Across the country, every state is taking action to ensure accessible coronavirus (COVID-19) testing and treatment, engaging in cross-agency collaboration, employing unique approaches to testing, and preventing price-gouging on drugs and medical supplies. Here’s a sampling of what states are doing.
Testing and Quarantine Initiatives
Washington State: With the most coronavirus infections in the country, Washington is replicating drive-through testing practices used in South Korea and Great Britain. Employees of the University of Washington’s medical system can now get tested for coronavirus and influenza A and B without leaving their cars. The system’s medical center in Seattle turned a hospital garage lot into a drive-through clinic that can test a person every five minutes. People with symptoms register online and get an appointment for testing and typically get results within a day or so. Individuals don’t have to sit in a waiting room where they spread or contract the infection, and the ventilation of the open air reduces possible exposure for health care workers. The university also plans to work with the Bill and Melinda Gates Foundation to provide coronavirus testing kits that patients can use at home.
The state has also purchased a hotel and is converting a former youth detention center to house individuals and families placed in quarantine.
Rhode Island: Five experts from the US Centers for Disease Control and Prevention’s epidemic intelligence service are “embedded” with state health officials, according to Rhode Island’s Department of Health director to help the state build its response capacity. Specifically, the CDC officials are helping trace those who have come in contact with people who have tested positive for the virus since returning from a trip to Europe. The trip, by students and staff of a Catholic high school in Pawtucket, stopped in Italy. Gov. Gina Raimondo has also set up a 24/7 public hotline staffed with health care professionals for those with questions about the coronavirus or how to self-quarantine.
Nationwide, many states are ramping up their cross-agency state and local collaboration to spearhead efforts to control the infection by ramping up coordination among all state and local agencies. As one example, Maryland’s Institute for Emergency Medical Services Systems and its Department of Health, in partnership with the state’s hospital association, are coordinating around surge planning, including ambulance re-routing plans, suspension of voluntary admissions, and developing enhanced methods of medical monitoring for home-bound patients with mild to moderate symptoms.
Medicaid, Insurance Coverage, and Family Leave
Several states have issued some type of directive or emergency order for the insurance plans they regulate. Washington State specifically noted that short-term plans must abide by the order. States operating state-based insurance marketplaces also encouraged residents to check their insurance exchanges’ websites to see if they could be eligible for Medicaid or a special enrollment period.
Kentucky’s Medicaid enrollees will no longer be required to get prior authorizations to be tested or treated for coronavirus and, via an executive order, the state’s Department of Insurance would require private insurers to eliminate copays and other charges.
Michigan Gov. Gretchen Whitmer announced the state Medicaid program is waiving all copays and cost-sharing for testing and health care treatment related to the coronavirus.
Washington State Insurance Commissioner Mike Kreidler issued an emergency order to state health insurers requiring them to waive copays and deductibles for any consumer requiring testing. Insurers also must allow a one-time early refill for prescription drugs, and suspect prior authorization requirement for treatment or testing. In addition, if an insurer does not have enough medical providers in its network to provide testing and treatment, it must allow enrollees to be treated by another provider within a reasonable distance at no additional cost.
Nationwide, Blue Cross Blue Shield Association (BCBS) announced its 36 BCBS companies will waive prior authorizations and increase coverage for COVID-19 and increase access to prescription drugs, enhanced telehealth, and other clinical support systems. The actions will apply to fully-insured, individual, and Medicare members. It also expressed a commitment to working with state Medicaid and Children’s Health Insurance Program agencies to ensure that beneficiaries have access to needed testing and services.
California Gov. Gavin Newsom has directed commercial and Medi-Cal (Medicaid) health plans to waive cost-sharing for all medically necessary screening and testing related to the coronavirus. The California Employee Development Department announced that those unable to work due to exposure to COVID-19 may file a disability insurance claim and those caring for a family member exposed to the virus may apply for paid family leave.
