State policymakers must often take action during an emerging crisis even when evidence identifying the best policy approach is not be available. This report, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, explores successful state responses to dramatic increases in antipsychotic prescription rates in Medicaid-enrolled children in foster care. It highlights several strategies, including payment reforms, delivery system innovations, and quality supports for clinical care.
The report results from a convening by the National Academy for State Health Policy of researchers and state officials with expertise in financing and operating Children’s Health Insurance Program and Medicaid programs, children’s health, and health policy and pharmacy research. The meeting preceded the release of a Patient-Centered Outcomes Research Institute-funded study, which examines the comparative effectiveness of state oversight systems in Ohio, Texas, Washington, and Wisconsin.
Children and youth with special health care needs (CYSHCN) are a diverse population whose health care needs and costs often exceed those of most children. Improving care for this population is critical, yet challenging, due to the complexity of conditions of some children, and the multitude of systems (e.g., health, education, social services) and supports that children typically use.
With Medicaid and CHIP programs financing health care services for 44 percent of all CYSHCN in the United States, state Medicaid agencies are increasingly targeting CYSHCN as part of their health system transformation efforts to improve health care quality and outcomes. A recent NASHP 50-state scan of state Medicaid managed care programs found that 37 states and Washington, DC, now enroll some or all populations of CYSHCN in risk-based Medicaid managed care. As state payment and delivery system reform efforts advance, tailoring quality measurement and improvement strategies to CYSHCN is a growing priority for many states to improve care for this vulnerable population.
Despite this growing interest, states face numerous barriers in implementing quality improvement strategies for CYSHCN. For example, many Medicaid agencies lack the resources and capacity to develop robust quality improvement initiatives for this population of children. Many existing quality measures have limitations in their applicability across all CYSHCN populations, and may not fully assess the overall quality of care. Surveys that can be used to measure family experience with care are often challenging and burdensome to administer. Quality improvement is a lengthy and iterative process and requires substantial time and resources for non-complex patient populations. These challenges are more pronounced when developing quality improvement initiatives that meet the unique needs of CYSHCN.
Some state Medicaid agencies, however, are leading the way by designing innovative programs and exploring new ways to align and embed quality measurement for CYSHCN in within broader state initiatives.
- Michigan: Michigan’s Children’s Special Health Care Services (CSHCS) program serves children with special needs. Michigan Medicaid utilizes the Consumer Assessment of Healthcare Providers and Systems 5.0 Child Medicaid Health Plan Survey with the Children with Chronic Conditions measurement set to assess the experience of care and quality of care for children enrolled in the CSHCS program. The survey results are used to guide improvements in the CSHCS program, and they are factored into incentive payments for the state’s managed care organizations (MCOs).
- New York: As part of New York’s overall Medicaid Redesign Team initiatives, the state is changing how children, including CYSHCN, are served in the state’s Medicaid program. One new program that is specifically driving quality measurement and improvement for CYSHCN is Health Homes Serving Children (HHSC). Through this program, participating Health Homes use a care management model to support to Medicaid-enrolled children with complex physical and/or behavioral health conditions. Health Homes report on the “Health Homes Measures Subset,” which is a list of performance measures designed to assess members’ well-being and the impact of care management activities. Some of these measures include adolescent well-care visits, time from health home referral to outreach, and follow-up after hospitalization for mental illness. The HHSC program also develops and maintains a Quality Management Program that monitors, evaluates, and ultimately improves the quality of care for members. The current quality measurement activities are laying the groundwork for New York to eventually integrate Health Homes into its statewide transition to value-based payments, with the goal of holding Health Homes accountable for the quality of care rendered and the outcomes of their members.
