Children and youth with chronic illness, behavioral and special health care needs, and medical complexities often require specialized care, prescription medications, medical technology and equipment, and increased care coordination, and can have unmet health care needs. They are especially dependent on public insurance programs with nearly half (44.8 percent) using public health insurance (e.g., Medicaid, Children’s Health Insurance Plan [CHIP]) for health coverage. State Medicaid and CHIP programs play an essential role in the coverage, structure, and delivery of care for this group of children. This includes designing, implementing, and operationalizing payment and financing strategies, enrollment and eligibility practices, scope of services and supports, and cross-system partnerships.
Coverage, Benefits, and Service Design
Under federal Medicaid law, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services benefit requires states to provide children and youth under age 21 who are enrolled in Medicaid with comprehensive and preventive services, including some services, such as dental services, that states are not required to cover for adults. In addition to EPSDT, state Medicaid programs cover a wide variety of benefits and services for children with chronic and complex needs. These include home and community-based services (e.g., home health care, personal care, durable medical equipment, and case management), family caregiver supports, and behavioral health crisis services. States are using various strategies and approaches to delivering comprehensive and integrated services for children with chronic and complex needs.
Behavioral Health Crisis Services
Coordinated Care
Home and Community-Based Services
Family Caregiver Supports
Medicaid Managed Care for Children with Chronic and Complex Needs
Many state Medicaid programs serve some or all of the children with chronic and complex needs they cover through Medicaid managed care (MMC) delivery systems. Some states have designed and implemented MMC programs specifically for children with chronic and complex needs, including the use of specialized MMC plans and enrollment policies. Typically, these specialized MMC programs offer benefits that may not be available through standard MMC programs, providing states an opportunity to strengthen the structure and delivery of health care. Additionally, there are a variety of strategies states can use through MMC to help ensure access to quality care for children with chronic and complex needs, including assessing children to more comprehensively identify their health and behavioral health needs, establish network requirements for specialty providers, promote continuity of care during transitions, and measure performance and quality.
Designing MMC Programs to Serve Special Populations
Strategies to Support High-Quality Care through MMC
Partnerships to Support Access to Care
Children and youth with chronic and complex needs are typically served by a myriad of systems, agencies, providers, and programs. Partnerships among these programs and systems are critical to ensuring access to public insurance coverage for eligible children, minimizing duplication of efforts, and helping reduce the complexity of programs, services, and supports that families must navigate.
Performance and Quality Measurement
Quality measurement is a critical component of many state programs, including Medicaid. Measuring the quality of care that children receive is a priority for state and national health policymakers, public and private health plans, providers, and others. States are using quality measurement in health system reforms (e.g., linking performance and quality to payment for services) and for programs serving specialized populations, including children and youth with chronic and complex needs.