Managed Care – The National Academy for State Health Policy

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Roundtable Discussion: Driving Quality Outcomes and Managing Cost for Children with Special Needs

States are increasingly using managed care to deliver services to children with complex health needs enrolled in Medicaid. This roundtable discussion features the work of two states that have made innovative efforts in this area. Participants will have an opportunity to raise questions and discuss opportunities and challenges to improving care quality and controlling costs for children with medical complexity in Medicaid managed care.

Which Way Is the Wind Blowing? MCOs at a Crossroads

Q&A: How Rhode Island Tackles Social Determinants of Health through its Accountable Entity Model

November 27, 2018/in Policy Rhode Island Blogs Accountable Health, Blending and Braiding Funding, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health, Value-Based Purchasing /by Elinor Higgins

Across the country, states are launching new payment models that reward quality, promote care integration, improve access, and address the social determinants of health (SDOH) in an effort to improve population health. One of these ground-breaking initiatives is Rhode Island’s Accountable Entity (AE) Program, created to improve the health of Rhode Islanders enrolled in Medicaid managed care plans.
Rhode Island’s program is designed to encourage Medicaid managed care organizations (MCOs) and providers to deliver more cost-effective care through value-based payments, improve coordinated care delivery, and focus on population health in ways that go beyond traditional clinical care. Rhode Island Health System Transformation Project Director Lauretta Converse and AE Program Director Deborah Correia Morales, members of National Academy for State Health Policy’s (NASHP) State Accountable Health Models workgroup, recently shared how their program is addressing SDOH during the first year of AE implementation.
Could you describe Rhode Island’s accountable entity program and how it fits into your managed care model?
State officials developed the AE program through an amendment to the state’s 1115 Medicaid Demonstration Waiver as a way to move the existing Medicaid MCO model away from fee-for-service and towards value-based care to expand its ability to improve health outcomes and decrease costs. The AEs are provider organizations that once certified by the Executive Office of Health and Human Services (EOHHS ) are eligible to contract with one of the state’s MCOs. Specific contractual requirements set forth by the EOHHS provide guidelines for how MCOs and AEs should proceed in coordinating teams of providers with the goal of aligning financial incentives, improve their capacity to manage complex conditions, and better address social needs. The AEs, through increased delivery system integration and improved information exchange, will enhance the capacity of the MCOs and providers to support and serve high-risk populations. AE participation is voluntary, but once MCOs enter into an AE contract, they are eligible to receive incentive funding from a pool of total incentive dollars. During project Year 1, 15 percent of those dollars is allocated to the MCO incentive pool while 85 percent is allocated to the AE incentive pool.

EOHHS is the certifier not the contractor. The Rhode Island EOHHS certifies AEs, but contracts are developed between the AEs and the MCOs.

How are you incorporating SDOH into the AE model?
AEs are accountable for care coordination for their attributed populations and are required to adopt a defined population health approach. Rather than having individual providers treat patients’ individual health issues one at a time, AEs coordinate a team of providers who take on increasing financial risk for treating the whole person. A central element of the AE model is the required integration of strategies to address SDOH. The strategies must include assessment of social needs, screening and referral to community resources, and using community partnerships and engagement to address identified needs. Rhode Island has taken this on through a three-legged stool approach: certification, payment, and incentives.
How certification works:
In the first year of the program, the EOHHS certified six AEs. The state’s EOHHS uses a set of certification standards that require:

The identification of three key domains of social need
Evidence of capacity to address those domains;
A process for screening, managing referrals; and
Arranging supports for patients who need them.

AEs work with their providers to identify the best points of contact with their patients, and are able to bring aspects of care management to a broader population. AEs must be able to demonstrate clear evidence of their capacity to address the three priority domains, which could be through defined relationships with community-based organizations, in-house social supports, or an agreement with a separate social supports agency.
Possible key domains include housing stabilization and support, education and literacy, food security, safety and domestic violence, employment, and transportation. As expected, the AEs all received conditional certification because they did not yet meet the necessary standards for providing services and supports from within the community or for screening and referring patients based on the SDOH [ ]. Rhode Island state officials recognize that the AEs need support, in this case in the form of incentive payments, to develop their capacity in this area and to reach the goal of emphasizing community-based resources and services in addition to institutional care.
How payment works:
Certified AEs participate in an EOHHS-designed, value-based, Alternative Payment Methodology (APM) and total cost of care (TCoC) model through contractual partnerships with MCOs. EOHHS contracts with MCOs, which then subcontract with the AEs, which makes the MCOs responsible for ensuring AE contractual compliance. These contracts are intended, over time, to move AEs away from shared savings to increased financial risk and responsibility and to move provider payments from volume-based to value-based arrangements. Payments to AEs, made by the contracted MCO, are based in part on the quality of the care they deliver to their members, as determined by the EOHHS Quality Scorecard, which includes an SDOH measure.
How incentives work:
AE infrastructure development and implementation are supported through the Health System Transformation Project (HSTP), an amendment to the state’s 1115 Medicaid Demonstration Waiver. Entering into APM contracts makes AEs eligible to receive incentive payments from their managed care partners, and AEs receive the funds in exchange for meeting milestones established by AEs and MCOs in an individualized HSTP plan. The milestones initially are based on infrastructure and capacity building and will transition to performance-based outcome metrics. well the AEs perform in accordance with the plan dictates the amount of incentive funding earned.
AEs are required to allocate 10 percent of their received incentive funds to establish partnerships between the AE and community-based organizations that support behavioral health care, substance abuse treatment, or SDOH. A key tenet of addressing SDOH is engaging with community supports so that relationships for referral, follow-up, and tracking are established. As such, it is a requirement of the program that the agreements between community partners and AEs be formalized along with the process of identifying partners’ specific service and referral needs.
How do AEs engage with community partners to help reach their goals and address social determinants of health?
EOHHS identified four steps for AEs to use to develop meaningful community-based partnerships in Rhode Island.
First, it is necessary to identify the appropriate partners to assist in addressing SDOH within a particular community. The next step is to formalize the agreement between the AE and the community partner to establish expectations and hold each party accountable for their responsibilities. The third step is to establish bi-directional care management tracking so that all parties, including the MCO, are as up-to-date as possible on the care of patients within the AE. Finally, partners develop metrics for measuring the SDOH efforts and need for any adjustments to maximize the impact of the partnership.
All of these steps are supported through a requirement that the AEs allocate 10 percent of their incentive funding to community-based organizations.
Why are social determinants so integral to new payment and delivery models?
An increasingly familiar statistic — only 20 percent of health outcomes are due to clinical health care — establishes the importance of addressing societal, behavioral, and environmental factors when attempting to improve health. Addressing SDOH not only improves the overall health of a community, it increases the capacity of a system to prevent poor health outcomes and to manage and treat the health needs of the people it serves. A payment and delivery model that holds providers accountable for the full range of factors that influence health outcomes is a model that is likely to decreases costs and improves results.
What are your next steps?
Thus far, AEs have identified housing, food, and domestic violence as their top social determinants. EOHHS hopes to see AEs increasingly engaged in addressing these issues in their communities while taking on additional financial risk and better meeting certification standards in Year 2 of the program.