- Texas: Texas Medicaid serves children and youth with disabilities and complex conditions in a specialized managed care program called STAR Kids, which uses several strategies to measure and improve the quality of care for enrollees. Prior to the launch of STAR Kids, a study established baseline data for utilization, access, and consumer satisfaction. Now that the program is in its first year, Texas Medicaid will conduct a post-implementation survey of the children enrolled in STAR Kids to assess its performance, compare the performance of MCOs, and determine which measures to integrate into future quality improvement activities. Texas Medicaid also plans to implement additional quality improvement activities for STAR Kids over the next several years, including releasing MCO report cards that can help STAR Kids enrollees and their families select a health plan, and linking financial incentives and disincentives to MCO performance.
To learn more about these and other innovative Medicaid quality measurement strategies targeted to CYSHCN, read NASHP’s new issue brief, State Strategies for Medicaid Quality Improvement for Children and Youth with Special Health Care Needs. The brief includes a table highlighting selected Medicaid quality measurement sets and tools for children, and three case studies featuring ongoing work Michigan, New York, and Texas.
For more information about NASHP’s work on Medicaid Quality Measurement and CYSHCN, contact Becky Normile at email@example.com.
by Jill Rosenthal and Manel Kappagoda of ChangeLab Solutions
The United States ranked 15th among affluent countries in life expectancy in 1980. By 2009, it had dropped to 27th place. Our fragmented health care delivery and public health systems, and the lack of coordination between the two, has resulted in an imbalance of high health spending and poor health outcomes.
A recent report by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, confirms what we already know: dramatically changing these statistics requires a combined approach that comprises investment in health care delivery and expanding “our focus to address how to stay healthy in the first place.”
This report, developed by NASHP and produced by ChangeLab Solutions, highlights leading states’ approaches to support community-based prevention initiatives by bridging the health care delivery and public health systems. It examines various mechanisms – both previously existing and created through health reform – that states can leverage to implement sustainable community-based prevention programs. They include Medicaid waivers, federal grants, accountable care and medical home models, pooled funding, and new federal requirements for nonprofit hospitals. The report includes opportunities and lessons from featured states (California, Maryland, Massachusetts, Minnesota, North Carolina, Oregon, Texas, and Vermont).
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As of July 1, 2011, there were 3,943,189 beneficiaries enrolled in Texas’s Medicaid program. Of these, 2,786,985 were enrolled in managed care. Texas has multiple comprehensive Medicaid managed care programs. Its STAR program is mandatory for Medicaid-enrolled children in managed care service areas and covers physical, behavioral, and oral health services. A primary care case management program provides these services to children in areas not covered by the STAR program. A managed care program for foster children, STAR Health, provides comprehensive and coordinated services.
In a small number of counties, a Behavioral Health Organization operates the Texas NorthSTAR program to provide comprehensive mental and substance abuse benefits to enrollees, including children in those counties.
Home and Community-Based Services are provided through waivers, including:
- Medically Dependent Children Program, provides services to support families caring for children and young adults who are medically dependent and to encourage de-institutionalization of children in nursing facilities;
- Youth Empowerment Services, which provides HCBS services for Medicaid-eligible children with serious emotional disturbance and their family; and
Under the Texas Administrative Code, medically necessary means:
“For Medicaid members birth through age 20, the following Texas Health Steps services:
The definition also specifies that medical necessity for children may take into account other factors relevant in the state’s adult medical necessity definition, including the following.
For non-behavioral health services, that services are:
For behavioral health services, that services:
|Initiatives to Improve Access
|Reporting & Data Collection||
The Texas Health and Human Services Commission requires managed care organizations to report on the number of check-ups provided to children under Texas Health Steps.
Behavioral health screenings are required at each Texas Health Steps checkup. Texas Health Steps offers primary care providers several developmental and behavioral health screening forms:
Texas Health Steps requires one of those standardized instruments to be used for a checkup to be considered complete.
|Support to Providers and Families||
Support to Families
The state has a Texas Health Steps webpage to help families understand how a child can get a checkup, as well as additional available services like transportation. A dedicated webpage for teens is aimed at informing adolescents about the benefit and helping to connect them to services.
Support to Providers
Texas Health Steps offers free online provider education on a number of topics, including:
In addition, the website provides introductions to Texas Medicaid Programs for Children and Texas Health Steps in particular.
