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Medicaid as a Tool for Promoting the Healthy Development of Young Children
(Birth to Age 3)
November 30, 2018
Jocelyn GuyerManaging Director
Manatt Health Strategies
Donna Cohen RossVice President
Center for the Study of Social Policy
1
Health Insurance Coverage:Young Children & their Parents
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Source: Urban Institute. Health Insurance Coverage Among Children Ages 3 and Younger and Their Parents in 2016. January 2018.; Zero to Three. High Baby & Toddler Poverty Rate a Wake-Up Call for America, Leading Early Childhood Development Expert Says. September 12, 2018.
Close to half of young children are covered by Medicaid, as compared to 1 in 5 of their parents. Parents are 4 times more likely to be uninsured than their children, due in part to the 14 states that have not expanded Medicaid through the ACA
20%
60%
8%
12%
Medicaid/CHIP
Employer
Non-Group/Other
Uninsured
Parents of Young Children
48%
44%
5% 3%Young Children (age birth to three)
2Care & Services for Young Children
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Primary and preventative care
Developmental screening and care to address identified problems
Support for social needs (i.e. food, housing, transit)
Healthy caregivers
Young children need basic care and services to ensure healthy physical, emotional, and social development
3
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Source: MACPAC. EPSDT in Medicaid.
Comprehensive health and development history
Comprehensive unclothed physical exam
Appropriate immunizations
Laboratory tests (including lead toxicity screening)
Health education
Vision, dental, hearing services
Other services covered under Medicaid and medically necessary to diagnosis or treat a condition, including behavioral health assessment and screening for maternal depression
EPSDT provides comprehensive healthcare services for children under age 21 who are enrolled in Medicaid
4
Leveraging EPSDT to Address the Health of Caregivers: Maternal Depression Screening and Treatment
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Source: American Academy of Pediatrics. Bright Futures. February 2017; Earles MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. Nov
2010:126(5).; Centers for Medicaid & Medicare . CMCS Informational Bulletin. : Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. May 11, 2016.
§ Maternal depression is a serious and widespread condition, especially among women with low incomes, and presents a significant early risk to child development
§ AAP-endorsed best practice: Maternal depression screening as part of the well-child visit
§ CMS guidance: “since maternal depression screening is for the direct benefit of the child, state Medicaid agencies may allow such screenings to be claimed as part of the EPSDT benefit”
§ States must cover medical necessary treatment for the child through EPSDT; treatment involving the mother and child together can be claimed as a direct service for the child
§ Costs associated with promoting maternal depression screening among providers are eligible for Medicaid administrative matching funds and can be reflected in managed care plan contracts
§ A growing number of states are changing Medicaid payment policies to cover maternal depression screening and treatment
5Priorities of State Medicaid Agencies
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Source: Kaiser Family Foundation. States Focus on Quality and Outcomes Amid Waiver Changes. October 2018.
According to a recent 50-State survey, Medicaid reform initiatives primarily emphasize adults, but States are beginning to focus more attention on children
Session 1November
2018
Program Expansions & Enhancements
§ Alternative Payment Models§ Focus on social determinants of health (SDOH)§ Care coordination for enrollees in the criminal justice system
§ Provider rate increases§ Expansion of community-based LTSS§ Expansion of behavioral health services and other efforts to address opioid use disorder (OUD)§ ACA Medicaid expansion (ID, NE, UT)
Eligibility Changes
Quality, Value, Outcome Initiatives
§ Work and community engagement requirements § Premiums and coverage lock-outs for non-payment§ Waivers of retroactive eligibility
State Medicaid Agency Priorities
Relevant to Improving Children’s Care
6Value Based Initiatives
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
§ Traditionally, health care providers have reimbursed based on the volume of services that they provide
§ Increasingly, States and insurers are moving toward paying providers based on outcomes through value-based payment initiatives
§ For example, a Medicaid managed care company might pay a pediatric system based on its ability to reduce hospitalization for children with severe asthma (not just on the number of days such children spend in the hospital)
7
Tools in Medicaid to Improve Outcomes for Young Children
Screening for maternal depression by pediatricians at well child-visits North Dakota covers maternal depression screening when performed during an EPSDT/pediatric visit and is
considered a risk assessment for the child. The pediatrician may bill the child’s Medicaid number.
Source: Agency for Healthcare Research and Quality. The Lourie Center for Children’s Social and Emotional Wellness.; Department of Health Care Services. Medi-Cal Managed Care Quality Strategy Report. June 29, 2018.; Institute
for Medicaid Innovation. Innovation in Maternal Depression & Anxiety. 2018.; Colorado’s Children’s Health Care Access Program. Medical Homes.; Academy Health. Implementing Social Determinants of Health: Interventions in
Medicaid Managed Care. February 2018.
