connecticut Medicaid is providing new payment incentives to practices and clinics that demonstrate a higher standard of person-centered medical care. In order to receive enhanced payments for medical home services, providers must be an active licensed physician, nurse practitioner or physician’s assistant specializing in general internal medicine, geriatrics, family medicine or general pediatrics that functions as a primary care provider for a set panel of patients.
Connecticut requires that participating medical homes meets and receives NCQA medical home recognition standards. In addition, Connecticut mandates that medical home practices must:
  • Meet federal EPSDT screening requirements;
  • Participate in a specific smoking cessation incentive program;
  • Participate in initiatives to decrease racial and ethnic health disparities; and
  • Adhere to consumer protection standards.
Delaware No information at this time.
District of Columbia
The Health Services for Children with Special Needs (HSCSN) managed care plan provides comprehensive services to children, most of whom have an SSI-level of disability. In addition to a broad set of benefits available, the plan is required to coordinate with other services and systems, including Individuals with Disabilities Act (IDEA) services, mental health and substance abuse services, child protective services, and other systems that can involve transitions for children with special health care needs, such as Title V.
Contract and plan provisions for HSCSN managed care plan require that the MCO provides all enrollees with a Care Coordinator, whose responsibilities include:
  • At minimum 4 face-to-face visits per year to understand the needs of enrollees and their families;
  • Development and coordination of a treatment plan for enrollees
  • Arranging transportation for the enrollee and the enrollee’s family; and
  • Assisting with planning and arranging services, transitions between care settings, and aging out of the HSCSN plan.
Florida’s Medicaid program encourages pediatric primary care providers to serve as medical homes for children in need of care coordination services. Physicians delivering the EPSDT benefit receive support from nurses and social workers who help to coordinate care for enrolled families.
Services for Medicaid-enrolled children with special health care needs are managed the Children’s Medical Services Network, which partners with two integrated care systems:
  • A Pediatric Integrated Care System (“Ped-I-Care”) based at the University of Florida’s Department of Pediatrics, and
  • A South Florida Community Care Network comprised of the Broward Health and Memorial Healthcare Systems.
Georgia No information at this time.
Hawaii No information at this time.
Care coordination across settings, including referral and transition management is considered a “critical element” for the practices participating in the Idaho Medical Home Collaborative. Additionally, Idaho’s Section 2703 State Plan Amendment states that health home providers, “identify and lead the team based care coordination approach between the clinic and specialist so the whole person’s care is taken into account in both chronic disease and mental health treatment.” Finally a key role of the EPSDT Service Coordinators in the ESC Program is coordination of services such as health, educational, early intervention, advocacy and social services.
Public Act 96-1501 requires Illinois to move at least 50% of recipients eligible for comprehensive medical benefits in all programs administered by the Department of Healthcare and Families Services’ (HFS) to a risk-based care coordination program by January 1, 2015. To meet the state goal, HFS, in working with other state agencies and community partners developed the Care Coordination Innovations Project,” which includes projects such as:


  • Care Coordination Entities (CCEs)/Managed Care Community Networks (MCCNs)
  • Medicare/Medicaid Financial Alignment Initiative- Capitation and managed FSS demonstrations.
  • Children with Complex and/or Multiple Chronic Medical Needs

The eligible patient population as identified under the initial provider solicitation includes children in the families of adults enrolled in a CCE or MCCN. Enrollees in a CCE must also be enrolled in Illinois Health Connect. Medicaid beneficiaries who are enrolled in a managed care organization will not be eligible to enroll in a CCE. Initially, the choice to enroll in a CCE or MCCH will be voluntary—except for Medicaid beneficiaries in 5 mandatory managed care regions of the state—and is scheduled to begin in July 2014.  The provider solicitation clarifies that the state intends to expanded mandatory enrollments once sufficient plans are available to give beneficiaries a choice.


Behavioral Health
Illinois’ Screening, Assessment, and Support Services (SASS) program is designed to improve the coordination and delivery of mental health services to children and adolescents. SASS often directs children (including those covered by Medicaid) from hospital-based services to the community mental health centers so that they can be treated within the community.