Nevada Gov. Steve Sisolak adopted an emergency regulation to ensure residents with health insurance policies regulated by the state Division of Insurance can obtain medical services and prescriptions related to the coronavirus at normal costs. This emergency regulation prohibits insurers from imposing out-of-pocket costs for a provider, urgent care center, or emergency room visit testing. Insurers also cannot charge Nevadans for the test. Health insurers must provide information on patients’ available benefits, possible telehealth services and preventative measures related to the novel coronavirus.
New York Gov. Andrew Cuomo announced a directive requiring health insurers to waive cost-sharing associating with novel coronavirus testing, including emergency room, urgent care, and office visits. In addition, New Yorkers receiving Medicaid coverage will not have to pay a copay for any testing related to COVID-19. Health insurers must also keep people informed about their available benefits, offering telehealth services when possible.
California Attorney General Xavier Becerra issued a price gouging alert, reminding residents that the state’s anti-price-gouging law protects people impacted by an emergency from illegal price gouging on drugs, medical supplies, food, gas, and other essential supplies.
The Centers for Medicare & Medicaid Services (CMS) has awarded the Lewin Group and its partners, which includes the National Academy for State Health Policy (NASHP), a seven-year contract to support implementation and monitoring for CMS’ Integrated Care for Kids (InCK) Model.
Launched in January 2020, this model is part of CMS’s strategy to fight the opioid crisis and address its impact on vulnerable Medicaid and the Children’s Health Insurance Program (CHIP)-covered children and their caregivers. The InCK Model aims to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable payment models to coordinate physical and behavioral health care with services to address health-related needs. InCK funding will provide Connecticut, Illinois (2 awards), New Jersey, New York, North Carolina, Ohio, and Oregon with the flexibility to design interventions for their local communities that align health care delivery with child welfare support, educational systems, housing and nutrition services, mobile crisis response services, maternal and child health systems, and other relevant service systems. By bringing together medical, behavioral, and community-based services, InCK strives to reduce fragmentation in service delivery and expand access to care for children and youth.
The Lewin Group, NASHP, and the other team members will support implementation of the InCK Model through technical assistance, program monitoring, measuring awardees’ progress on critical program milestones and outcomes measures, data collection and analysis, and critical feedback loops to support awardees’ work toward their goals.
“The Lewin Group is excited to contribute to this innovative approach that breaks new ground in the delivery of child- and family-centered care and the development of pediatric alternative payment models. We look forward to working with CMS to positively impact of the health of the next generation,” said Lisa Alecxih, Lewin Chief Capabilities Officer.
“NASHP is delighted to partner with the Lewin Group to support this innovative CMS InCK model,” said Trish Riley, NASHP’s executive director. “We bring to this work our decades of expertise in state health care delivery system design, cross-sector partnerships, payment reform, and the unique needs of children and their families.”
The Lewin Group is an established leader in health care and human services policy research, analytics and consulting at the federal and state level.
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.
Introduction by Trish Riley, NASHP Executive Director
For decades, the proposal to convert the Medicaid program from an open-ended entitlement to capped funding as a “block grant” has been a fiercely argued policy, legal and ideological debate. Opponents contend that capped financing violates the foundation of Medicaid as an entitlement and would severely impair states’ abilities to address needs because there is no provision to adjust for medical and prescription drug cost increases nor to accommodate natural disasters or economic downturns that cause more people to need Medicaid’s protections.
Proponents argue that a block grant, much like the Children’s Health Insurance Program, provides more flexibility to states to design their programs and constrain cost growth. Here, the Trump Administration takes a new tact, using the Section 1115 waiver authority, to test the viability of a block grant concept on a subset of Medicaid enrollees.
The proposal does not address rising health care costs but does contain a “special circumstances adjustment” that could address unforeseen circumstances that are out of a state’s control. The guidance could encourage those states that have not expanded Medicaid eligibility to childless adults eligible under the ACA to do so. It could also allow states that have expanded eligibility to roll back current levels of coverage.
Because Section 1115 waivers are designed to test innovation in the Medicaid program, the Administration proposes a means to test the efficacy of a block grant, limiting its reach to a subset of Medicaid enrollees. NASHP’s Anita Cardwell walks us through what CMS’ new rules are proposing and notes that legal challenges are inevitable. Should the Administration succeed in approving these waivers, rigorous, independent evaluation will be critical for policymakers to assess its impact.