Leveraging managed care contracts to incentivize initiatives tied to young children’s care and services
California requires MCOs to conduct two annual performance improvement plans (PIPs), with one PIP aligning
with one of four priority focus areas pre-selected by the State, of which two of the four focus on child or maternal
development
Leveraging quality strategy using value-based initiatives to encourage pediatric provider transformation
Washington D.C.’s Lourie Center for Children’s Social & Emotional Wellness utilizes CMS recommended HHS
National Quality Strategy to implement weekly home visits for low-income families with young children
Investing in new approaches to primary care, including integrating behavioral and physical health
Colorado has one of the country’s most established pediatric medical home initiatives, which integrates mental,
physical, and oral health preventative services
Expanding care coordination initiatives that address children’s social and emotional development and SDOH
New York requires providers in value-based purchasing arrangements to implement at least one SDOH intervention
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
8
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Leading Edge States Focused on Promoting Young
Children’s Health
North Carolina is currently undergoing a major
delivery system transformation that
establishes robust care management, including
requirements to address socio-economic drivers of health outcomes such as housing instability, food
insecurity, lack of
transportation and
interpersonal violence
North Carolina
Launched First 1,000 Days
on Medicaid Initiative, a cross-sector approach that features 10 evidence-based
interventions found to promote child
development by improving birth outcomes, addressing
child/caregiver mental health, increasing home visiting, supporting early
literacy in primary care and via other strategies
New York
Coordinated Care Organizations (CCOs) work in conjunction with Early
Learning Councils promote kindergarten readiness through alignment of
quality measures, joint support for developmental
screening, trauma-
informed training on
adverse childhood
experiences
Oregon
9
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
An Overlooked Opportunity: Health Service Initiatives
States are allowed to use up to 10% of CHIP coverage expenditures on administrative costs, including program administration, non-listed benefits, outreach to enroll eligible children and Health Services Initiatives (HSIs)
Health Services Initiatives:§ Must directly improve the health of low-income children (under age 19) who are
eligible for CHIP and/or Medicaid§ May benefit all children regardless of income§ May provide direct services and public health initiatives§ Encourage evidence-based practices
Source: Center for Medicaid & CHIP Services. Frequently Asked Questions: Health Services Initiative. January 12, 2017.; Oklahoma Health Care Authority. Reach Out and Read Coming to More SoonerCare members. October 31, 2018.; Medicaid Final Rule. 42 CFR 438.330 May 6, 2016.
Oklahoma’s Reach Out & Read HSI leverages CHIP administrative dollars to support early literacy, language development, and caregiver-child interaction during well-child visits. Funding also supports developmental screening.
10
Future Landscape: Newly Elected Governors Pledge Big Initiatives for Early Childhood Development
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Source: Center for American Progress. Newly Elected Governors Support Expanding Early Childhood Programs. November 7, 2018.
§ Pledged a “cradle to career” platform§ Increase funding for nurse home visits
for new parents§ Expand prenatal and child care
Gov-Elect Janet Mills (ME)
§ Pledged to expand home visiting and Head Start programs
§ Plans to convene a Children’s Cabinet to prioritize young children
Gov-Elect J.B. Pritzker (IL)§ Advocated for universal preschool for children
as young as three§ Pledged to increase birth-to-three services (i.e.
home visiting programs) and invest in early childhood workforce
§ Longstanding support for early childhood advocacy through the Pritzker Foundation
Gov-Elect Gretchen Whitmer (MI)
§ Proposed an education platform centered on a child’s first 1,000 days
§ Plans to establish a state funding source for early intervention services for infants and toddlers
Gov-Elect Gavin Newsom (CA)
11New Initiatives at the Federal Level - CMMI
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Source: Centers for Medicare & Medicaid Services. Integrated Care for Kids Model. August 23, 2018.; Centers for Medicare & Medicaid Services. Maternal Opioid Use Model. October 23, 2018.
§ State Medicaid Agencies partner with
“lead organization” to provide
pediatric delivery reform and state
payment model reform, focusing on
Medicaid-eligible children through
integrated physical and behavioral
health
§ $16M per State, up to 8 States, for 7
year program
Integrated Care for Kids (InCK) Model
§ State Medicaid Agencies drive
transformation of the care delivery
system for pregnant and postpartum
Medicaid-eligible women with opioid
use disorder (OUD)
§ $64.5M total, up to 12 States, for 5
year program
Maternal Opioid Use (MOM) Model
Notice of Funding Opportunity (NOFO) expected to be released in early 2019
12
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Jocelyn GuyerManaging DirectorManatt Health Strategies
Donna Cohen RossVice PresidentCenter for the Study of Social Policy
13
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Appendix
14Medicaid Expansion States (as of Nov 2018)
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Wyoming
Wisconsin
WestVirginia
Washington, D.C.
Washington
Virginia
Vermont
Utah
Texas
Tennessee
SouthDakota
SouthCarolina
Rhode Island
Pennsylvania
Oregon
Oklahoma
Ohio
NorthDakota
NorthCarolina
NewYork
NewMexico
New Jersey
New Hampshire
Nevada Nebraska
Montana
Missouri
Mississippi
Minnesota
MichiganMassachusetts
Maryland
Maine
Louisiana
Kentucky Kansas
IndianaIllinois
Iowa
Idaho
Hawaii
Georgia
Florida
Delaware
Connecticut
Colorado
California
ArkansasArizona
Alaska Alabama Implemented Medicaid expansion (32 States & DC)Adopted, but not yet implemented (4 States)
Not yet adopted (14 States
Source: Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions. November 7, 2018.
15
Medicaid Income Eligibility Limits for Children ages 1-5 as
a Percent of the Federal Poverty Level (as of April 2018)
November 30, 2018 | Manatt Health Strategies | Center for the Study of Social Policy
Wyoming
Wisconsin
Washington, D.C.
Washington
Virginia
Vermont
Utah
Texas
Tennessee
South
Dakota
South
Carolina
Rhode Island
Pennsylvania
Oregon
Oklahoma
Ohio
North
Dakota
North
Carolina
New
York
New
Mexico
New Jersey
New Hampshire
Nevada Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky Kansas
IndianaIllinois
Iowa
Idaho
Hawaii
Georgia
Florida
Delaware
Connecticut
Colorado
California
ArkansasArizona
Alaska Alabama
<200% FPL (33 States)
200% up to 300% FPL (13 States)
≥300% FPL (4 States & D.C.)
West
Virginia
Source: Centers for Medicare and Medicaid Services. Medicaid, CHIP & Basic Health Program Eligibility Levels. April 2018.