Coordination of physical and behavioral health services for Medicaid beneficiaries with co-morbidities is required of managed care organizations (MCOs). MCOs provide case management for Medicaid beneficiaries receiving behavioral health services, coordinating between physical and behavioral health providers.
Children with special health care needs receive care coordination services through a special program, Care Select. They enroll in special managed care organizations designed to improve communication across provider settings and arrange more holistic, whole-person service delivery (addressing physical, behavioral, and social needs).
Section 2703 Health Homes
Iowa has two approved Section 2703 health home state plan amendments. The first, approved in June 2012 and effective July 1, 2012, is for Medicaid enrollees with two qualifying chronic conditions, or one qualifying chronic condition and risk for a second; a body mass index over 85 for the pediatric population is one of the qualifying chronic conditions. The second health home state plan amendment is for adults with serious mental illness and children with a serious emotional disturbance, and was approved on June 18, 2013. Specifically, Iowa is planning to establish two types of health homes to serve three groups of children with at least one mental health condition:
  • Primary care health homes would serve Medicaid-enrolled children with a single chronic mental health diagnosis and minor functional impairments.
  • Specialized health homes would serve both (1) children with a serious emotional disturbance and high risk or (2) complex children with multiple diagnoses that require a multi-system involvement. In addition to the features of the primary care health home, these specialized health homes would have competency in dual diagnosis, incorporate SED waiver services, and fully integrate case planning across school systems, juvenile courts, and the child welfare system.
Inter-Agency Agreements

Iowa’s Department of Public Health, under an agreement with Iowa Medicaid, has established contracts throughout the state with regional Title V agencies to both assist families in accessing EPSDT services and assist primary care providers in linking families to services. All of these agencies also participate in the State Medicaid program.  The regional Title V agencies have four responsibilities for EPSDT:  informing, care coordination, screening, and diagnosis and treatment. The agencies bill the Department of Public Health for informing and care coordination on a fee-for-service basis and bill the Medicaid agency for Medicaid-covered services (such as EPSDT screens) through the claims processing system, as would any other qualified provider.

