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 Transitioning CYSHCN into Medicaid Managed Care: An Emerging Issue for Title V Programs

By Veronica Helms
Program Manager, Child and Adolescent Health, AMCHP

Creating a comprehensive, quality system of care for CYSHCN has been one of the most challenging priorities for state Title V programs and key stakeholders such as Medicaid, health plans, provider groups, and families.  As states undergo health reform, many struggle to provide high-needs populations with quality, cost-effective care.  Recent state successes in managed care has led to increased reliance on managed care to improve access, improve program quality, and reduce program costs for such populations. When coupled with ongoing budgetary pressures, Medicaid managed care is increasingly looked upon by states as a vehicle to promote healthier outcomes for high-needs, high-risk populations such as CYSHCN.  
The Managed Care Environment
Historically, most CYSHCN were enrolled in fee-for service (FFS) commercial or Medicaid insurance coverage plans in the 1990s. During this time, conversations regarding managed care as an emerging model sparked discussion among state public health officials. Title V CYSHCN programs and advocates for CYSHCN were concerned about whether managed care systems would meet the complex health care needs of children generally and CYSHCN in particular. During this time, shifts to managed care first began to occur for CYSHCN, but these experimental shifts did not result in nationwide momentum. 

Although FFS commercial models historically dominated the health care market, this trend has changed as most of today's commercial insurance is managed care (75 percent). Moreover, two-thirds of states (32 states) have mandated the enrollment of at least some CYSHCN into managed care arrangements with the trend continuing. Under federal law, states are required to identify individuals with special health care needs to managed care organizations (MCOs). Medicaid MCOs are then required to assess enrollees with special health care needs and identify any ongoing conditions that require treatment or monitoring. Additionally, state Title V CYSHCN programs have a statutory requirement to serve CYSHCN in their state.  Altogether, health reforms, federal requirements and the changing roles of state Title V CYSHCN programs pose important opportunities and unique challenges for states which choose to transition CYSYHCN into managed care arrangements.

AMCHP Action Learning Collaborative (ALC) for States Transitioning CYSYCN into Medicaid Managed Care
Recognizing the needs of state Title V programs related to the transition of CYSHCN into Medicaid managed care arrangements, AMCHP received funding from the Maternal and Child Health Bureau (MCHB) to further explore this emerging need. In April 2014, AMCHP convened seven state teams in Washington, DC for a day-long meeting to discuss strategies, opportunities, and challenges in this area. State teams were multidisciplinary and comprised of representatives from Title V, Medicaid, health plans, families/consumers, and pediatricians. This multisector approach allowed teams to collaboratively discuss the needs of CYSHCN in their states. Seven states participated in the ALC: Alabama, Colorado, Kentucky, Louisiana, Michigan, New Mexico and Washington.

Key Themes
As state Title V CYSHCN programs and their key partners face strategic decisions about their roles and responsibilities in the context of health reform and CYSHCN transitions to Medicaid managed care, many states consistently cited many key themes and challenges. Below are just a few of the challenges described by states:

  • Provider Network Adequacy: Many states expressed difficulties recruiting and retaining both primary care physicians and specialty care providers for health plans serving CYSHCN. Since many CYSHCN require consistent, ongoing primary and/or specialty care, this was a major area of concern for state teams seeking to promote a quality system of care for CYSHCN in their state. This issue represents a crucial access issue.  
  • Care Coordination: Many states struggled to clearly define and demarcate statewide responsibilities and expectations regarding care coordination. In many states, multiple systems serve CYSHCN, providing care coordination services which differ in definition and scope across sectors. Many of the multidisciplinary state teams decided to focus on utilizing Title V expertise in care coordination and further clarify care coordination roles and responsibilities across sectors.
  • Provider Education: Due to the ever-evolving nature of health reform, many states struggled to provide providers with up-to-date information regarding the transition of CYSHCN in Medicaid managed care. The need to provide education and outreach to providers varied by state with some states citing the need to educate providers on the managed care process overall and others citing the need to educate providers on more specific components of the managed care system, such as service changes and billing procedures.
  • Patient Education: Similar to states' need to educate providers about the Medicaid managed care system, many states also described the need to educate families of CYSHCN about the managed care system overall (including enrollment), the benefits of competing plans (if the consumer has the choice), and  how their child's health care service system could change in a managed care environment. Many states described planned efforts to work collaboratively with Medicaid and health plans to provide such education.
  • Collaboration and Communication with Key Partners: There is a pressing need for state Title V CYSHCN programs to strengthen their knowledge, understanding and engagement with public and private health insurance coverage systems to effectively communicate the needs of CYSHCN. Many Title V representatives described the ongoing need to communicate the statewide role of Title V in an effective, efficient, and comprehensive manner to key partners such as Medicaid and health plans. This was particularly important for state teams when considering potential service replication across systems.

Upcoming Issue Brief
For more information, AMCHP will release a follow-up issue brief in early fall 2014. The issue brief will feature detailed information regarding the historic and recent context of managed care for CYSHCN and will also feature current state efforts in transitioning CYSHCN into Medicaid managed care arrangements. It highlights seven states – Alabama, Colorado, Kentucky, Louisiana, Michigan, New Mexico and Washington – and describes emerging trends, challenges, and successes in this area.