Texas Health Steps also offers providers Child Health Clinical Record Forms to assist providers in documenting all the required components of a well-child visit. The use of these forms is not mandatory.
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:
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.
Pediatric and general dentists participating in Texas Health Steps are being trained to provide children aged 6-35 months with a First Dental Home. Dentists can bill an all inclusive bundled code for a First Dental Home visit, which has the following components:
The Texas Medical Home Work Group has been meeting regularly for more than three years. This group, convened by the Texas Department of State Health Services, exists to, “to enhance the development of Medical Homes within the primary care setting.” Several state agencies are represented in the group, as are a wide range of stakeholders. The group serves as a forum to coordinate and share information on public and private medical home activities in the state. These activities have included:
- A now-suspended plan for a $12 million Medicaid Health Home Pilot for children. Further information on the previously planned pilot is available in this National Academy for State Health Policy (NASHP) report.
- The development of an online course to help primary care providers serve as medical homes for pediatric populations. The course is offered in conjunction with Texas Health Steps, Texas Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit.
Last updated: December 2013
The following state agencies are represented on the Texas Medical Home Work Group:
Additional participating stakeholders include health plans, providers, provider professional associations, and the primary care association.
It also bears noting that primary care providers in Texas have a history of enthusiastically supporting medical homes. The Primary Care Coalition, a group of almost 15,000 doctors from the Texas Academy of Family Physicians, the Texas Chapter of the American College of Physicians, and the Texas Pediatric Society released a 2008 report, The Primary Solution, calling for the Texas legislature to, “support a patient-centered primary care medical home for all Texans.”
States can make important strides in eradicating cervical cancer deaths. This report features promising state and federally qualified health center policies that support high performance in cervical cancer screening within the context of the medical home. Drawing from Colorado, Maine, Maryland, New York, Texas, Vermont, and Virginia, this report summarizes innovative programs, practices, and partnerships that facilitate improvement in cervical cancer screening. Experiences in these states offer examples for adoption by others to ensure high-quality preventive care for women. This publication was made possible through the support of the Health Resources and Services Administration.
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Program Type: Texas operates a separate CHIP program, called CHIP.
Number of Children Covered: In FY2013, 1,034,613 children were covered by CHIP.*
State’s Enhanced Federal Match Rate: For FY2014, the federal match is 71.08%, and for FY2015 it is 70.64%.
*Data from Medicaid and CHIP Payment and Access Commission March 2014 MACStats report.
The Children’s Health Insurance Program (CHIP) was created in 1997 to provide quality health coverage for children under 19 in families that earned too much to qualify for Medicaid but were unable to afford coverage in the private market. Each state has the option to cover its CHIP population under its Medicaid program, design and structure a separate CHIP program, or establish a combination program using both options.
The Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 strengthened the program through increased federal funding, new outreach and enrollment opportunities, mental health parity, the requirement to cover dental care, and other provisions. In 2010, the Affordable Care Act (ACA) extended CHIP funding through federal fiscal year 2015 and required states to maintain Medicaid and CHIP eligibility levels and processes for children through 2019.1
Participation Rate: 82% of eligible children in Texas participated in either Medicaid or CHIP in 2011, the last year for which we have national data. The national average was 87.2% in 2011.2
Eligibility Levels: States establish CHIP eligibility levels within federal rules. Under the ACA’s maintenance of effort requirement, they must maintain CHIP eligibility levels they had in place when ACA was enacted until September 30, 2019. Beginning in 2014, eligibility levels for CHIP were revised based on Modified Adjusted Gross Income (MAGI).
|Modified Adjusted Gross Income (MAGI) Eligibility Levels for CHIP in Texas (by Age Group) in 2014|
|Ages 0 – 1||Ages 1 – 5||Ages 6 – 18|
|199-201% FPL||145-201% FPL||134-201% FPL|
Under ACA, states must cover all children with incomes up to 133% FPL in Medicaid, but if they had been covered in CHIP (Title XXI) prior to 2014, the state still receives the Title XXI match. Conception to birth coverage is also offered under the CHIP unborn child option up to 202% FPL. Eligibility levels do not include the mandatory 5% income disregard. Data from CMS eligibility table.