KanCare expects that the health plans are actively engaged in care coordination for their members. One of the KanCare Contracting Principles, as identified in the Section 1115 Waiver that created KanCare, is that the health plans are required to perform a number of functions related to care coordination. This includes undertaking a health risk assessment to identify health and service needs in order to develop care coordination and integration plans for each member. Additionally, there are several measures among the quality measures that are tied to Kansas’ pay for performance program that are related to care coordination, or indicate that care coordination is occurring, including:
  • Annual monitoring for patients on persistent medications;
  • Follow-up after hospitalization for mental illness;
  • Decreased utilization of inpatient services; and
  • Increased integration of care.
Care coordination is also a central part of Kansas’s Section 2703 Health Homes State Plan Amendment. Kansas defines its health homes as: “A team of health professionals: May include a physician, nurse care coordinator, nutritionist, social worker, behavioral health professional (including mental health or substance use disorder providers), and can be free standing, virtual, hospital-based, community mental health centers, etc.”
Medicaid children younger that 21 who are diagnosed with severe emotional disabilities receive case management services from the Child Targeted Case Management Program. These services are provided by qualified case managers in 14 community mental health centers across the state. Covered services include, among others:
  • A written comprehensive assessment of the child’s needs
  • Arrangement of the delivery of needed services
  • Assistance in accessing needed services
  • Preparation and maintenance of case records
  • Case consultation; and
  • Crisis assistance.
Managed Care
Kentucky’s Medicaid managed care contract requires plans to provide an EPSDT coordinator who’s responsible for coordinating and overseeing case management services and continuity of care. Plans must also coordinate care for children receiving school-based health services in order to avoid duplicative services.
Under Bayou Health, the Louisiana Department of Health and Hospitals is simultaneously implementing two separate payment models designed to encourage care coordination.
The first is a prepaid model; in which three managed care plans (Amerigroup Louisiana, Amerihealth Mercy of Louisiana, Inc. and Louisiana Health Care Connections, Inc.) receive monthly risk-adjusted capitated payments. The plans also receive lump sump payments for obstetrical delivery to cover the cost of prenatal and post-partum costs. Networks are liable for 100% of any costs above the capitation rate.
The second is the shared savings model; in which two managed care plans (Community Health Solutions, Inc. and United Healthcare of Louisiana) receive per-member per-month (PMPM) enhanced primary care case management fees and, if earned, lump sum shared savings payments. The CCNs are required to pay a portion of these fees to primary care providers as a PMPM care coordination payment. The network’s fee is also subject to certain performance and savings benchmarks being met.
Patient-Centered Medical Home (PCMH)
In 2008, the Maine legislature authorized the development of the Patient-Centered Medical home (PCMH) Pilot. Three collaborators jointly lead the PCMH pilot development, including the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition. Fifty practices were selected to participate in the pilot, including four pediatric practices.
Practices participating in the PCMH pilot receive per member per month (PMPM) payments from Medicaid, Medicare, and commercial payers. Practices also receive support from a learning collaborative, practice coaching, and consultation with experts. Eight community care teams (CCTs) provide support to providers in operating as medical homes. CCTs coordinate services and connect patients to additional community resources to support their health improvement goals, achieve better health outcomes, and reduce avoidable costs.
Section 2703 Health Homes
In January 2013, CMS approved Maine’s 2703 health home state plan amendment. To be eligible for health home services, adults and children enrolled in Medicaid must have two qualifying chronic conditions, or one qualifying condition and risk of a second. Health home enrollees are linked to a primary care provider who serves as the patient’s medical home, providing acute and preventive care, managing chronic illnesses, coordinating specialty care and referrals to social, community, and long-term services and supports. The roughly 159 health homes across the state are closely tied to the PCMH pilot; practices are required to participate in the PCMH pilot learning collaborative and also receive support from community care teams.
Accountable Communities
Maine is in the process of implementing accountable care organizations through its Accountable Communities Initiative, which seeks to achieve the triple aim by using shared savings based on quality performance, practice-level transformation, coordination across the continuum of care, and community-led innovation. Under this initiative, Medicaid providers will enter into direct contracts with the Maine Department of Health and Human Services using a shared savings model linked to provider attainment of quality benchmarks. These ACOs will be responsible for the coordination of primary, acute, and behavioral health care, as well as long-term services and supports. All MaineCare members who receive the full Medicaid benefit package, including children, will be eligible for accountable community attribution.
The state has produced the Maryland Uniform Consultation Referral Form to facilitate referrals and follow-up services when screens uncover health conditions in a child.
Maryland has an Administrative Care Coordination/Ombudsman (ACCU) program that provides information and consultation for Medicaid and managed care recipients to enhance their access to Medicaid services. Local health departments
provide linkages to care and care coordination services to “at risk” pregnant or postpartum women, and children to assist recipients with access and utilization of the managed care system and other health related services.
Maryland also has a multi-payer medical home program in which Medicaid participates.
No information at this time.
Managed care plans in Michigan provide case management services for enrollees needing “extended use of resources and help navigating the system of care.” Medicaid plans are also required to work with and coordinate service delivery with a variety of community-based providers, such as:
  • Local health departments,
  • Local human services departments,
  • Family planning agencies,
  • Child and adolescent health centers and programs, and
  • Behavioral health agencies.
Medicaid primary care providers serving children with special health care needs are expected to have experience coordinating care for children who receive care from multiple providers.
Michigan’s Medicaid program also participates in a multi-payer patient-centered medical home initiative known as the Michigan Primary Care Transformation Project. The project is working to coordinate care and build linkages across settings and services. Managed care contracts require health plans to make per member per month payments to medical homes serving children with special health care needs.
