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New Federal Initiatives Help States Expand Support for Children and Families Affected by Substance Use

December 4, 2018/in Uncategorized Blogs Behavioral/Mental Health and SUD, Care Coordination, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Hannah Eichner

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In the recent election, Republican and Democratic gubernatorial candidates offered strategies to address the opioid epidemic and meet the needs of children and families affected by substance use disorder (SUD). Incoming and incumbent executives will have new federal resources – including the new Maternal Opioid Misuse (MOM) and Integrated Care for Kids (InCK) models and the SUPPORT for Patients and Communities Act – to bolster their state efforts.
The MOM and InCK models, recently announced by the Center for Medicare & Medicaid Innovation (CMMI), are designed to help selected states better coordinate and integrate treatment and support to improve outcomes and reduce costs.

Under the MOM model, state Medicaid agencies and care-delivery partners will work to improve care for pregnant and postpartum women with opioid use disorder (OUD). CMMI will award up to $64.5 million over five years, with the funds divided in varying amounts among up to 12 MOM cooperative agreements.
Under the InCK model, state Medicaid agencies and community partners will collaborate to bolster prevention, early identification, and treatment for children covered by Medicaid. CMMI will award up to eight InCK cooperative agreements, with up to $16 million available to each awardee over a seven-year period.

More information about applying for these initiatives is expected in early 2019.
The recent SUPPORT for Patients and Communities Act includes a number of provisions that also support children and families affected by SUD, including several provisions that could provide new funding to states and new ways for states to use existing federal funds. A previously-published NASHP blog described some of the law’s provisions affecting state Medicaid agencies, while this blog focuses on other key provisions targeting children and families.
Several of the act’s provisions address the impact of childhood trauma. There are multiple connections between SUD and trauma — childhood trauma is a risk factor for SUD and growing up with a parent who has an SUD is itself considered a traumatic experience. Recognizing the significant and long-lasting impacts of childhood trauma, the SUPPORT Act:

Creates an interagency task force to develop best practices for identifying and supporting children and families who have experienced or are at risk of experiencing trauma. The task force is also responsible for crafting a coordinated federal response to families impacted by SUD and other forms of trauma. These best practices and coordinated federal approach will help states as they promote evidence-based approaches to care. (Section 7132)
Permits the US Centers for Disease Control and Prevention to collect data about adverse childhood experiences through existing public health surveys, in cooperation with states, with $2 million in annual funding. States can use the findings to track trends, allocate resources, and refine programs that address adverse childhood experiences. (Section 7131)
Authorizes $50 million per year for grants to state, local, and tribal educational agencies to increase student access to trauma support services by linking educational agencies with mental health systems. The US Secretary of Education would administer the grants in coordination with the Assistant Secretary for Mental Health and Substance Use. (Section 7134)

Other parts of the law are designed to strengthen care delivery systems for children and families affected by SUD. These provisions:

Authorize $20 million in grants to state governments and other entities to develop and evaluate family-focused SUD residential treatment programs, which permit children to reside with parents in the treatment facility. Due to the recently-enacted Family First Prevention Services Act, evidence-based SUD treatment services for certain parents will soon be eligible for funding from current state allocations of Title IV-E child welfare dollars (learn more in this NASHP blog.) The grants will help additional programs qualify Title IV-E funding. An additional provision requires the US Department of Health and Human Services (HHS) to issue guidance on how states can promote family-focused residential treatment programs and leverage both Medicaid and Title IV-E funds to support them. (Sections 8083 and 8081)
Appropriate $15 million for HHS to conduct a randomized evaluation of a “recovery coach” program that provides integrated treatment and supportive services to parents who have temporarily lost custody of their children due to SUD. If the evaluation shows positive results, the program could potentially be funded using a state’s existing Title IV-E dollars under the Family First Prevention Services Act. (Section 8082)
Authorize HHS to provide grants to any state agency to improve implementation of plans of safe care for substance-exposed infants. Existing law requires states to create plans of safe care for all substance-exposed infants. If HHS chooses to award these grants, funds could be used for a number of purposes, including to improve access to treatment, train health professionals and child welfare staff, and strengthen cross-agency collaboration. This provision also requires HHS to provide written guidance and technical assistance outlining how to implement plans of safe care. (Section 7065)

To learn more about how states are supporting children and families with SUD:

View NASHP’s issue hubs that highlight important information and resources about the InCK and MOM models.
Read the NASHP issue brief and view the webinar addressing State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.

Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to NASHP’s webinar on the topic.
View presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.

NASHP is also in the process of creating a new policy academy that will support states working to improve access to care for Medicaid-eligible pregnant and parenting women with SUD and/or mental health conditions. The call for applications will be released in December 2018.

State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

October 30, 2018/in Uncategorized Colorado, Pennsylvania, Texas Reports Behavioral/Mental Health and SUD, Care Coordination, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Hannah Eichner, Becky Normile and Carrie Hanlon

The opioid epidemic has heightened states’ efforts to prevent and treat of substance use disorder (SUD) in pregnant and parenting women. The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration, interviewed Colorado, Pennsylvania, and Texas officials about the unique interagency approaches they are using to promote recovery for this population. This new report explores:

State coverage, care delivery, and financing strategies to support pregnant and parenting women with SUD;
Available state and federal funding sources for these initiatives; and
Key considerations for states working to promote recovery.

Read or download: State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

Download webinar slides and listen to the webinar that explored how Colorado supports pregnant and parenting women with SUD. The speakers were:
- Amy Cooper, Women’s Services Coordinator, Office of Behavioral Health, Colorado Department of Human Services;
- Susanna Snyder, Maternal Child Health Policy Specialist, Health Programs Office, Colorado Department of Health Care Policy and Financing; and
- Dr. Kaylin Klie, Physician, Denver Health; Assistant Professor, University of Colorado Department of Family Medicine

Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.

SUPPORT for Families and Communities Act: New Funding and Flexibility for States to Address Substance Use Disorder

October 23, 2018/in Uncategorized Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by Kitty Purington

Last week, Congress sent the SUPPORT for Patients and Communities Act, a wide-ranging bill that seeks to address the country’s opioid crisis across a number of policy areas, to the President for his signature. The act contains numerous provisions that affect how state Medicaid agencies structure and administer services and supports for individuals with opioid and other substance use disorders (SUD).
Medication-assisted treatment (MAT) emerges as a central strategy, and the act gives states some flexibility to expand SUD service delivery using Institutes for Mental Disease (IMDs). A number of provisions also address the impact of SUD on pregnant women, infants, children, and youth. The table below highlights some of the act’s key provisions affecting state Medicaid programs.

