Care coordination is a core element of efforts to strengthen systems of care that, when designed and implemented effectively, can improve health outcomes and quality of care for children and youth with special health care needs (CYSHCN) and their families while reducing costs.[1] Financing of care coordination is critical to the quality and sustainability of these services and systems. State health officials have expressed a need for assistance in identifying financing strategies to support care coordination systems for CYSHCN. This resource identifies key components and themes across five states’ approaches to financing care coordination for CYSHCN through Medicaid, which can be used to support the implementation of high-quality care coordination as outlined in the National Care Coordination Standards for Children and Youth with Special Health Care Needs (CYSHCN). These standards, released by the National Academy for State Health Policy in October 2020, outline the core, system-level components of high-quality care coordination for CYSHCN and are designed to help state health officials and other stakeholders develop and strengthen care coordination systems for CYSHCN.
Care coordination systems can be financed by a variety of sources and strategies. Given that state Medicaid programs provide health care coverage for nearly half 44 percent of all CYSHCN, it presents an important opportunity to support care coordination services and systems for these children.[2] State Medicaid agencies can finance care coordination services for CYSHCN through direct fee-for-service (FFS) reimbursement to providers and/or a Medicaid managed care (MMC) arrangement that includes capitated payments to managed care organizations (MCO). A capitated payment arrangement provides a fixed rate for each enrolled member over a specified period (e.g., per-member per-month), often through contracted Medicaid MCOs.
Types of Medicaid Service Delivery Models
- Standard MMC: Standard MMC is a type of health care delivery system designed to manage costs, utilization, and quality of care. Standard MMC models provide services through contracted arrangements between state Medicaid programs and a managed care entity (e.g., managed care organizations, primary care case management, and prepaid health plans) in exchange for a set per member per month (PMPM) payment.[3] These models typically serve the general Medicaid population.
- Specialized MMC: States with specialized MMC operate similarly to standard MMC models, in that they contract with a managed care entity to provide services through a PMPM payment. Specialized MMC programs are often designed to meet the unique needs of Medicaid beneficiaries with chronic and/or complex conditions. Through this arrangement, state Medicaid programs can require the provision of certain targeted benefits (e.g., specialized care coordination or specific screenings), reporting requirements, and quality measures beyond what is typically offered under a standard MMC approach.
- Medicaid FFS: Under a Medicaid FFS model, the state Medicaid program pays providers directly for services rendered to Medicaid enrollees. CYSHCN receiving services under a Medicaid FFS model must identify providers who participate in Medicaid and accept new patients. There is typically no organized provider network or care management requirements.[4]
Funding care coordination services allows state Medicaid programs to set requirements and guidelines regarding reimbursable care coordination services, provider qualifications, and reporting. While MCOs are the primary recipient of Medicaid funding for care coordination services, other entities often also fund or are otherwise involved in care coordination for CYSHCN enrolled in Medicaid. Education systems, public health programs, and behavioral health and social service agencies, all provide care coordination services and supports to CYSHCN and their families. State Medicaid agencies can collaborate with these entities to braid funding and/or guide and administer Medicaid-financed care coordination services for the CYSHCN served by their programs.
Highlights of Approaches to Medicaid Financing of Care Coordination for CYSHCN in Five States
NASHP selected five state Medicaid programs (California, Florida, Georgia, Texas, and Wisconsin) that finance care coordination services for CYSHCN. These states were chosen for their geographic diversity and variation in approaches to payment design, authority, oversight and administration, and quality measurement. To understand each state’s approach, NASHP reviewed publicly available resources including Medicaid state plans and managed care contracts and conducted key informant interviews with two states (Texas and Wisconsin).
Key care coordination financing themes in these programs include:
- Leveraging collaborations between state Medicaid agencies and other entities to support care coordination for CYSHCN. Three states leveraged partnerships to support their Medicaid-financed care coordination services for CYSHCN. Two states (CA, FL) collaborated with their state Title V CYSHCN program, and one state (GA) worked with their state behavioral health agency to implement Medicaid-funded care coordination services for CYSHCN.