Child and Teen Checkups (C&TC) Coordinators
Administrative, outreach, and education services are provided to children and their families who are eligible for C&TC services by C&TC Coordinators. Each C&TC contracting Community Health Board/tribe has a C&TC Coordinator, who is often a county or tribal public health nurses (PHN). Among their responsibilities, C&TC Coordinators must:
  • Provide timely information to eligible families/children about the C&TC program and its services;
  • Identify and assist families needing or requesting assistance with access to C&TC services;
  • Maintain provider lists and make these lists available to families/children;
  • Provide follow-up referrals; and
  • Coordinate with other related child/health programs (coordination with WIC is a required C&TC activity).
Medical Homes
Since July 2010, the Minnesota Department of Health and the Department of Human Services have led the Health Care Homes Project, which serves more than 2 million Minnesotans (including children) through 190 certified health care homes (“health care home” is Minnesota’s name for a Patient Centered Medical Home). The state defines a health care home as “an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.” For more information on Minnesota’s Health Care Homes project, see NASHP’s medical homes map.
Accountable Communities for Health 
In 2011, Minnesota launched a Health Care Delivery Systems Demonstration within Medicaid. Building upon this work, Minnesota received a State Innovation Model grant from CMS in 2013, which will be used in part to support the development of Accountable Communities for Health. These communities will integrate medical care, mental health and chemical dependency, community health, public health, social services, schools and long-term services and supports. During phase one of this project (January-June 2013), nine accountable care organizations (ACO) were launched within the state. Phases two and three will allow for expanded ACOs and continued testing and infrastructure building. For more information on Minnesota’s ACO work, visit NASHP’s Accountable Care Map.
The Mississippi administrative code requires the Medicaid agency to pay for an EPSDT case manager for families of children with developmental disabilities. Case managers must have experience in service coordination for children with disabilities up to age 18 or two years of experience in service provision to children under 6 years of age. Case managers carry out Early Intervention/Targeted Case Management (EI/TCM) activities to assist and enable a child with developmental disabilities receiving the Mississippi Cool Kids benefit to gain access to needed medical and other services, provide service coordination for the child and his or her family, and assist in the development of the Individualized Family Services Plan (IFSP). Case Managers are required to make a minimum of one (1) face-to-face contact quarterly and documented successful contacts monthly.
Coordinated Care Organizations under the state’s MississippiCAN program are required to “be responsible for the management and continuity of medical care for all Enrollees.” In particular, contract language establishes their responsibility for child-specific care coordination such as:
  • “Appropriate referral and scheduling assistance for Enrollees needing specialty health care services, including those identified through EPSDT,” and
  • “Coordination with other health and social programs such as Individuals with Disabilities Education Act (IDEA), Part B and Part C; the Special Supplemental Food Program for Women, Infants, and Children (WIC); Head Start; school health services, and other programs for children with special health care needs, such as the Title V Maternal and Child Health Program.”
No information at this time.
Montana’s Passport to Health primary care case management program is intended to promote the medical home model and better coordinate care for Medicaid enrollees.
Montana also has a Health Improvement Program that provides more intense coordination and care management of high-risk, high-cost Medicaid beneficiaries. The program works with patients’ primary care providers to develop a holistic treatment plan, and it builds partnerships with a range of medical and non-medical (e.g., social service) resources to help coordinate care and manage each patient’s conditions.
“Care coordination [under the EPSDT, or Health Check, benefit] must include:
  1. Provision of effective outreach/education activities which informs parents (or caretakers) of the benefits of having their children receive HEALTH CHECK screening, diagnosis, and treatment services;
  2. Provision of consumer education to parents (or caretakers) which assists in making responsible decisions about participation in preventive health care and appropriate utilization of health care resources;
  3. Assurance of continuing and comprehensive health care beginning with the screening through diagnosis and treatment for conditions identified during screening;
  4. Provision of assistance to families in making medical and dental appointments and in obtaining needed transportation; and
  5. Establishment of case management of screening services to monitor and document that all HEALTH CHECK (EPSDT) services are delivered within established time frames.”
Nebraska has also launched a multi-payer patient-centered medical home pilot in which Medicaid managed care plans are participating.
Nevada has begun work to track referrals for EPSDT-eligible children using code modifiers: providers are instructed to use a specific modifier (TS) along with the well-child code to indicate that a referral or follow up is needed.
Managed care contracts in the state require managed care organizations (MCOs) to “put a basic system in place, which promotes continuity of care and case management.”  Under this continuity of care system, MCOs must have partnerships with primary care providers and specialists to “holistically address members’ health needs.” The contracts specify that “care coordination must include not only the specific diagnosis, but also the complexities of multiple co-morbid conditions, including behavioral health, and related issues such as the lack of social or family support.”
Nevada Medicaid is currently in the process of seeking approval from CMS for a section 1115 waiver.  The 1115 waiver is designed to encompass all services and eligible populations under a single authority that will provide the state broad flexibility to manage Medicaid and CHIP more efficiently. Through the use of the 1115 waiver, Nevada Medicaid intends to phase in managed care for all eligible recipients. As a part of its waiver initiative, Nevada Medicaid plans to implement medical homes and health homes for non-MCO enrollees, including those with chronic conditions, severe mental health issues, or patterns of utilization that indicate the enrollee may benefit from case management.
New Hampshire
Managed care contracts in New Hampshire require that managed care organizations (MCOs) implement comprehensive care management programs that at a minimum contain certain elements, including:
  • Care coordination
  • Support of patient-centered medical homes and health homes
  • Wellness and prevention programs
  • High cost/high risk member management programs

