by Joanne Jee
Where some may see opportunities for improved delivery and coordination of care and cost savings, others may wonder about possible disincentives for providing the full array of needed services. For more vulnerable populations, such as children and youth with special health care needs (CYSHCN), the concerns can be heightened.
CYSHCN have been historically exempted from Medicaid managed care, even as states increasingly moved other Medicaid enrollees into managed care delivery systems on a mandatory basis. But now most states have more experience with Medicaid managed care and there have been advancements in knowledge about care for CYSHCN. States also continue facing budgetary pressures. These factors lend to the context in which more states have started enrolling CYSHCN into Medicaid managed care. In 2010, thirty-two states required that in at least one of their Medicaid managed care programs and/or geographic areas, CYSHCN enroll in Medicaid managed care. Twenty states enrolled CYSHCN in managed care on a voluntary basis.
In a recent study supported by the Lucile Packard Foundation for Children’s Health, the National Academy for State Health Policy examined approaches to identifying and assessing the needs of CYSHCN in Medicaid managed care. A forthcoming report, Identification and Assessment of Children and Youth with Special Health Care Needs in Medicaid Managed Care: Approaches from Three States, summarizes findings from this work. While these states, California, Massachusetts and Michigan, are in varying phases of implementing Medicaid managed care for CYSHCN, their practices may be useful to other states that are serving or plan to serve these children through Medicaid managed care. These include:
- Incorporating provisions specifically addressing CYSHCN and their needs in health plan contracts. Managed care contracts in California and Michigan explicitly lay out health plan requirements with respect to CYSHCN. The California health plan contracts lay out requirements for the general population of CYSHCN as well as responsibilities related specifically to the population of children who are eligible for Title V program services, which are carved-out of managed care. These contracts recognize that not all CYSHCN are eligible for the Title V program, but that they nonetheless have special care needs. Identifying CYSHCN as a specific subpopulation in plan contracts and articulating specific requirements for their care could help to assure health plan focus on meeting the needs of this population.
- Tailoring state monitoring activities to address CYSHCN as a specific subpopulation. In Michigan, Medicaid health plans provide all Medicaid covered services to eligible CYSHCN who also are enrolled in the state’s Title V program. The state is taking some steps to tailor monitoring of care for this population. It requires health plans to use appropriate pediatric providers to review grievances and appeals filed by CYSHCN or their families. Health plans also must track grievances and appeals filed by this population separately from those filed by other Medicaid enrollees. Targeted monitoring of the care and coverage experience of CYSHCN could help to mitigate concerns, or identify any specific problem areas.
- Partnering with families and other stakeholders in the implementation of Medicaid managed care for CYSHCN. Some state Medicaid agencies have worked with families and health plans as partners in developing and implementing components of their managed care programs. Michigan held focus groups of families of CYSHCN before the transition to Medicaid managed care to identify issues, concerns, and possible options for making the transition as smooth as possible for families. The state also worked with health plans to review and make needed changes to contracts to ensure contracts explicitly addressed the care needs of this population. Massachusetts worked with its Medicaid health plans to develop questions for the assessment the plans administer to enrollees, including CYSHCN. By working with stakeholders as partners, the states were able to secure their buy-in on new policies and procedures, easing their implementation.
As states work to ensure that Medicaid managed care works for CYSHCN, they can consider some of the practices of California, Massachusetts, and Michigan. While these states also have areas to improve, their experience in a number of respects is instructive. Specific contract provisions, targeted monitoring, and partnering with stakeholders are key elements these states have adopted as they have moved to serve this population in Medicaid managed care. These and other practices can be put in place and evaluated to ensure that Medicaid managed care meets the specific needs of CYSHCN.