- Implementing capitated or combined capitated and FFS payment arrangements. Four states (CA, FL, GA, TX) pay capitated per-member, per-month (PMPM) rates to contracted Medicaid managed care organizations (MCO) to support and/or provide care coordination services. Two states (GA, WI) also use FFS payments to support specific care coordination services. Georgia uses FFS reimbursement to support peer support professionals, while Wisconsin uses FFS reimbursement to cover their program’s initial assessment and care planning and a monthly FFS reimbursement for ongoing care coordination.
- Using a variety of federal Medicaid authorities to finance care coordination services. Two states (GA, WI) authorize Medicaid coverage of care coordination services through a state plan amendment. This includes the targeted case management option, through which states can specify populations that are eligible for case management services, as well as the rehabilitation services option, which allows states to cover mental health and substance use services and can be targeted to populations with behavioral health conditions.[5] Four states (CA, FL, GA, TX) use Medicaid managed care contracts to require MCOs to provide care coordination services, and two states (CA, GA) require contracts or agreements between other entities. Additionally, three states (FL, GA, WI) initially financed these services through a mechanism that allowed the state to test their financing approach. These include a Community Alternatives to Psychiatric Residential Treatment Facility (PRTF) demonstration grant from the Centers for Medicare and Medicaid Services (CMS), a Health Care Innovation Award from the CMS Innovation Center, and a Medicaid reform pilot operated under a Section 1115 Demonstration Waiver.
- Covering screening and assessment, care plans, and team-based care coordination. All five states finance screening and assessment and individualized care planning for CYSHCN as a component of their care coordination program. While three state programs (CA, FL, TX) may provide team-based care coordination for CYSHCN when deemed appropriate and/or for specific populations of CYSHCN based on their managed care contracts, two states (GA, WI) require that these services are provided by a team. These two states also finance positions other than the care coordinator that are required to be part of the team, including peer support professionals and care coordination assistants.
- Tracking and assessing data for quality measurement. All five states track data to measure the quality of their Medicaid-financed care coordination services for CYSHCN. These measures include process measures such as the number of contacts that a care coordinator has with a child and their family, as well as outcomes such as changes in emergency service use. Three states (FL, GA, WI) conduct satisfaction surveys of enrollees to gather their input on the quality of services. At least three states (CA, GA, WI) regularly develop reports on their program and work with research partners to evaluate the quality of care.
The following table summarizes examples of Medicaid financing approaches for CYSHCN in the five selected states. This information is not meant to be an exhaustive list of all care coordination programs in each state. The table includes state information on eligible care coordination services, financing approaches, Medicaid authorities, and quality measurement used by each state program that can inform state efforts to enhance Medicaid support for care coordination for CYSHCN.
Conclusion and Selected Resources
There are a variety of approaches that states can use to finance care coordination services for CYSHCN through Medicaid. This brief highlights financing approaches across programs in five states. NASHP will continue to track state approaches to financing care coordination services for CYSHCN.
Selected Resources
For more information on care coordination and systems of care for CYSHCN, see:
- National Care Coordination Standards for Children and Youth with Special Health Care Needs (2020): This resource outlines the core, system-level components of high-quality care coordination for CYSHCN.
- National Standards for Systems of Care for Children and Youth with Special Health Care Needs (2017): This publication addresses the core components of the structure and process of an effective system of care for CYSHCN.
For more information on challenges, strategies, and approaches to financing care coordination for CYSHCN, see these resources:
- The Care Coordination Conundrum and Children and Youth with Special Health Care Needs (2015): This resource from the Catalyst Center at Boston University highlights considerations, challenges, and strategies for financing care coordination services for CYSHCN.
- Medicaid Managed Care Structures and Care Coordination (2017): This resource from the Journal of the American Academy of Pediatrics describes a study of Medicaid managed care structures that support care coordination for children.
- Principles of Financing the Medical Home for Children (2020): This article from the Journal of the American Academy of Pediatrics discusses key components of an effective financing strategy to support medical homes for children, which includes care coordination.