Medicaid Managed Care Proposed Rule Would Give States More Flexibility

November 20, 2018/in Policy Blogs CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care /by Kate Honsberger

The Centers for Medicare & Medicaid Services (CMS) has proposed a new regulation that gives states more flexibility to design and implement Medicaid managed care programs for Medicaid and Children’s Health Insurance Program (CHIP) enrollees. The proposal aligns with the Trump administration’s goal to reduce regulatory requirements imposed on states.
The majority of the proposed changes are policy and technical corrections to the 2016 Medicaid and CHIP Managed Care Final Rule. (The National Academy for State Health Policy has analyzed, and highlighted aspects of the rule relevant to children with special health care needs.) CMS notes the proposed rule addresses state officials’ concerns that existing federal regulations are overly prescriptive and administratively burdensome.
NASHP has performed an initial review of the proposed rule and found the following provisions may require fewer state administrative resources if the rule is finalized:

Rate setting:
- Rather than require states to develop and certify each individual rate paid per rate cell (or population group within certain regions, which can be numerous within Medicaid) to demonstrate actuarial soundness in managed care capitation rates as currently exists, states would have the option to develop and certify a rate range. Prior to the finalization of the 2016 regulation, most states used a rate range to justify managed care capitation rates.
Network adequacy:
- Instead of requiring time and distance standards for provider types within a managed care network, states would be able to implement a combination of “quantitative minimum access standards,” such as:
  - Minimum provider-to-enrollee ratios;
  - Maximum travel time or distance to providers;
  - A minimum percentage of contracted providers who are accepting new patients;
  - Maximum wait times for an appointment; and
  - Hours of operation requirements (for example, extended evening or weekend hours).
- The 2016 final rule required states to set time and distance standards for primary and specialist providers without providing a definition of specialist providers. The proposed rule clarifies that states may define “specialist” in whatever way they deem most appropriate for their programs.
Member information:
- To allow for the printing of shorter member marketing materials, states would only be required to include taglines in prevalent non-English languages and in large print on materials for potential enrollees who “are critical to obtaining services,” instead of all written materials.
- Managed care organizations (MCOs) would no longer have to provide monthly updates to paper provider network directories if they offer a mobile-enabled, electronic directory that is regularly updated.
- Provider directories would no longer have to indicate if an individual provider has completed cultural competency training – only the provider’s cultural and linguistic capabilities would be required, including the languages spoken by the physician or provider.
Quality rating system:
- The 2016 final rule required CMS, in consultation with states and other stakeholders, to develop a Quality Rating System (QRS) framework. States have the option to use the CMS-developed framework or establish their own QRS that contains “substantially comparable information about plan performance subject to CMS approval of the alternative system.” The proposed rule would:
  - Allow states to implement their own QRS as long as it was as “substantially comparable to the extent feasible to enable meaningful comparison across states,” and
  - Require CMS to identify a set of mandatory performance measures to be used in the QRS. A state alternative QRS would have to include the mandatory measures identified.

To submit a comment on the proposed rule, go to https://www.regulations.gov and follow the “Submit a comment” instructions. The public comment period is open through Jan. 14, 2019.

States Explore Strategies to Advance Palliative Care at #NASHPCONF18

September 18, 2018/in Policy Blogs Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Long-Term Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Workforce Capacity /by Kitty Purington and Hannah Dorr

States, as regulators, payers, and innovators of health care, are uniquely positioned to improve the lives of Americans with serious illnesses by promoting access to palliative care. The National Academy for State Health Policy (NASHP) is working with state leaders to expand and improve palliative care, explore how these services align with other initiatives (e.g., value-based purchasing and delivery system reform), and identify what states need to effectively advance palliative care services.

What is palliative care?
Palliative care is interdisciplinary, patient- and family-centered health care that addresses the physical, mental, social, and spiritual well-being of seriously ill individuals.

It can be provided in hospital, community, or home settings. While often confused with hospice care, which typically focuses on the last months of life, palliative care can be offered alongside curative care at any time.

Palliative care services can improve care and the quality of life of individuals with serious illness by better managing symptoms and stressors. They can also reduce costs, especially for complex populations with serious illnesses. A 2016 study that examined home-based palliative care found these services generated a 4.2 to 6.6 percent return on investment, primarily by reducing unnecessary hospitalizations.
At NASHP’s recent 2018 State Health Policy Conference, a group of state leaders explored these issues from a policymaker perspective and discussed what it would take to advance palliative care services in their states. Below are some of the key themes and opportunities raised during the session:

States need palliative care definitions and standards: State officials identified the need for tools and resources to help states license, reimburse, monitor, and measure high-quality palliative care. Definitions and standards tailored to state regulatory needs can help jumpstart state efforts. California, Maryland, and Colorado have all implemented regulations defining palliative care, which can serve as starting points for other states.

This work is supported by a grant from
The John A. Hartford Foundation, a national philanthropy based in New York City dedicated to improving the care of older adults.