Requires states to cover children in foster care up to age 26 and to suspend eligibility for juvenile justice-involved youth (Sec. 1001, 1002)	By calendar year 2023, states must provide former foster care youth with Medicaid coverage up to age 26, regardless of what state they lived in when they aged out of the foster care system. Currently, Medicaid must cover youth up to age 26 within the state the youth aged out of foster care, and states have the option to cover youth who age out of another state’s foster care system. For youth engaged in the criminal justice system, the act requires states to suspend, rather than terminate, Medicaid coverage while these youth are incarcerated, and to restore their Medicaid coverage upon their release, without completing a new application, unless they no longer meet eligibility requirements.
Creates a demonstration program to expand SUD treatment (Sec. 1003)	The act creates a new demonstration program to improve capacity for SUD treatment services, with a particular focus on MAT, neonatal abstinence disorder, pregnant and post-partum women, and adolescents. Ten states will receive planning grants, and of those states, five will be selected to receive enhanced federal match for SUD treatment and recovery services.
Additional requirements for Medicaid drug utilization review (Sec. 1004)	By October, 2019, states will be required to have safety edits and automated review processes in place to avoid prescription abuse, monitor and report on antipsychotic medication prescribing to children, and identify fraud and abuse by Medicaid enrollees, providers, and pharmacies.
Extends SUD health home enhanced match to 10 quarters (Sec. 1006)	For health home state plan amendments approved on or after Oct. 1, 2018, the act extends enhanced Federal Medical Assistance Percentages (FMAP) funding to states from eight quarters to ten.
Requires MAT to be included in state plans (Sec. 1006)	From Oct. 1, 2020 to Sept. 30, 2025, states will be required to include MAT services in their state plans. States may certify that implementing the provision is not feasible due to a shortage of qualified providers or facilities to provide MAT.
Changes in Institutions for Mental Disease coverage (Sections 1012, 1013, 5052)	Permits states to pay for services delivered outside of an IMD to pregnant/postpartum while they are receiving SUD treatment in an IMD facility. Creates a temporary state plan amendment option period (Oct. 1, 2019 to Sept. 30, 2023) that permits payment for IMDs for up to 30 days within any 12-month period for Medicaid beneficiaries. Maintenance of effort is required by states for both IMD and outpatient SUD services. States must demonstrate that they have a full continuum of SUD services available. Clarifies that states may pay capitation rates to managed care plans for enrollees receiving treatment in an IMD.
Clarifies payment for treatment at residential pediatric recovery centers (Sec 1007)	Permits states to pay for inpatient or outpatient services, including counseling for parents, at residential pediatric recovery centers that treat infants with neonatal abstinence syndrome.
Strengthens prescription drug monitoring programs (Sec. 1944)	Starting October 2021 , states must require Medicaid providers to check patients’ prescription drug history before prescribing controlled substances. The act allows for enhanced FMAP to states for expenditures to design, develop, or implement a prescription drug monitoring program that meet the act’s requirements.
Changes Medicaid managed care medical loss ratio (Sec. 4001)	Permits states to receive an enhanced share of remittances from Medicaid managed care plans that do not meet the minimum medical loss ratio of 85 percent.
Mandates reporting on adult behavioral health measures (Sec. 5001)	Beginning with the state report for 2024, states will be required to report on all behavioral health measures included in the adult core measure set.
Extends mental health parity to Children’s Health Insurance Programs (CHIP)	Requires all state CHIP programs to include coverage of mental health services, including behavioral health treatment. The provision explicitly notes that the requirement for these comprehensive services applies to both children and pregnant women regardless of the type of coverage (including separate CHIP programs) that a state has selected to operate.

How States Are Meeting the Needs of Children and Families Affected by the Opioid Epidemic

September 25, 2018/in Uncategorized Kentucky, New Hampshire, Virginia Blogs Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost Containment, Cost, Payment, and Delivery Reform, Health Coverage and Access, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Hannah Eichner and Becky Normile

The opioid epidemic is having a devastating impact on children and families and placing a significant strain on states as they work to develop effective programs and find new funding to respond to this crisis.
To address the crisis and promote healthy child development, states are implementing innovative whole-family approaches to prevention and treatment (see below). On the federal level, new funding is available and recently the federal Center for Medicare and Medicaid Innovation announced its Integrated Care for Kids model, which states can use to improve care and outcomes while reducing costs through early identification, integrated care coordination, and case management for physical and behavioral health care and non-clinical local services.

Need more information?

Read NASHP’s new report, State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis.
Attend a webinar exploring New Hampshire’s strategies to support families affected by OUD is scheduled for 2-3 p.m. (EST) Thursday, Sept. 27, 2018.
Check out presentations from #NASHPCONF18’s Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
Additional reports and webinars exploring state efforts to support pregnant and parenting women and children affected by the opioid epidemic will be published here in the weeks ahead.