- Implementing Social Determinants of Health Interventions in Medicaid Managed Care: How to Leverage Existing Authorities and Shift to Value-Based Purchasing (2018): This publication from Academy Health, Robert Wood Johnson Foundation, and, Nemours Children’s Health System describes strategies to leverage Medicaid funding and Medicaid managed care to support social determinants of health for children through value-based care coordination.
References
[1] National Academy for State Health Policy. National Care Coordination Standards for Children and Youth with Special Health Care Needs. Washington, DC, National Academy for State Health Policy, October 2020. https://nashp.org/national-care-coordination-standards-for-children-and-youth-with-special-health-care-needs/#toggle-id-1
[2] Williams, Elizabeth, and MaryBeth Musumeci. Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access. Kaiser Family Foundation, October 4, 2021. https://www.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-coverage-affordability-and-hcbs-access/.
[3] Managed Care, U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Accessed November 5, 2021. https://www.medicaid.gov/medicaid/managed-care/index.html
[4] Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concepts, Kaiser Family Foundation, June 22, 2015. https://www.kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/
[5] Centers for Medicare and Medicaid Services. Medicaid Definition of Covered Case Management Services Clarified. CMS.gov, November 30, 2007. https://www.cms.gov/newsroom/fact-sheets/medicaid-definition-covered-case-management-services-clarified.; Medicaid and CHIP Payment and Access Commission. Behavioral Health Services Covered under State Plan Authority. https://www.macpac.gov/subtopic/behavioral-health-services-covered-under-state-plan-authority/.
[6] California Department of Health Care Services. Whole Child Model and SB 586 Overview. October 2016. https://www.dhcs.ca.gov/services/ccs/Documents/WCMModelSB586.pdf.
[7] California Department of Health Care Services. Whole Child Model and SB 586 Overview. October 2016. https://www.dhcs.ca.gov/services/ccs/Documents/WCMModelSB586.pdf.; California Department of Health Care Services. Provider Standards, April 12, 2022. https://www.dhcs.ca.gov/services/ccs/Pages/ProviderStandards.aspx.
[8] California Department of Health Care Services. California Children’s Services Whole Child Model, February 15, 2022. https://www.dhcs.ca.gov/services/ccs/Pages/CCSWholeChildModel.aspx.; For more detail on these models, see: https://www.dhcs.ca.gov/services/Documents/MMCD/MMCDModelFactSheet.pdf
[9] California Health and Human Services Agency. Medi-Cal Managed Care Capitation Rates’ County Organized Health Systems (COHS) Model. California Health and Human Services Open Data Portal, May 16, 2022. https://data.chhs.ca.gov/dataset/medi-cal-managed-care-capitation-rates-county-organized-health-systems-cohs-model.
[10] State of California Health and Human Services Agency, Department of Health Care Services. Whole-Child Model (WCM): California Children’s Services (CCS) County Allocation Analysis, https://www.dhcs.ca.gov/services/ccs/Documents/AllocationMethod.pdf.
[11] California Legislative Information. SB-586 Children’s Services, September 25, 2016. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160SB586.
[12] California Department of Health Care Services. Template for Memorandum of Understanding Between [Plan] and [County] California Childrens Services (CCS) Whole Child Model Program, March 2018. https://www.dhcs.ca.gov/services/ccs/Documents/WCM-MOU-Template-REVISED-March2018.pdf.
[13] California Department of Health Care Services. Template for Memorandum of Understanding Between [Plan] and [County] California Children’s Services (CCS) Whole Child Model Program, March 2018. https://www.dhcs.ca.gov/services/ccs/Documents/WCM-MOU-Template-REVISED-March2018.pdf.
[14] California Department of Health Care Services. Integrated California Children’s Services and Whole Child Model Dashboard. December 2021. https://www.dhcs.ca.gov/services/ccs/Documents/WCM-DB-Dec21.pdf.
[15] California Department of Health Care Services. Whole Child Model and SB 586 Overview. October 2016. https://www.dhcs.ca.gov/services/ccs/Documents/WCMModelSB586.pdf.; California Department of Health Care Services. California Children’s Services Advisory Group Meeting. April 22, 2021. https://www.dhcs.ca.gov/services/ccs/Documents/210422-CCS-AG-PowerPoint.pdf.