Workforce shortage is a potential barrier: States report that trained professionals — able to address palliative care needs in primary care and as members of specialized palliative care teams — are in short supply. To address this issue, Rhode Island supports provider education on palliative care as part of its cancer control program, and recently expanded the training to providers who treat other serious illnesses. As part of its State Innovation Model test grant, Rhode Island is also developing patient tools for advanced care planning and is offering education to providers to help them feel better equipped to hold these difficult discussions.
Monitoring utilization and quality can be challenging: State Medicaid agencies can support reimbursement for palliative care in a number of ways, including:
- Through managed care contracting;
- As a distinct state plan option; and
- By leveraging existing physician billing codes.

While these payment mechanisms are readily available, participants noted limitations persist. Even with enhanced reimbursement rates for palliative care, one state official reported that provider uptake was low and that the enhanced payment was underutilized. Other officials from states that had activated specialized billing codes for palliative care expressed concern about the quality of care delivered and adherence to best practice standards. States without specialty codes or a specific benefit noted that it was impossible to gauge utilization or quality given the lack of claims data.
California, which requires its Medicaid managed care plans to cover palliative care services as a package of benefits, is an example of a state that has developed a comprehensive regulatory framework to address some of these issues. Its notice to plans outlines eligibility criteria, describes service components (including advance care planning, palliative care assessment and consultation, access to a palliative care team, and mental health services) and requires plans to monitor and report palliative care utilization and provider data to California’s Department of Healthcare Services.

Stakeholder engagement can help when defining and developing palliative care services. State officials reported that engaging a broad range of agencies and stakeholders to develop palliative care initiatives was helpful. At least 27 states have multi-stakeholder taskforces or councils established specifically to advise on palliative care, and those groups provide a readymade forum for state policymakers.

State policymakers are working hard to move state systems toward more comprehensive and value-driven care, often with a special focus on populations that have chronic, complex, and high-cost care needs. Over the next two years, NASHP will convene a Leadership Council of state officials to identify promising policies and develop state recommendations and an implementation roadmap to increase access to and quality of palliative care.
NASHP will also be providing technical support to 10 states to assist them in advancing palliative care through resources, such as development of model legislation or Medicaid managed care contract language, and review of state regulations of palliative care providers and facilities. Look for announcements about publically-available palliative care resources and the technical assistance opportunities at NASHP’s website.
If your state has implemented or is exploring innovative strategies to support palliative care in Medicaid, please share your state’s experience with NASHP, contact Hannah Dorr.

Washington’s Medicaid Chief Examines the Future of Medicaid and Health Reforms

June 26, 2018/in Policy Washington Blogs Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Population Health, Quality and Measurement, State Insurance Marketplaces, Value-Based Purchasing /by NASHP Writers

MaryAnne Lindeblad oversees Washington State’s Apple Health (Medicaid) program, which serves more than 1.8 million residents. She also chairs the National Academy for State Health Policy’s executive committee and is a National Association of Medicaid Directors board member. Lindeblad took time recently to talk to NASHP about the future of Medicaid and health care reform.
Many state officials are despairing at the prospect of federal cuts to Medicaid, can innovation save the day?
We have no choice but to innovate and find different models for delivering and paying for health care. Historically, Medicaid programs often responded to budget pressures by cutting rates, cutting eligibility, cutting services, or contracting out the management of services to a managed care plan. We have exhausted those approaches. We need to find other tools to cover our (low-income) population in a way that is effective and produces the desired outcomes, and one opportunity is to look at other countries for models.
Which countries?
I recently had the opportunity to participate in a webinar with health officials from Spain. We could learn from their system of treating individuals with chronic care needs, some of which we are beginning to implement in Washington. I also believe we must focus more on the social determinants of health, including housing, employment and food security, and provide more robust behavioral health care.
(Note: Spain’s complex care plan uses interdisciplinary primary care teams to coordinate care among specialists, social workers, nursing facilities, home care aides, mental health providers, caregivers, and the patient, which has generated a marked decrease in hospital admissions. Team member receive bonuses, tied to performance measures, based on individual care plans. It also permits program flexibility across regions to meet specific populations’ health care needs.)
What is Washington doing to reform the health care delivery and payment system?
We have about 85 percent of our enrollment in one of our five managed care plans. In 2016, we began integrating behavioral health services into our managed care delivery system. We started in one region in the state in 2016 and will complete the whole state by January 2020. Already, we have seen improved outcomes and reduced hospitalization by having one care manager serve as a point of entry into the health care system for our highest needs, highest risk individuals. Our integrated systems are more responsive to our members’ needs. We are also beginning to build in social determinants of health into our managed care contracts and delivery systems in order to hold providers more accountable for things that directly affect people’s health, such as housing, food security and job and educational opportunities.
We also implemented a robust health home program and to date, we are seeing improved health outcomes and significant cost savings especially for our dual-eligible population.
How effective is your value-based payment (VBP) initiative, which replaced a traditional fee-for-service model with one that rewards providers for delivering quality care?
As a part of our 1115 Medicaid transformation waiver, we require our health plans serving our Medicaid population to move to VBP arrangements. By the end of 2018, we expect to have at least 50 percent of services paid through a value-based arrangement and our goal is to reach 90 percent by 2021, with commercial markets reaching 50 percent by 2021.
We have 1.8 million people in our Medicaid program, 370,000 state employees and retirees, and we will soon add 250,000 teachers in 2020. When purchasing for this many covered lives, our Health Care Authority is well-positioned to drive innovation across the state in both publically- and privately-purchased health care.
Is VBP delivery reform currently your most potent tool?
It is certainly one of our major tools among an array of options including improved care coordination, chronic care management, and integration to name a few. Because we were able to obtain a 1115 transformation waiver, we have an opportunity to test a number of tools over the course of the next four years. In addition, as a part of our Healthier Washington initiative, we are engaging our nine accountable communities of health to bring together leaders to improve health care resources, population health, and whole-person care. They are a great way to meet local needs and engage individuals from multiple sectors at a community level in identifying community health related needs and local solutions.
What do you think of the Medicaid work requirements?
It is difficult to find and keep a job if you have untreated health issues so I would rather invest in programs that provide access to quality and accessible health care first and provide the supports to maintain health. In addition, as a part of our 1115 waiver, we have added supported employment services for individuals that may need some additional supports to both find and keep jobs.
What keeps you up at night?
Being able to maintain the level of access and health insurance coverage that we currently have.
We still have an uninsured rate of around 6 percent in Washington and continue to have a successful (Affordable Care Act) insurance exchange. Can we maintain that level of insurance coverage? What will happen to Medicaid and our exchange in the future? If those programs are rolled back, we will lose ground and it will be more difficult to maintain the gains we have seen in our state. We will be back to seeing emergency rooms visits going up, hospital bad debt rising again, and fewer individuals having routine access to primary care.
We also need to make sure we have a workforce that can meet the demands of the populations we serve. We have many gaps today, especially in behavioral health and primary care. We need to address these shortages and look to how we can best use mid-levels and work our health care professionals to the top of their license.
This is a pivotal time in health care – we have a tremendous opportunity to change how we deliver health services and improve the health of those we serve. We cannot waste it.
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Hear Lindeblad speak at NASHP’s 31st Annual Health Care Policy Conference, Aug. 15-17, 2018, in Jacksonville, FL
Raising the Bar: Value-Based Purchasing to Address Population Health State health policymakers are identifying innovative mechanisms to address the social determinants of health by including new requirements or incentives within value-based purchasing and contracting arrangements. This session highlights how states are using value-based payment roadmaps and Medicaid managed care contracting as levers to increase health and well-being and to control costs. Officials from three states discuss their models, share strategies, and identify practical ideas to address the social and economic factors that influence health through value-based purchasing.
Also, read more about accountable health models: States Develop New Approaches to Improve Population Health Through Accountable Health Models