The contracts require that in coordinating care MCOs “ensure that services provided to children are family driven and based on the needs of the child and the family.” Care coordination services for children are required to:

  • Include family involvement
  • Deliver behavioral health services that are anchored in the community
  • Build upon the strengths of the child and family
  • Integrate services among multiple providers and organizations working with the child, and
  • Utilize a wraparound model of care within the context of a family driven model of care.

MCOs are expected to develop relationships with resources in the community, including schools and juvenile justice systems.

New Jersey has in place a Medicaid medical home demonstration project. Managed care organizations (MCOs) are required to participate in the project, which includes the use of multi-disciplinary teams to coordinate care for Medicaid beneficiaries. The Medicaid agency provides flexibility in the payment methodology used by MCOs to support the medical homes but require that the MCOs “submit payment methodologies for review … that support care coordination and reward quality and improved patient outcomes.”
MCOs are also tasked with coordinating care and service delivery with a variety of community-based organizations and agencies, including:
  • State agencies, local health departments, Head Start and WIC programs;
  • Schools;
  • Social service organizations;
  • Consumer organizations, and
  • Civic/community groups.
MCOs must also maintain systems dedicated to coordinating physical and behavioral health services for enrollees.
New Jersey is also launching a Medicaid Accountable Care Organization (ACOs) demonstration that will allow regional ACOs to participate in a shared savings model and coordinate services for Medicaid beneficiaries, including children.
In 2009, New Mexico enacted Chapter 143 of the 2009 Laws, intended to provide medical homes for members of the state’s Medicaid, Children’s Health Insurance Program (CHIP), and State Coverage Initiative (SCI) program (SCI is a public-private managed care program in New Mexico that targets low-income adults without insurance working for small employers).  The statute directed the New Mexico Human Services Department to apply for a waiver or state plan amendment to implement a medical home program, and to work with managed care contractors to “promote, and if practicable, develop” a medical home program.
In amendments to the state’s MCO contracts that took effect in July of 2009, HSD encouraged the development of Patient-Centered Medical Homes (PCMH) via financial assistance to select provider groups to begin the PCMH certification process. New managed care contracts under Centennial Care also require MCOs to establish patient-centered medical home initiatives.
Managed care contracts also require that Medicaid MCOs work with the Child, Youth and Families Department (CYFD) to coordinate services with CYPD Protective Services, Family Services, and Juvenile Justice Services divisions.
Children as well as adults are being enrolled into two medical home initiatives in New York:
  • The multi-payer Adirondack Medical Home Demonstration; and
  • The statewide Patient-Centered Medical Home Program for individuals enrolled in Medicaid, Family Health Plus or Child Health Plus.
The state is pursuing Health Homes authorized to receive additional federal financial participation under Section 2703 of the Affordable Care Act. Children are eligible to receive health home services; however, the state is using a priority enrollment algorithm that prioritizes non-pediatric populations. The state has also considered developing a health home program specifically for children.
The state’s Coordinated Children’s Services Initiative is a multi-agency initiative that supports county-level provision of cross-systems services to children with serious emotional disturbance (SED) who are at risk of residential placement. At the state level, participating partners include the Department of Health (which houses the Medicaid agency) and the Office of Mental Health. Every county in New York has designated a Single Point of Access to link children to Office of Mental Health (OMH) resources.
Care Coordination is a critical element of Community Care of North Carolina’s (CCNC) Medical Home model. CCNC describes its medical home as a place to receive preventive and sick care; and where patients have continuous relationships with providers; and where patients have enhanced access; and have access to care coordination services. The CCNC networks provide care coordination services for their patients, including children.
The primary form of care coordination provided by the networks is population management to support practices, which includes: customized reports, patient assessment and care planning, and medication management. CCNC also has case managers present in all 100 counties in the state.
North Carolina Medicaid makes fee-for-service payments to the providers in the networks for the services they deliver to enrollees. In addition, both primary care providers and the networks receive per member per month (PMPM) payments to pay for care coordination services.
  • The networks receive $13.72 PMPM for the Aged, Blind, and Disabled (ABD) population, and $3.72 for the non-ABD population.
  • Primary care providers receive a $5.00 PMPM for the ABD population, and $2.50 for the non-ABD population.
North Carolina has several other initiatives related to Care Coordination for children including:
  • The Pregnancy Medical Home. The North Carolina Division of Medical Assistance (DMA), the North Carolina Division of Public Health (DPH), and CCNC have partnered to design and implement a comprehensive, coordinated, maternity care program to pregnant Medicaid patients. The Pregnancy Medical Home program aims to improve outcomes for mothers and babies and reduce medical care costs.
  • Affordable Care Act Section 2703 Health Homes. Delivered by CCNC, the Health Home program is defined by coordination of care for patients, including children, that have two qualifying chronic conditions, or one qualifying chronic condition and at risk for a second.
  • Care Coordination for Children (CC4C). This program is a partnership between CCNC, DMA, and DPH. It is an at-risk population management program that serves children from birth to 5 years of age who meet certain risk criteria.
North Dakota
North Dakota offers Targeted Case Management services for pregnant women eligible for North Dakota Medicaid and their children, up to six months of age. These services include arranging appointments and linking participants to services such as prenatal education and parenting resources.
North Dakota Medicaid also runs the Experience HealthND Medicaid Health Management Program for Medicaid recipients with chronic conditions including: asthma, COPD, diabetes, and heart failure. In this program beneficiaries work with Registered Nurse Care Managers to assist patients with managing their health conditions.
Managed care organizations (MCOs) in Ohio are required to engage in a number of care coordination activities, including:
  • Supporting efforts to promote the patient-centered home model (e.g., by assisting providers to achieve certification)
  • Supporting efforts to develop Medicaid Health Homes
  • Assure a single point of care management for each Medicaid enrollee
  • Implement a risk-stratified Care Management Program that “must offer and provide care management services which coordinate and monitor the care for members with complex needs. ”
The MCO must employ a Care Management Director, a nurse responsible for operating a Care Management Program and ensuring Medicaid beneficiaries’ services are coordinated. Plans are also responsible for coordinating behavioral health services with physical health services, including services obtained through the community behavioral health system (behavioral health services for which the MCO is not financially responsible).
No information at this time.
Oregon’s Coordinated Care Organizations (CCOs), which enroll both adults and children, are based on the coordinated care model, key elements of which include:
  • Best practices to manage and coordinate care;
  • Shared responsibility for health;
  • Performance is measured;
  • Paying for outcomes and health;
  • Transparency and clear information.