[16] Florida Agency for Health Care Administration. Attachment II, Exhibit II-C: Children with Special Health Care Needs Specialty Plan, September 1, 2021, 16. https://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2021-10-01/Exhibit_II_C_Child_Spec_Needs_2021-10-01.pdf.
[17] Florida Department of Health. About CMS Plan, June 20, 2022. https://www.floridahealth.gov/programs-and-services/childrens-health/cms-plan/about/index.html; Sunshine Health. Florida Medicaid Member Handbook: Children’s Medical Services (CMS) Health Plan, April 2022, 21. https://www.sunshinehealth.com/content/dam/centene/Sunshine/pdfs/CMS-Title19-Handbook.pdf.; Sunshine Health. Managing Your Child’s Care. https://www.sunshinehealth.com/members/cms/resources/care-management.html.
[18] Sunshine Health. Managing Your Child’s Care. https://www.sunshinehealth.com/members/cms/resources/care-management.html.
[19] Florida Department of Health. CMS Title V Program, November 10, 2021. https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/title-5-program/index.html.; Florida Department of Health. Medical Foster Care, November 18, 2021. https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/medical-foster-care/index.html.
[20] Florida Agency for Health Care Administration. Attachment II, Exhibit II-C: Children with Special Health Care Needs Specialty Plan, September 1, 2021, 16. https://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2021-10-01/Exhibit_II_C_Child_Spec_Needs_2021-10-01.pdf.
[21] State of Florida. 2021-2022 Operating Budget, Department of Health, Children’s Medical Services, Children’s Special Health Care. Transparency Florida. Accessed June 28, 2022. http://transparencyflorida.gov/OperatingBudget/AgencyDetailLevel.aspx?FY=22&BE=64300100.
[22] State of Florida. Children’s Medical Services Plan, May 2014. https://www.flgov.com/wp-content/uploads/childadvocacy/ahca_childrens_medical_services_5-14.pdf.; Florida Agency for Health Care Administration. Florida Medicaid Reform Pilot. https://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/reform_pilot.shtml.
[23] Online Sunshine. 2021 Florida Statutes, Title XXIX, Chapter 391, 391.026 Powers and Duties of the Department, 2021. http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=Children%27s+Medical+Services&URL=0300-0399/0391/Sections/0391.026.html.
[24] Florida Agency for Health Care Administration. CY 2019 MMA Performance Measure Scores, 2019. https://ahca.myflorida.com/Medicaid/Quality_mc/pdfs/CY_2019_MMA_Performance_Measure_Scores.pdf.; Florida Agency for Health Care Administration. Attachment II, Exhibit II-C: Children with Special Health Care Needs Specialty Plan, September 1, 2021, 16. https://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2021-10-01/Exhibit_II_C_Child_Spec_Needs_2021-10-01.pdf.
[25] Florida Agency for Health Care Administration. Attachment II, Exhibit II-C: Children with Special Health Care Needs Specialty Plan, September 1, 2021, 16. https://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2021-10-01/Exhibit_II_C_Child_Spec_Needs_2021-10-01.pdf.
[26] Ibid.
[27] Center for Excellence for Children’s Behavioral Health, Georgia Health Policy Center. High Fidelity Wraparound, October 2018. https://gacoeonline.gsu.edu/files/2019/02/High_Fidelity_Wraparound_Revised-10.2018.pdf.
[28] Substance Abuse and Mental Health Services Administration. Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders: State and Community Profiles, June 2019. https://store.samhsa.gov/sites/default/files/d7/priv/samhsa-state-community-profiles-05222019-redact.pdf.
[29] Center for Excellence for Children’s Behavioral Health, Georgia Health Policy Center. High Fidelity Wraparound, October 2018. https://gacoeonline.gsu.edu/files/2019/02/High_Fidelity_Wraparound_Revised-10.2018.pdf.