How States Can Improve Access to Care for Children Under the Medicaid Managed Care Rule

June 12, 2018/in Policy Colorado, Virginia Blogs 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, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Health System Costs, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Kate Honsberger

Next month, states face new federal requirements for establishing and maintaining Medicaid managed care provider networks. As they work to comply with these new rules, states have an opportunity to strengthen access to care for children and youth with special health care needs (CYSHCN).
Medicaid and requirements, which address how enrollees access care and the scope of provider networks, are scheduled to go into effect July 1, 2018. The network adequacy provisions of the rule, in particular, may have implications for how CYSHCN can access care.
As outlined in a recently published NASHP analysis, the rule requires states to develop and implement network adequacy standards in their Medicaid managed care programs, including time and distance standards, for certain types of providers:

Pediatric dental
Pediatric primary care
Pediatric behavioral health, including mental health and substance use disorder services
Pediatric specialist
OB/GYN
Adult primary care
Adult specialist
Adult behavioral health, including mental health and substance use disorder services
Hospital
Pharmacy
Long-term services and supports that require the enrollee to travel to the provider

In requiring network adequacy standards – yet avoiding dictating the specific time and distance standards themselves — the rule recognizes that states differ in their geographic conditions and provider capacity. It thereby gives states flexibility to establish standards in a way that fits their unique needs.
Many CYSHCN, especially those with complex needs, typically use multiple specialty providers and home- and community-based providers. By including these provider types in network adequacy standards, states can help ensure access to pediatric and specialty services for CYSHCN.
NASHP recently analyzed how states provide managed care services to CYSHCN enrolled in Medicaid. Several states have implemented network adequacy policies in their Medicaid managed care programs. Of the six states NASHP studied, all of the states include time and distance standards for generalist, specialist, and behavioral health care providers. These standards varied for urban, rural, and frontier areas in geographically diverse states. For example:

Colorado’s Accountable Care Collaborative Phase II program specifies that enrollees must have access to primary care providers (PCPs) within 30 miles or 30 minutes in urban areas, 45 miles or 45 minutes in rural areas, and 60 miles or 60 minutes in frontier areas.
Texas requires MCOs to establish networks in its STAR Kids program so that enrollees have access to two age-appropriate PCPs within 30 miles (or 20 miles in more densely-populated areas). Texas also requires that managed care organizations (MCOs) contract with telehealth providers to ensure access to specialty care in rural areas.
In Virginia’s CCC Plus program, MCOs must offer enrollees a choice of at least two providers of each provider service type located within 60 minutes of their residences, and a choice of at least two specialists within a 30-mile radius in urban areas and no more than a 60-mile radius in rural areas.

In addition to network adequacy requirements, state Medicaid agencies and MCOs use other strategies to ensure that CYSHCN have access to specialty providers. One approach is an analysis of fee-for-service claims data to identify the providers that enrollees have used in the past. The state then makes efforts to enroll those providers who have a history with these children in MCO networks. This strategy is employed by MCOs in Ohio and by the Texas Medicaid agency, which has used the method to help ensure that “significant traditional providers” are included in its MCO networks. Virginia’s Medicaid agency works with the state’s 13 hospital health systems to ensure that they contract with at least three of the participating Medicaid MCOs in the hospital system’s geographic area.
As states work to comply with the network adequacy requirements spelled out in the managed care final rule, they have an opportunity to strengthen access to care among all of their CYSHCN.
For more information about how states are organizing their Medicaid managed care programs to ensure access to care for CYSHCN, visit NASHP’s recent analysis of six state programs.

Identification and Assessment of Children and Youth with Special Health Care Needs in Medicaid Managed Care: Approaches from Three States

February 20, 2014/in Policy Reports Cost, Payment, and Delivery Reform, Health Coverage and Access, Maternal, Child, and Adolescent Health /by NASHP, Julien Nagarajan and Joanne Jee

Increasingly, states are relying on managed care delivery systems to serve Medicaid enrollees that have historically been exempt from enrollment in managed care, such as children and youth with special health care needs (CYSHCN). The federal Medicaid managed care regulations establish the broad requirements for states to identify and assess individuals with special health care needs. However, little has been recently documented about specific state policies or procedures for identifying and assessing CYSHCN. This report, prepared with the support of the Lucile Packard Foundation for Children’s Health, looks at such approaches in three states – California, Massachusetts and Michigan – and includes some promising practices states may consider in implementing Medicaid managed care for this vulnerable population.