Benefit Package: States that operate Medicaid expansion CHIP programs must follow Medicaid rules, including providing all Medicaid covered benefits to enrolled children. In separate CHIP programs, states have substantial flexibility in designing CHIP benefit packages within broad federal guidelines. In addition to general medical and dental benefits, other benefits offered in Texas’s CHIP program include (but are not necessarily limited to):
Delivery System: The CHIP system has HMO coverage in metropolitan areas and an exclusive provider organization in most rural areas. Many HMOs have contracts in Texas to provide services to both Medicaid and CHIP enrollees.
Premiums & Cost Sharing: Within federal parameters, states can set CHIP program premium and cost sharing levels. In total, any family contribution to the cost of coverage cannot exceed five percent of family income.
|Premiums and Selected Cost Sharing in Texas’s CHIP Program, 2013|
|Family Income Level||Premiums||Office Visits||Inpatient Services||Prescription Drugs|
|151-185% FPL||$35 per year||$20||$75||$10-$35|
|186-200% FPL||$50 per year||$25||$125||$10-$35|
Note: MAGI-adjusted income levels for premiums and cost sharing were not available at the time of publication.
Efforts to Simplify Enrollment and Renewals: CHIPRA established a five-year incentive program to support state efforts to simplify enrollment and renewal of eligible children in Medicaid and CHIP.3 From FY2009 – FY2013, Texas did not qualify for incentive payments.4
|Enrollment and Renewal Strategies Implemented in Texas, as of December 2013|
|Elimination of in-person interview*||
|Use of presumptive eligibility||
|Elimination of asset test*||Use of 12-month continuous eligibility||
|Use of joint application and renewal forms*||
|Use of express lane eligibility||
*ACA requires states to implement this strategy beginning January 2014. For definitions of strategies in this chart, see the Centers for Medicare and Medicaid Services December 2009 State Health Official letter.
Other Program Characteristics: Below are some other key program characteristics of Texas’ CHIP program.
|Require a waiting period?5||Yes, 3 months|
|Offer a buy-in option?6||No|
|Cover dependents of public employees?7||Yes|
|Cover lawfully residing children without a five-year waiting period?8||Yes|
Quality Measures: States may report on a “core set” of quality measures for children. Texas reported on 15 measures for federal fiscal year 2012. Among the measures is access to primary care providers, listed below
|Percentage of Children and Adolescents Visiting a Primary Care Provider, by Age (FFY 2012)|
25 months – 6 years
Source: Department of Health and Human Services, 2013 Annual Report on the Quality of Care for Children in Medicaid and CHIP, September 2013. The measure is for the percentage of children ages 12 to 24 months and 25 months to 6 years receiving a visit to a primary care provider within the past year; and every two years for children ages 7 to 11 years and 12 to 19 years. Note: These data include CHIP only.
1 Information in this fact sheet has been verified by the state.
2 Genevieve Kenney et al., Medicaid/CHIP Participation Rates Among Children: An Update. September 2013. https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf407769
3 To qualify for incentive payments each fiscal year, states had to implement at least 5 out of 8 specified strategies and increase child enrollment in Medicaid above a state-specific target level.
4 InsureKidsNow.gov. “CHIPRA Performance Bonuses: A History (FY 2009 – FY 2013).” https://www.insurekidsnow.gov/professionals/eligibility/pb-2013-chart.pdf
5 States may implement waiting periods up to 90 days in CHIP. A waiting period is the length of time a child must be uninsured before s/he can enroll in CHIP.
6 States can allow families with incomes above the upper income eligibility limit to pay the full cost to purchase coverage for their uninsured children through CHIP.
7 CHIPRA provided states the option to cover the income-eligible dependents of state employees under CHIP.
8 CHIPRA provided states the option to remove the five-year waiting period for lawfully residing children