[30] Center for Excellence for Children’s Behavioral Health, Georgia Health Policy Center. High Fidelity Wraparound, October 2018. https://gacoeonline.gsu.edu/files/2019/02/High_Fidelity_Wraparound_Revised-10.2018.pdf.
[31] Center for Excellence for Children’s Behavioral Health, Georgia Health Policy Center. High Fidelity Wraparound, October 2018. https://gacoeonline.gsu.edu/files/2019/02/High_Fidelity_Wraparound_Revised-10.2018.pdf.
[32] Substance Abuse and Mental Health Services Administration. Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders: State and Community Profiles, June 2019. https://store.samhsa.gov/sites/default/files/d7/priv/samhsa-state-community-profiles-05222019-redact.pdf.
[33] Georgia Department of Community Health, Medicaid Division. Georgia Title XIX State Plan Amendment, GA 17-002 Community Behavioral Health Rehabilitation Services, https://medicaid.georgia.gov/organization/about-georgia-medicaid/medicaid-state-plan/approved-state-plan-amendments.
[34] Substance Abuse and Mental Health Services Administration. Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders: State and Community Profiles, June 2019. https://store.samhsa.gov/sites/default/files/d7/priv/samhsa-state-community-profiles-05222019-redact.pdf.
[35] Center for Excellence for Children’s Behavioral Health, Georgia Health Policy Center. High Fidelity Wraparound, October 2018. https://gacoeonline.gsu.edu/files/2019/02/High_Fidelity_Wraparound_Revised-10.2018.pdf.
[36] Substance Abuse and Mental Health Services Administration. Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders: State and Community Profiles, June 2019. https://store.samhsa.gov/sites/default/files/d7/priv/samhsa-state-community-profiles-05222019-redact.pdf.
[37] Substance Abuse and Mental Health Services Administration. Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders: State and Community Profiles, June 2019. https://store.samhsa.gov/sites/default/files/d7/priv/samhsa-state-community-profiles-05222019-redact.pdf.
[38] Texas Health and Human Services. STAR Kids. https://www.hhs.texas.gov/services/health/medicaid-chip/medicaid-chip-members/star-kids.; Texas Health and Human Services, Health and Human Services Commission. STAR Kids Contract Terms, March 1, 2022. https://www.hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/programs/contracts/star-kids-contract.pdf.
[39] Ibid.
[40] Texas Health and Human Services, Health and Human Services Commission. STAR Kids Contract Terms, March 1, 2022. https://www.hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/programs/contracts/star-kids-contract.pdf.
[41] Texas Health and Human Services. STAR Kids Managed Care Advisory Committee. https://www.hhs.texas.gov/about/leadership/advisory-committees/star-kids-managed-care-advisory-committee.
[42] Children’s Wisconsin. Special Needs Program. https://childrenswi.org/medical-care/special-needs-services.
[43] Corden, Timothy E, and Tera Bartelt. The Pediatric Complex Care Program (CCP) at the Children’s Hospital of Wisconsin (CHW) / Medical College of Wisconsin (MCW). Complex Care Journal, January 23, 2020. http://complexcarejournal.org/wp-content/uploads/2020/01/PR-Corden-1.23.2020.pdf.
[44] Ibid.
[45] Ibid.
[46] Wisconsin Department of Health Services. Wisconsin Medicaid State Plan, December 5, 2017. https://www.dhs.wisconsin.gov/mandatoryreports/mastateplan/3-1a-case.pdf.
[47] ForwardHealth. Former Health Care Connections Benefit Redesigned and Renamed as Case Management for Children with Medical Complexity, April 2018. https://www.forwardhealth.
Acknowledgements
The National Academy for State Health Policy (NASHP) extends its thanks and appreciation to the Lucile Packard Foundation for Children’s Health for its support of this work.
This resource was authored by NASHP Policy Associate Olivia Randi and NASHP Research Analyst Zack Gould. Many thanks to NASHP Senior Program Director Karen VanLandeghem and NASHP Project Director Kate Honsberger for contributing to the work through input, guidance, and draft review.