Joanne Jee

Julien Nagarajan

February 2014

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Medicaid Managed Care for Children and Youth with Special Health Care Needs

February 3, 2014/in Policy Blogs Health Coverage and Access, Maternal, Child, and Adolescent Health /by NASHP

by Joanne Jee
February 2014

Where some may see opportunities for improved delivery and coordination of care and cost savings, others may wonder about possible disincentives for providing the full array of needed services. For more vulnerable populations, such as children and youth with special health care needs (CYSHCN), the concerns can be heightened.

Read more

Reporting and Data Collection

December 10, 2013/in Policy Cost, Payment, and Delivery Reform, Health Coverage and Access /by NASHP

States and the Federal Government collect a variety of data on Medicaid services delivery to children and adolescents. These data are used for program evaluation, managing relationships with Medicaid managed care organizations (MCOs) that serve children, and measuring and improving the quality of services available to children. This section describes data collection initiatives in states, reporting by MCOs, and quality measurement using the CMS’s core set of children’s health care quality measures for CHIPRA Medicaid/CHIP (Child Core Set).

Alabama	No information at this time.
Alaska	As part of Tri-State Child Health Improvement Consortium (T-CHIC), Alaska is requiring successful medical home pilots to address the following areas: Developing, adopting and implementing quality measurement tools; Developing, adopting and/or improving Health Information Technology, Electronic Health Records (EHR), and participation in Health Information Exchanges (HIE); and Developing, adopting and/or improving medical home approaches The participating medical homes also must comply with the CHIPRA Core Measures for voluntary use by Medicaid and CHIP programs.
Arizona	The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, provides EPSDT Tracking Forms that must be used by providers to document all age-specific, required information related to EPSDT screenings and visits. Providers may choose to use an electronic EPSDT Tracking Form generated through AHCCCS or the provider’s electronic health record system if the electronic form includes components on the AHCCCS EPSDT Tracking form, such as: Documentation of comprehensive physical exam Age-appropriate screenings Developmental surveillance Anticipatory guidance Social-emotional health surveillance Age-appropriate lab and immunizations, and Medically necessary referrals including those to the member’s dental home starting at 1 year of age, or sooner as needed, for routine biannual examinations.
Arkansas	The Arkansas Foundation for Medical Care (AFMC) staffs Quality Improvement specialists that work with providers on a number of projects. A number of these quality improvement projects have focused on issues affecting children including: Adolescent Health, Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Pediatric Overweight, Breastfeeding Promotion, Pregnancy and Tobacco Use, Well Child Screening, and EPSDT. For many of these quality improvement projects data and metrics are an important aspect of the initiative. For example, for the Well Child Screening initiative the QI teams are tracking indicators related to the number of well visits in the first 15 months of life, administration and documentation of immunizations in accordance with national recommendations, and completion of an EPSDT medical screening components according to age-specific schedule.
California	The Medicaid program offers Managed Care Performance Dashboards that offer quarterly insights on plan performance, including on consumer satisfaction for children’s families. Performance measure reports on HEDIS scores include data for: Childhood Immunization Status Children and Adolescents’ Access to Primary Care Practitioners Well-child visits in the Third, Fourth, Fifth, and Sixth Years of Life
Colorado	In 2013, Colorado added a well child visit “key performance indicator” to its Accountable Care Collaborative program. Providers and the entities administering the program will be able to earn incentive payments based on performance on this indicator.
Connecticut	Utilization data: Under the administrative services organization structure, services are provided on a fee-for-service basis and all claims go through the state’s Medicaid Management Information System. Reporting: Connecticut Voices for Children conducts independent performance monitoring of care delivered to Medicaid children under a contract between the Department of Social Services and the Hartford Foundation for Public Giving. Voices for Children analyzes that data collected by DSS and issues reports on a range of topics, including utilization of well-child, emergency room, and dental care. Connecticut’s External Quality Review Organization, Mercer Government Human Services, collects measures for well-child visits (3, 4, 5, and 6 years of life) and developmental screening (9, 18, and 24 month).
Delaware	No information at this time.
District of Columbia	The District requires its managed care organizations (MCOs) to compile and submit quarterly reports for HealthCheck utilization and outreach efforts. These reports are generated by MCOs using encounter data, and supplemented by other data sources.
Florida	Managed care organizations are required to report on a set of performance measures that include HEDIS measure for: Adolescent Well Care Visits Childhood Immunization Status Follow-up for Children Prescribed ADHD Medication Immunizations for Adolescents Lead Screening in Children Well-child Visits in the First 15 Months of Life Well-child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Children and Adolescents’ Access to Primary Care The measure set also includes measures defined by the state Medicaid agency, including measures of transportation timeliness and availability.
Georgia	Managed care organizations (MCOs) must select certain care elements to monitor in physician profiles; one possible element is preventive care, which includes Medicaid well-child visits.MCO contracts also require the MCO to submit an EPSDT report that, at a minimum, lists: Number of live births, Number of initial newborn visits within 24 hours of birth, and Number of members that received an initial health visit and screening within 90 calendar days of enrollment MCOs must establish internal tracking systems registering compliance with the state’s Health Check requirements. These systems must track: Initial newborn Health Check visit occurring in the hospital; Periodic and preventive/well child screens and visits as prescribed by the periodicity schedule; Diagnostic and treatment services, including Referrals; Immunizations, lead, tuberculosis and dental services; and A reminder/notification system. External Quality Review reports track several performance measures related to Health Check Services, including children’s access to primary care providers, well-child visits, and others.
Hawaii	Managed care plans are required to submit encounter data at least once per month. Electronic Data Reporting Hawaii Medicaid is in the process of implementing an online EPSDT reporting system that allows providers to submit data electronically. The system will capture information on vaccines, screenings, and referrals, and would provide prompts and alerts for services that are due.