New guidance from the Centers for Medicare & Medicaid Services (CMS) would allow states to receive part of their federal Medicaid funding through a capped financing model. Through CMS’ Healthy Adult Opportunity (HAO) option, states would be able to seek approval through a Section 1115 waiver to accept a set amount of federal Medicaid funding for certain eligible adults.
While the option is limited to a specific portion of the Medicaid-eligible population, this is a significant change from Medicaid’s current structure in which the program operates as an open-ended entitlement and states receive federal matching payments based on their Medicaid program spending without a predetermined funding limit. The following describes some of the key elements of the HAO model.
The HAO model targets adults under age 65 who are not eligible for Medicaid due to:
- Disability or need for long-term care services and supports,
- Eligibility under a state plan designation.
States could use the model to cover adults who would be eligible through the Affordable Care Act’s (ACA) Medicaid expansion, but states will also be permitted to use the initiative to cover other groups of individuals. For example, states could use the HAO demonstration to provide coverage for:
- Individuals with severe mental illness;
- Those needing substance use disorder treatment; or
- Individuals with HIV/AIDS.
States will also be allowed to set the income eligibility standard under the demonstration, and the guidance permits states to require an asset test for individuals seeking coverage under the HAO model. However, for states to receive the enhanced federal match available for the ACA Medicaid expansion population, states will need to have an income standard of at least 133 percent of the federal poverty level, will not be able to apply an asset test, and will not have the ability to cap enrollment. But the guidance does not explicitly indicate that enrollment cannot be capped if a state agrees to accept a lower match rate.
States that pursue this new option will receive a capped amount of federal Medicaid funding for the populations covered under the HAO model. States’ spending would be matched by the federal government, but only up to a certain limit, and states would assume the risk for any expenditures for the demonstration population that exceed the defined amount. CMS is providing states with two financing options to select — an aggregate cap model or a per capita cap model.
States that cover new populations that they lack data for, such as the expansion population, will initially need to use the per capita cap model. CMS will calculate a per enrollee base amount for each eligibility group that is included in the demonstration using previous year expenditures, or if those are not available then it will be based on national and regional expenditures. CMS will trend the base amount for each group forward to the demonstration year, multiply each of these amounts by the number of enrollees for that year to account for changes in enrollment, and then total them to establish an overall per capita cap.
Under the aggregate cap model, CMS will determine a base year amount using prior expenditures based on the populations and services included in the demonstration, and will trend this amount forward to each demonstration year, but without consideration of enrollment changes. If a state would like to pursue the aggregate cap option for a population that has not been covered previously, they must first operate their HAO demonstration under the per capita cap model for at least two years. The guidance requires states using the aggregate cap model to annually spend at least 80 percent of their aggregate cap amount on health services.
Unlike the per capita cap model, states that use the aggregate cap approach that are able to keep costs below their annual cap and meet certain reporting and performance criteria may be eligible to reinvest a part of the savings into their Medicaid programs. These reinvestments must be determined to be likely to promote Medicaid program objectives and could include providing Medicaid services for groups not covered by the state plan, paying for services that are not in the state plan – such as pre-vocational services, initiatives to improve care quality and access, and allowable benefits and services designed to address certain social determinants of health.
In some cases, states could use the shared savings to support existing state-funded programs, such as a statewide tobacco cessation program. CMS also notes that states can use any annual savings to offset expenditures that exceed the cap for the subsequent three demonstration years. Also, while the guidance indicates that CMS will make changes to the base amount or annual caps to “adjust for state flexibilities that could significantly affect enrollment to ensure that states do not achieve savings from disenrolling individuals,” it does not provide further details about how this type of adjustment would be implemented.
Rather than the traditional Medicaid benefit package, states that opt to pursue the HAO initiative will be able to structure a benefit package that aligns with private market coverage, although they will need to include at a minimum the benefits in the Essential Health Benefit (EHB) package. This means that states will not be required to provide services such as non-emergency medical transportation (NEMT) and coverage of early and periodic screening, diagnostic and treatment services (EPSDT) for individuals ages 19 to 20 included in an HAO demonstration. However, states could opt to provide these services, along with others, in addition to EHBs.