Children can experience many negative consequences as a result of their parents’ opioid use disorder (OUD). Prenatal opioid exposure can cause neonatal abstinence syndrome in infants, which is usually treated by costly hospitalizations and may increase the risk of developmental disabilities. Children affected by parental substance misuse are at increased risk of adverse childhood experiences and trauma, which can have significant short- and long-term physical, mental, and behavioral consequences.
A new National Academy for State Health Policy (NASHP) issue brief, written in partnership with the Alliance for Early Success, identifies the following promising state strategies developed by Kentucky, New Hampshire, and Virginia to support children and families:

Facilitate access to and coverage of services by improving identification of at-risk infants and children, enabling rapid access to treatment, expanding coverage of services, and enhancing provider capacity. For example, New Hampshire’s Project First Step embeds licensed alcohol and drug counselors (LADCs) within its Division of Children, Youth, and Families (DCYF) district offices. The LADCs train child welfare and juvenile justice staff about substance misuse — including screening and facilitating access to treatment — to enable DCYF staff to better meet the needs of children and families affected by OUD.
Implement family-focused care delivery models, such as providing family-centered treatment approaches for the family unit, offering care at home and in the community, coordinating care, and providing trauma-informed care. Virginia’s Medallion 4.0 Medicaid managed care program contract requires Medicaid managed care organizations to provide specialized care coordinators for substance-exposed newborns and align a mother’s and infant’s care plan. Additionally, Virginia’s Medicaid 4.0 contracts promote delivery of trauma-informed care, particularly for children impacted by the foster care system.
Align and maximize resources across systems by sharing data and leveraging diverse funding sources. Kentucky’s Sobriety Treatment and Recovery Team (START) program is a family-centered, service delivery model within the state’s child welfare system that pairs families affected by substance use disorder (SUD) with a child protective services (CPS) worker and a family mentor who has lived experience with SUD. The CPS workers and family mentors coordinate care, offer rapid access to treatment, and provide comprehensive wrap-around services. The program weaves together funding from a Title IV-E waiver demonstration, Medicaid, the Temporary Assistance for Needy Families block grant, and state general funds. The state has also established a data-sharing agreement to advance the program between its Department for Community Based Services and its Department for Behavioral Health, Developmental, and Intellectual Disabilities.

An additional report and webinar exploring state strategies to support pregnant and parenting women affected by substance use disorders, including opioid use disorder, will be published in the weeks ahead.

State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis

September 25, 2018/in Uncategorized Kentucky, New Hampshire, Virginia Reports Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Hannah Eichner, Becky Normile and Carrie Hanlon

The opioid epidemic continues to have devastating consequences for children and families across the country, with growing social and financial implications for states. The National Academy for State Health Policy (NASHP), in partnership with the Alliance for Early Success, interviewed Kentucky, New Hampshire, and Virginia officials representing state Medicaid, child welfare, and behavioral health programs to explore how their child-serving agencies were responding to the opioid epidemic. This new report explores:

State strategies to support young children and families affected by the epidemic;
Available state and federal funding sources for these initiatives; and
Key considerations for states working to improve services and outcomes for this vulnerable population.

Read or download: State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis

Listen to a webinar that featured two New Hampshire officials detailing their state’s strategies to support families affected by the opioid epidemic. The speakers are:
- Geraldo Pilarski, Bureau of Community, Family, and Program Support Administrator, New Hampshire Division for Children, Youth and Families, and
- Erica Ungarelli, Bureau for Children’s Behavioral Health Director, New Hampshire Division for Behavioral Health
Download webinar slides. View the webinar:
Explore resources from #NASHPCONF18’s session: Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.