Idaho	Idaho Medicaid has reporting requirements for two of its initiatives: the Idaho Medical Home Collaborative multi-payer pilot and its ACA Section 2703 State Plan Amendment. Practices participating in the Medical Home Collaborative must achieve National Committee for Quality Assurance (NCQA) PCMH recognition and report on measures in three categories: clinical measures, including chronic disease outcome measures and preventive measures; practice transformation; and patient and provider/staff satisfaction. Idaho Medicaid is using claims and chart-based process and outcome measures as endorsed by the National Quality Forum to track progress on six goals for the state’s health home program. Two of these are specific to children: Improve care for asthma among adults and children. Increase preventive care for children.
Illinois	Illinois collects data on several Healthcare Effective Data and Information Set measures pertaining to children, including measures of well-child visits, developmental screenings, and immunizations. The state’s Medicaid agency also collects and reports data on a number of the CHIPRA children’s health quality measures (see the table on page 19 of the state’s annual report on Medicaid for FY10-12). The majority of CMS-416 data collected in Illinois comes from claims data. The state processes the data through its Medicaid Management Information System (MMIS) and then sends it to a Enterprise Data Warehouse, an analysis tool within Illinois’ MMIS. Illinois uses the CMS-416 data to track and show participant rates, and publishes the data online for others to use. Oral Health The state’s Medicaid dental contractor, DentaQuest, processes all dental claims and sends the Department of Healthcare and Family Services a weekly file of all services that were adjudicated during the week. The state then puts this information through its MMIS system for re-adjudication of the data to ensure that all edits are met.
Indiana	Managed care organizations (MCOs) are required to collect quality measurement data on areas that include: EPSDT services, immunization rates, and blood lead testing. MCOs also offer performance bonuses to providers based on HEDIS measures as part of the Indiana 2014 Performance Bonus Program for Hoosier Healthwatch. Among the measures determining performance bonuses are: Annual well-child visits: 3-6 years of age Annual well-adolescent visits: 12-21 years
Iowa	Iowa uses its fee-for-service claims payment system to keep track of services for mandatory reporting to CMS. The state also analyzes its CMS Form-416 data at a county-by-county level and uses this data to pinpoint where in the state Medicaid-enrolled children face issues in accessing dental and physical health services. Primary Care Case Management As outlined in the procedural guide for the primary care case management (PCCM) program, known as the Medicaid Patient Access to Services System (MediPASS), Iowa Medicaid provides participating providers with information on the utilization of enrolled families and children on a quarterly basis. Providers may also receive a Quarterly Member Utilization Exception Report. Quality Assurance/Utilization Reviews are performed by Medicaid on a quarterly basis to collect and analyze provider information on 24-hour access, appointment access for urgent and routine care, and proper use of referral numbers. Child and Adolescent Reporting System The Title V child health agencies that deliver many services under the Medicaid benefit all use a Child and Adolescent Reporting system electronic health record to record the provision of services. The system provides a clinical record for all children receiving services at one of the agencies, not only children enrolled in Medicaid. Behavioral Health Currently, Medicaid pays for general developmental screens, social-emotional developmental screens, and autism screens all under the 96110 CPT code. Iowa uses claims data to, among other things, produce the CHIPRA core measure on developmental screening. Contract language for the Iowa Plan for Behavioral Health requires the behavioral health organization (BHO), Magellan Health Services, to submit monthly or quarterly reports (depending on the specific indicator) to the Department of Public Health and the Department of Health Services on child-specific measures, including 7-, 30-, and 90-day mental health readmission, integrated services and supports, involuntary hospitalizations, and improvement in the psychosocial domain of Medicaid children and adolescents who are receiving services.
Kansas	KanCare, as part of its Section 1115 Waiver, has a significant quality measurement component. Additionally, each of the three KanCare health plans and their subcontractors are required to obtain accreditation by the National Committee for Quality Assurance. In terms of Evaluation Design of its 1115 Waiver, Kansas incorporates different measures from the KanCare contracts related directly to the goals of the KanCare program. This includes quantitative measure such as: Healthcare Effectiveness Data and Information Set (HEDIS); mental health measures including Serious Emotional Disturbance (SED) Waiver reports and National Outcome Measures; Substance Use Disorder measures; and Case Record reviews. Kansas also includes a number of qualitative reports such as: Consumer Assessment of Health Plans Survey (CAHPS), Substance Abuse Disorder consumer surveys, Provider Surveys, and other reports/surveys. KanCare also has a pay for performance (P4P) program that ties payment to six performance measures related to operations for the first year, and fifteen performance measures related to quality for the later years. Among the fifteen quality measures that Kansas will be tying to payment are: well-child visits in the first 15 months of life and preterm births.
Kentucky	Kentucky Medicaid managed care contract language requires contractors to submit encounter data for each of their members who receive EPSDT services, as well as quarterly and annual reports on EPSDT services for CMS reporting.
Louisiana	Louisiana contracts with IPRO to serve as an External Quality Review Organization (EQRO) to monitor the different managed care plans. The results form IPRO’s analysis are available on the Louisiana Department of Health and Hospitals Bayou Health page. IPRO tracked plan compliance with contract requirements including those related to care coordination, screening and referral services for EPSDT beneficiaries, and the integration of behavioral health and referral services as defined by the EPSDT benefit. Additionally, each CCN operating under the managed care plans are required to report on different performance measure sets including AHRQ and CHIPRA measures.
Maine	Improving Health Outcomes for Children (IHOC) The Improving Health Outcomes for Children (IHOC) grant works to: Collect and report on the use of evidence-based child health quality measures; Expand Health Information Technology to improve the flow of child health data; and Promote a collaborative child health learning environment. Under the grant, Maine developed a Master List of Pediatric Measures that builds upon the CHIPRA Initial Core Set of Children’s Health Care Quality Measures. This list includes measures on topics such as well child visits, general development and autism screening, oral health, and behavioral health. Primary Care Provider Incentive Payment (PCPIP) Program Maine’s Primary Care Provider Incentive Payment (PCPIP) program includes child-specific quality and access measures on which participating providers are measured, including: Percentage of members 0-20 years of age who had one or more EPSDT procedure(s) during the reporting period; Well-child visits in the first 15 months of life; Follow-up care for children prescribed attention-deficit/hyperactivity disorder medication; Adolescent well care visits; and Children aged 1-3 who had a developmental screening during the measurement year.