Prescription Drugs and Medicaid Drug Rebate Program
To address prescription drug costs, the HAO option will permit states to have a closed drug formulary that aligns with formularies provided through exchange coverage in the commercial health insurance market. The guidance stipulates that states provide coverage of certain drugs for individuals with HIV or behavioral health conditions.
However, although states would be allowed to omit coverage of certain prescription drugs, states would still be able to receive rebates through the Medicaid Drug Rebate Program. States could also make arrangements with manufacturers for supplemental rebates by including the manufacturers’ drugs on the state formulary.
Other Key Elements of the HAO Model
In its guidance, CMS indicates that it is “offering flexibilities currently available to states in a comprehensive suite of pre-packaged waiver authorities.” CMS notes that although its intent is to provide states with a “menu” of program design options, each demonstration will be approved on a case-by-case basis. States will be able to implement program elements to the populations covered by the demonstration, such as:
- Charging higher premiums and cost-sharing requirements not allowed under traditional Medicaid for most individuals in the HAO model (individuals’ aggregate out-of-pocket costs could not be more than 5 percent of income, measured on a monthly or quarterly basis), and suspending enrollment for nonpayment;
- Including conditions on eligibility, such as work requirements;
- Choosing to waive retroactive coverage and hospital presumptive eligibility requirements; and
- Conducting eligibility renewals before the standard 12-month renewal period to align with the open enrollment period of exchanges.
States operating under an HAO demonstration will also be allowed to implement certain changes without additional federal approval, unless the change has the potential to “substantially” impact enrollment. These could include programmatic changes to benefits, premiums, and copayments, or certain administrative modifications, such as changes in provider payment rates.
States that already have an approved 1115 waiver to cover populations that would be eligible for coverage through the HAO model would be permitted to transition those waivers into HAO demonstrations – for example, a state with an existing waiver to provide coverage to the Medicaid expansion population group.
Delivery Systems, Payment Models, and Managed Care
States seeking to participate in the HAO demonstration will be encouraged to implement payment and delivery system reforms to “improve the effectiveness of coverage, improve health outcomes and reduce the cost of care.” To align with Medicare and commercial payers, CMS suggests that states consider incorporating arrangements and strategies like ones established through the Center for Medicare & Medicaid Innovation (CMMI) that have demonstrated promising outcomes.
States will generally be allowed to use any mix of fee-for-service and managed care delivery systems, and as long as certain guidelines are met states will have the ability to modify these arrangements during the demonstration. If states are serving the HAO demonstration population through managed care, they will generally have to comply with specified statutory requirements related to beneficiary protections and decision making, access to services, and assessing program administration and delivery system quality. But states will be allowed to suggest their own strategies for ensuring network adequacy, access to care, and availability of services, and will also not have to request prior federal approval of managed care rates.
Monitoring and Evaluation
States participating in the HAO demonstration will be required to have a written strategy to evaluate care access and quality, and the health outcomes of enrollees, using measures from the CMS Adult Core Set. CMS is also expecting HAO demonstration states to report on certain performance measures related to enrollment, retention, access to care, and financial management on a quarterly basis. Also, participating states are expected to have an independent assessor provide suggestions for changes that could be made during the demonstration period.
Legal challenges are expected because, as noted by many analysts and highlighted in a recent letter from some House Democrats, there are questions about whether CMS has the ability to use the 1115 authority to change Medicaid’s financing in this way. The HAO demonstration model may also be challenged on the grounds that it does not promote the overall objectives of the Medicaid program.
States considering the model will need to carefully weigh the potential implications, because choosing to accept limits on federal Medicaid funding — even for only a portion of the program’s eligible individuals — introduces financial risk for states. For example, state Medicaid program spending regularly fluctuates as economic shifts occur, new treatments become available, or states experience public health emergencies or natural disasters. While the guidance does contain a “special circumstances adjustment” that would allow states to propose updates to address these types of situations, this would require states to undertake additional negotiations with CMS.