WV Medicaid Covers an Innovative and Less Costly Treatment Model for Opioid-Affected Infants

February 27, 2018/in Uncategorized West Virginia Blogs Behavioral/Mental Health and SUD, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Health Coverage and Access, Healthy Child Development, Infant Mortality, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Safety Net Providers and Rural Health /by Becky Normile and Carrie Hanlon

Image courtesy of tuelekza at FreeDigitalPhotos.net

Each year, state Medicaid programs cover more than $1 billion to care for infants with neonatal abstinence syndrome (NAS) – a condition caused by opioid use during pregnancy. NAS often results in expensive hospital stays in order to treat the infant’s withdrawal symptoms, such as irritability, poor feeding, seizures, and respiratory distress.
Earlier this month, the Centers for Medicare & Medicaid Services (CMS) approved a new financing approach for these infants in West Virginia that may usher in an effective, lower-cost treatment option for state Medicaid programs struggling to cover the cost of NAS.
Infants born with NAS are typically treated in hospitals, including special care nurseries and neonatal intensive care units, and Medicaid payment for this treatment is costly. The average length of hospital stay for infants with NAS is 17 days, costing nearly $1.5 billion annually. About 80 percent of these hospital costs are covered by Medicaid.
Non-hospital settings can offer NAS treatment for infants with less severe symptoms at a lower cost — $600 compared to $2,600 in a special care nursery, or $4,000 in a neonatal intensive care unit. Until now, Medicaid coverage of NAS treatment has only included bundled payments to hospitals or fee-for-service payments to providers in non-hospital settings like neonatal withdrawal centers or outpatient follow-up clinics. West Virginia Medicaid recently received CMS approval to cover a new approach — a bundled payment for NAS services in non-hospital settings, referred to as NAS treatment centers.
West Virginia has been particularly hard hit by the opioid epidemic. According to the Centers for Disease Control and Prevention, West Virginia had the highest rate of deaths due to drug overdose in the United States in 2016, reaching 52 per 100,000 residents. It also has one the highest rates of NAS with 33.4 cases of NAS for every 1,000 hospital births.
There is currently one NAS treatment center in West Virginia, Lily’s Place, which provides a comprehensive array of services to prevent or reduce withdrawal symptoms among infants with prenatal exposure to opioids. It also provides education and counseling support to families and caregivers. As a designated NAS treatment center, Lily’s Place will now be reimbursed by Medicaid through a prospective bundled payment that is designed to cover NAS treatment services such as pharmaceutical withdrawal management, withdrawal monitoring, developing a care plan, and therapeutic swaddling.
The bundled payment includes NAS services provided by registered nurses, licensed counselors, and social workers. Physician treatment services and room and board costs are not included in the bundled payment. West Virginia’s NAS treatment center model represents a cost-effective and patient-centered approach to treating NAS and supporting the whole family impacted by opioid use.
Since 2000, the number of pregnant women using or dependent on opioids nationwide increased five-fold, and there has been a corresponding five-fold increase in the number of infants born with NAS over the same period. Additionally, a 2014 study found that one in five women enrolled in Medicaid filled a prescription for an opioid during pregnancy. The drastic rise in opioid use during pregnancy and NAS reinforces the need for effective interventions that support the mother-infant dyad.
New clinical guidelines from the Substance Abuse and Mental Health Services Administration provide important guidance and resources for states, providers, and others caring for pregnant and parenting women with opioid use disorder (OUD) and their infants. These guidelines highlight evidence-based strategies for providing individualized care that promote the health of mothers and infants, including:

Implementing screenings for substance use disorder and mental health comorbidities for pregnant women;
Establishing community-based teams of clinicians to engage to support the pregnant women with OUD;
Providing and managing medication-assisted treatment for pregnant women with OUD;
Developing and managing a treatment plan for the postpartum period, a time when women are at higher risk for returning to substance use; and
Screening, assessing, monitoring, and treating NAS for infants exposed to opioids.

This summer, the National Academy for State Health Policy (NASHP) will publish two policy briefs that explore state policies and strategies that promote the continuum of care for women with OUD over the course of their perinatal period, and support the health and well-being of young children impacted by the opioid epidemic.
Explore additional NASHP opioid epidemic resources:

For more information about NASHP’s work on the impact of opioids on women and children, and the role of Medicaid and other public programs contact Carrie Hanlon or Becky Normile.

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