Maryland	The state issues report cards on Medicaid managed care organizations (MCOs) that compare MCOs on several metrics, including “Keeping Kids Healthy.” This domain includes measures of: Immunizations Well-child visits to physicians and dentists Lead testing
Massachusetts	No information at this time.
Michigan	The Michigan Department of Community Health publishes Statewide Aggregate Reports of Medicaid health plan performance on HEDIS measures. These measures include metrics in a child and adolescent care domain, including: Childhood Immunization Status Immunizations for Adolescents Well-Child Visits in the First 15 Months of Life (Six or More Visits) Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Adolescent Well-Care Visits Lead Screening in Children Appropriate Treatment for Children With Upper Respiratory Infection Appropriate Testing for Children With Pharyngitis Follow-Up Care for Children Prescribed ADHD Medication The department also collects high-level data into a Health Plans Quality Checkup document for consumers. Medicaid health plans are given “below average,” “average,” or “above average” ratings on five key indicators. A Keeping Kids Healthy indicator measures how well “children in the plan get regular checkups and important shots that help protect them against serious illness.”
Minnesota	Child and Teen Checkups (C&TC) Reporting The state uses specialized software to track C&TC-enrolled children and to assist C&TC Coordinators and outreach staff in conducting and documenting outreach and follow-up activities. The software generates and tracks standard mailings to the children and families about the program as well as information on how to access services. Once a month, updated information on enrolled children and families is collected from the state’s Medicaid Management Information System (MMIS) and MAXIS, a computer system used in Minnesota to determine eligibility for public programs. Encounter data is also collected on a monthly basis from health plans. This information is then compiled and distributed to users of the software, who can update beneficiary information such as name, address, and language.
Mississippi	Billing Only enrolled Mississippi Cool Kids providers are permitted to bill for EPSDT screens, and these providers must use an EPSDT modifier when billing. Reporting Requirements Mississippi’s coordinated care program, MississippiCAN, includes EPSDT-specific contract language for participating coordinated care organizations (CCOs)—capitated health plans with specified care management responsibilities—on data and reporting. The state Medicaid agency evaluates EPSDT claims data and sample medical records to determine CCO compliance with EPSDT service provision requirements. CCOs are required to achieve a screening rate of 85% and an immunization rate of 90%; those who do not meet these rates are required to refund Mississippi Medicaid $10 per enrollee for all enrollees under age 12 months. Medicaid publishes the screening rates of CCOs that achieve rates of 85% or greater for the Medicaid population and the medical community in applicable service areas. CCOs are also required to make these screening rates known to potential enrollees in educational and marketing presentations. MississippiCan CCOs also supply the Department of Medicaid with encounter data that includes claims payment for EPSDT services. In addition to the encounter data, the CCOs must submit quarterly 416 reports that indicate whether the CCOs have met the screening and immunization standards described above.
Missouri	No information at this time.
Montana	No information at this time.
Nebraska	Managed care contracts specify that “improvement in child/adolescent care” are an objective of the Nebraska Health Connection managed care program and: “Data for the measures used in this approach are derived from HEDIS and HEDIS-like measures of data collection for performance measures, encounter data, quarterly and annually data reporting required of the contractors, and client satisfaction surveys. Other sources of data may include findings from the External Quality Review (EQR) Technical Report, evaluation results of improvement initiatives, and results from on-site visits.”
Nevada	Nevada is modifying its Medicaid Management Information System (MMIS). As part of a long-range effort, EPSDT staff have developed an electronic version of an EPSDT screening form. Eventually, the form will be completed online and the information will be fed directly into the MMIS system. Managed care organizations (MCOs) in Nevada are required to report on child-specific performance measures. They can receive incentive payments (see page 11) based on performance on Health Effectiveness Data and Information Set (HEDIS) measures for well-child visits and childhood immunization status. They must also report on a non-incentive measure for children and adolescents’ access to primary care practitioners.
New Hampshire	Managed care organizations in New Hampshire are required to report on measures sets that include: CHIPRA Child Quality Measures NCQA Medicaid Accreditation and HEDIS/CAHPS Measures CAHPS measures that include for children with chronic conditions In the first year of operation of the managed care program, the Adolescent Well Care Visits HEDIS measure is a performance incentive measure for managed care organizations.
New Jersey	New Jersey has in place a performance-based incentive program for managed care organizations (MCOs). MCOs earn back an amount withheld from their capitation payment based on performance on maternity care and prevention screening measures; the latter category includes a measure of the percentage of Medicaid enrollees aged 3-17 who have evidence of a body mass index percentile documentation. MCOs must also report annually on a set of HEDIS performance measures that include: Childhood Immunization Status (requires Member Level Data) Immunizations for Adolescents Well-Child Visits in First 15 Months of Life Well-Child Visits in the 3rd , 4th , 5th and 6th Years of Life Appropriate Testing for Children with Pharyngitis Adolescent Well-Care Visits Follow-Up Care for Children Prescribed ADHD Medication Child and Adolescent Access to Primary Care Practitioners Lead Screening in Children
New Mexico	The New Mexico Human Services Department (HSD) completes the CMS Form-416, using encounter data submitted by managed care organizations (MCOs) and the state’s fee-for-service third party administrator. Managed care organizations in the state transmit encounter data to the HSD electronically on a weekly basis. Data and system requirements for Medicaid managed care organizations are laid out in a MCO/CSP Systems Manual. The state’s Medicaid Management Information Systems edits the incoming data: the system verifies the validity of the recipient, as well as the validity of the diagnosis and the procedure. Data from fee-for-service claims and from managed care encounter data is housed together in the same database. However, each claim is marked as fee-for-service or managed care inside the data warehouse and tagged with information identifying the specific managed care organization that submitted it. New managed care contracts under Centennial Care require that MCOs use the most recent version of the CAHPS Adult and Child Survey Instruments, including the Children with Chronic Conditions to assess member satisfaction as part of Health Effectiveness Data and Information Set (HEDIS) reporting requirements and report on them to the Human Services Department. The contracts also include performance measures that pertain to Medicaid services for children, such as a measure of the percentage of members ages 5-11 and 12-18 who are identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.
