The Centers for Medicare & Medicaid Services (CMS) recently released a request for information (RFI) for input from states, providers, health systems, and families to better coordinate care from out-of-state providers for children with complex health conditions enrolled in Medicaid. The deadline to submit comments is March 23, 2020.
States have long addressed issues of access to care, provider availability, service delivery system design, and public insurance reimbursement for children with medical complexity (CMC). This RFI addresses considerations for CMC who may require specialized treatment or therapy that is not offered by in-state providers and therefore need services in other states, complicating the ability of states to coordinate and deliver care effectively.
Coordinating care for enrollees from out-of-state providers can also present an administrative burden for state officials who are required to screen and enroll these providers in their Medicaid programs in order to provide payment for services. This RFI is part of a requirement from the Medicaid Services Investment and Accountability Act of 2019 which calls for the secretary of the Department of Health and Human Services to issue guidance to states on this topic.
CMS is seeking input from states and stakeholders who have experience with specific aspects of coordinating care from out-of-state providers, including:
- Sate initiatives that have promoted and/or improved the coordination of services and supports provided by out-of-state providers to children with CMC;
- Administrative, fiscal, and regulatory barriers that states, providers, and enrollees and their families experience that prevent children with CMC from receiving care, such as community and social support services, from out-of-state providers in a timely fashion, as well as examples of successful approaches to reducing those barriers;
- Measures that have been or can be employed by states, providers, health systems, and hospitals to reduce barriers to coordinating care for children with CMC when receiving care from out-of-state providers; and
- Best practices for developing appropriate and reasonable contract terms and payment rates for out-of-state providers in both Medicaid fee-for-service and managed care systems.
For a full list of requested information please review the RFI. CMS will review input from states and stakeholders and issue guidance by October 2020. The new guidance will include:
- Best practices for using out-of-state providers to provide care to children with CMC;
- Coordinating care provided by out-of-state providers to children with CMC, including services provided in emergency and non-emergency situations;
- Reducing barriers that prevent children with CMC from receiving care from out-of-state providers in a timely fashion; and
- Processes for screening and enrolling out-of-state providers, including efforts to streamline these processes or reduce the burden of these processes on out-of-state providers.
The National Academy for State Health Policy (NASHP) encourages states to submit relevant information to shape future guidance.
The RFI was posted on January 21, 2020 and comments are due March 23, 2020.
View the CMS RFI for instructions on how to submit comments. NASHP will share the release of any future CMS guidance on this topic as part of its ongoing work in the area of children with medical complexity.
To review NASHP resources related to children with medical complexity and children and youth with special health care needs, please visit its resource page.