Oregon’s contracts with the CCOs mandate that they must adopt both a Community Health Assessment (CHA) and a Community Health Improvement Plan (CHP). The contracts also stipulate that: “To the extent practicable, Contractor shall include in the CHA and CHP a strategy and plan for:

  1. Working with the Early Learning Council, the Youth Development Council, Local Mental Health Authority, oral health care providers, the local public authority, community based organizations, hospital systems and the school health providers in the Service Area; and
  2. Coordinating the effective and efficient delivery of health care to children and adolescents in the community.”

The CCOs are designed to have the flexibility needed to support models of care that are patient-centered, team-focused, and reduce disparities. The CCOs coordinate services to focus on prevention, chronic illness management, and person-centered care. The CCOs have one budget that grows at a fixed rate for mental, physical, and (for some) dental care; and they are held accountable for the health outcomes of the populations they serve.

The Oregon CCO model also builds upon and integrates the Patient-Centered Primary Care Home Program (PCPCH). The PCPCH is the Oregon’s name for the Patient Centered Medical Home. Oregon’s CCOs are required to implement PCPCHs to the extent possible.

No information at this time.
No information at this time.
South Carolina
Medicaid managed care contracts in South Carolina require plans to participate in care coordination activities, including:
  • Developing referral systems to connect enrollees with specialists,
  • Monitoring and follow-up activities for in-networks providers and creation of linkages to providers outside of the plan’s network
  • Targeted case management services, including for children in foster care or the juvenile justice system or children with serious emotional disturbance, and
  • Transferring medical and developmental data to school settings to coordinate care with school-based services.

Beneficiaries enrolled in the state’s Medical Home Network primary care case management program. The state provides a list of patient-centered medical home practices in the state.


Through the Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant), South Carolina Medicaid is helping 18 pediatric primary care practices transform to become patient-centered medical homes. The project provides a Patient Centered Medical Home Toolkit to help guide practices through the medical home certification process.