New York	Reporting on quality of services for children Medicaid officials in New York rely on a combination of National Committee for Quality Assurance (NCQA) Health Effectiveness Data and Information Set (HEDIS) measures and additional measures developed by the state—together known in New York as the Quality Assurance Reporting Requirements (QARR)—to monitor the quality of care provided by Medicaid MCOs. Several child-specific HEDIS measures are included in required reporting under New York’s QARR, including measures for well-child visits in the first 15 months of life, well-child visits in the 3rd, 4th, 5th, and 6th year, and adolescent well-care visits. This data is used to issue MCO-specific performance reports. The MCOs submit person-specific data on an annual basis that the Medicaid agency can use to analyze the results by race and ethnicity, location, and Medicaid coverage group. The Medicaid agency offers a managed care reference guide on encounter data submissions to provide MCOs with additional information on the process. Collecting data for the Form CMS-416 New York requires MCOs to submit encounter data on physical health, mental health, and (where applicable) oral health to the Medicaid agency. Data elements included in encounter data include procedure codes and are listed in the “MEDS II Data Element Dictionary.” Each month Medicaid-contracted MCOs submit electronic encounter data. This data, along with claims submitted through the fee-for-service Medicaid system, is used to populate the Form CMS-416. Claims data for dental services or services provided to children who are not enrolled in managed care is submitted to eMedNY, the Medicaid program’s claims processing system. Managed care encounter data is also used to calculate risk-adjusted capitation rates, giving managed care plans a financial incentive not to underreport data. Oral Health Medicaid uses fee-for-service claims data and encounter data from MCOs to determine the number of sealants placed.
North Carolina	Community Care of North Carolina (CCNC) maintains an Informatics Center in connection with the Division of Medical Assistance (DMA), the Office of Rural Health and Community Care (ORHCC), and the Centers for Medicare & Medicaid Services (CMS). The Informatics Center contains health care claims data provided by Medicaid and includes a Case Management Information System that is used by the CCNC care managers to help coordinate the care of Medicaid recipients, including children (for more information see Care Coordination). North Carolina, via the DMA and ORHCC, was awarded $9.2 million dollars to work on three of the five categories of the CHIPRA Quality Demonstration Grant. North Carolina’s CHIPRA grant will experiment with new and existing quality measures for children, promote health information technology as a tool for the delivery of care to children, and create and evaluate models that will improve the delivery of care while demonstrating impact on health, quality, and cost.
North Dakota	Providers are encouraged to use the MCH/Health Tracks Pediatric Assessment Form to meet documentation requirements. These requirements can also be met using an internal form as long as the information contains all of the components listed in the Health Tracks Service Requirements. Documentation requirements include each component of a well-child screen under the EPSDT benefit.
Ohio	Appendix M of Ohio’s managed care contracts specify minimum performance standards on select quality measures. Several child-specific measures specified in the contracts are NCQA Healthcare Effectiveness Data and Information Set (HEDIS) metrics, including measures of child and adolescent access to primary care and number of child and adolescent well-care visits. The contracts also gauge performance based on children’s rating of a health plan (in a CAHPS survey) and use a CHIPRA core set measure of asthma-related emergency room visits.
Oklahoma	No information at this time.
Oregon	The Oregon Health Authority is required to regularly report to the Oregon Health Policy Board, the Governor, and the legislative Assembly on its progress in implementing Coordinated Care Organizations (CCOs). Oregon has also released a set of Year 1 CCO Accountability Metrics for reporting purposes in the first year, which include measures of developmental screening by 36 months and mental health assessments for children in Department of Human Services custody. Additionally the Oregon Health Authority (OHA) will collect CMS CHIPRA Core Measures, including: Childhood & adolescent immunizations Well child visits Appropriate treatment for children with pharyngitis and otitis media Annual HbA1C testing Utilization of dental, emergency department care (including emergency department visits for asthma) Pediatric Central Line-Associated Bloodstream Infections Follow up for children prescribed ADHD medications The Oregon Health Authority is also tracking 17 CCO incentive metrics. The incentive metrics include several that are specific to children: Adolescent well-care visits Developmental screening in the first 36 months of life Elective delivery Follow-up care for children prescribed Attention Deficit Hyperactivity Disorder (ADHD) medication. Mental and physical health assessment within 60 days for children in DHS custody
Pennsylvania	No information at this time.
Rhode Island	No information at this time.
South Carolina	South Carolina’s Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant) is supporting work to collect CHIPRA quality indicator data from 18 pediatric practices,
South Dakota	South Dakota’s Medicaid program relies on fee-for-service claims submissions to gather data on the EPDST benefit. Dental claims are processed by Delta Dental, which transfers claims data back to the Department of Social Services The Department of Social Services offers providers a list of well-child billing codes on its website that crosswalks each screening code to the state’s EPSDT periodicity schedule. The state collects effectiveness of care measures to monitor PCCM providers on a number of clinical standards including immunization status, asthma control, and follow-up after hospitalization for mental illness. The state also utilizes the complaint resolution process, recipient surveys, twenty-four hour access surveys, and caseload monitoring to identify quality and (or) access issues among providers.
Tennessee	Tennessee is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn, including adolescent well-care visits and well child visits in the first 15 months of life.
Texas	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.
Utah	No information at this time.
Vermont	No information at this time.
Virginia	Virginia is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn including, adolescent well-care visits and well child visits in the first 15 months of life.
Washington	Washington collects a variety of NCQA HEDIS measures from Medicaid managed care plans, including measures pertaining to children. This includes measures of childhood and adolescent immunization status, well-child visits, and child access to primary care providers. Managed care organizations in Washington are required to implement a performance improvement plan if NCQA HEDIS measures of well care visits for children and adolescents fall below set benchmarks.
West Virginia	Medicaid managed care organizations in West Virginia are required to report to the state quarterly on: EPSDT screening and referral rates, Well-child visit rates Dental visits, and Immunization rates.
Wisconsin	Managed care contracts in Wisconsin require that enrolled children receive at least 80% of the expected number of HealthCheck screens; managed care organizations that fail to meet this metric face recoupment of some of their capitation payments.
Wyoming	No information at this time.