South Dakota Primary Care Case Management (PCCM)
Medicaid enrollees in the PCCM program are required to select one primary care provider who is responsible for providing primary care services, referrals for necessary specialty services, and monitoring the health care and utilization of all managed care covered services.
Tennessee has an initiative called TENNderCare Connection, which seeks to ensure coordination of care between the managed care organizations (MCOs) and school-based medically necessary services. This initiative was created through an interagency agreement between the Tennessee Department of Education and the Bureau of TennCare. To assist in this process, Tennessee has developed a form that delineates the responsibilities of TennCare, the MCOs, and the Schools to coordinate care.
Managed care contracts also require that MCOs “shall have written policies and procedures for the TENNderCare program that include coordinating services with child-serving agencies and providers.”
Texas Health Steps offers an online training module for primary care providers on creating and maintaining medical homes for children and adolescents.
Primary care provider that provide a medical home for Medicaid enrollees under age 20 who have special health care needs can receive payment for Clinician-Directed Care Coordination Services. Primary care providers offering these services to children and adolescents must provide:
  • A written care plan shared among providers, agencies, and organizations involved with the child,
  • Coordination of care among multiple providers,
  • A central record of all pertinent medical information about the child,
  • Assistance to the family in communicating clinical issues when the child is referred for additional care.
These may be both face-to-face and non face-to-face.
Standardized referral forms for children provided by the state help primary care providers to link children with needed services.
A managed care plan for foster children, STAR Health, provides a coordinated, comprehensive health system for enrolled children. Children receive a medical home and coordination of physical and behavioral health services, as well as other clinical service management benefits.
No information at this time.
No information at this time.
Virginia No information at this time.
Care coordination services are provided by Medicaid managed care organizations (MCOs), which must develop formal Care Coordination Plans for enrollees with special health care needs. MCOs are charged with ensuring continuity of care across care settings for enrollees with chronic conditions. The Regional Support Networks that manage mental health services for Medicaid beneficiaries also each have a Children’s Care Coordinator on staff.
Washing has two Medicaid health homes state plan amendments coordinating care and providing care management for Medicaid beneficiaries with chronic conditions, including mental health conditions. The state’s health homes embed care coordinators in community-based settings and are responsible not only for coordinating medical care but also for referring beneficiaries to community-based and social service supports.
West Virginia Medicaid employs six HealthCheck Outreach Workers who try to assist a medical home model of care delivery, connecting children with primary care providers who coordinate the child’s care.
Managed care organizations have a number of responsibilities to coordinate care for Medicaid beneficiaries, including:
  • Formally designating an individual or entity responsible for coordinating a beneficiary’s care,
  • Developing systems to assure referrals and case management,
  • Coordinating physical services with behavioral health services received through fee-for-service providers,
  • Coordinating with school-related health services,
  • Coordinating with delivery of community and social services, and
  • Working with local health departments to avoid duplication of services.
West Virginia is partnering with Oregon and Alaska on a CHIPRA demonstration grant to support a Tri State Children’s Health Improvement Consortium. The state is working with ten pediatric practices to support care coordination and transformation of those practices into patient-centered medical homes.
Managed care contracts in the state encourage managed care organizations to “assist with the coordination of covered mental health services” by establishing contractual relationships with community-based mental health agencies and school-based providers.
The Wraparound Milwaukee program contacts with eight community agencies for over 100 care coordinators to facilitate the delivery of services to the SED children in the program using an individualized wraparound approach.
Wyoming, in partnership with Maryland and Georgia, received a CHIPRA Quality Demonstration Grant in 2010 to implement and/or expand a Care Management Entity (CME) provider model using high fidelity wraparound and intensive care coordination. Through this grant Wyoming seeks to improve clinical, functional, and cost outcomes, access to home and community-based services, and youth and family resiliency of Medicaid children and youth with serious behavioral health challenges.
The coordination services the CMEs offer include:
  • Family Care Coordination (FCC)
  • Family Support Partner
  • Youth Support Partner
  • Youth and Family Training and Support
  • Service Intensity Evaluation
  • High Fidelity Wraparound Supervisor/Coach
Wyoming believes that this program will demonstrate improved access, reduced use of restrictive services, improved clinical and financial outcomes for children in the target population, reductions in disproportional use of restricted services by racial and ethnic minorities, and improved quality of care.
Wyoming’s 1915(i) State Plan Amendment also establishes that Family Care Coordinators will work to coordinate care and secure wraparound services for children. Care Management Entities and primary care physicians are expected to work together to track EPSDT requirements and coordinate care.