The HAO model could be appealing to the 14 states that have not implemented Medicaid expansion because it would provide them with greater flexibility to manage their Medicaid program benefits and impose certain enrollee requirements. If these states do pursue the HAO initiative to expand Medicaid, while more individuals would gain health coverage and it would meet EHB standards, the coverage provided would be less robust than that provided to traditional Medicaid expansion enrollees and individuals would likely face other enrollment restrictions. One of the 14 non-expansion states that has expressed interest in this approach is Oklahoma, whose governor announced his intention to pursue the concept to expand Medicaid with the inclusion of work requirements and premiums. However, his proposal could be in conflict with Oklahoma voters’ views, if they pass an initiative on the ballot this year to implement traditional Medicaid expansion. Another state, Tennessee, already has a proposal pending with CMS that requests to implement a “modified block grant” model that would allow for federal funding increases if enrollment rises, along with requests for certain program flexibilities. However, Tennessee’s plan differs from the recent guidance as it does not propose to implement the ACA’s Medicaid expansion, and instead would apply the block grant funding model to enrollees who are low-income parents, children, and individuals with disabilities.
The governor of Alaska – a state that has already implemented expansion – has indicated interest in seeking a block grant financing model and commissioned a study on the issue, so there may be interest in the HAO demonstration among policymakers there.
NASHP will continue to track and report on state activity related to the HAO model in the coming months.
Starting in early 2020, Idaho will launch a new value-based payment model that will compensate federally qualified health centers (FQHCs) and other providers based on how much they improve the cost and quality of care delivered to Medicaid enrollees. The agency plans to sign contracts to implement the model in January, with implementation beginning July 1, 2020.
Both FQHCs and other types of providers have expressed interest in participating in this value-based model.
Idaho has operated a Medicaid Primary Care Case Management (PCCM) program since 1993 and has worked to advance patient-centered medical homes (PCMHs) since 2008, when the Governor’s Select Committee on Health Care recommended PCMH implementation as a priority. In 2016, Idaho Medicaid launched its Healthy Connections program, which blended the two initiatives. In 2017, the Medicaid agency began working to incorporate value-based payment into Healthy Connections. The agency submitted a State Plan Amendment (SPA) in October 2019 to secure Centers for Medicare & Medicaid Services (CMS) approval of its new payment model, which awards payment to FQHCs and other providers based on how much they improve costs and quality of care provided to Medicaid enrollees.
How Healthy Connections Value Care Operates
In the Healthy Connections program, primary care providers (PCPs) are paid on a fee-for-service basis, plus a per member per month (PMPM) care management fee. Care management fees range from $2.50 to $10 and vary based on the characteristics of the PCP’s practice and the patients attributed to the PCP. Specifically, PCPs qualify for one of four reimbursement tiers based on their capabilities – those who qualify for higher tiers receive higher care management fees. The types of capabilities considered in tier assignment include being able to both send and receive data from the state health data exchange or offering extended hours of service to patients. Also, the PMPM care management fee is higher for beneficiaries with disabilities or special needs.
The Healthy Connections Value Care (HCVC) program will operate under Section 1905(t) of the Social Security Act and builds on the structure of the Healthy Connections program. Participating PCPs will continue to receive both fee-for-service payments and care management fees. Participating PCPs, including FQHCs and rural health centers (RHCs), will participate as one of two types of organizations:
- Accountable primary care organizations are primary care clinics (or groups of clinics) that serve at least 1,000 Medicaid enrollees. Clinics that wish to participate as a group must create a legal entity and sign a joint operating agreement. (Hospitals may not participate in this type of organization.)
- Accountable hospital care organizations are integrated networks of providers that include an acute care hospital and serve at least 10,000 Medicaid enrollees.
Both types of organizations (referred to collectively as value care organizations or VCOs) are expected to contain Medicaid’s total cost of care (TCOC) and improve quality for their Medicaid patients. Both types of VCOs will share in any savings or losses they generate. The specific amounts will be determined through an annual settlement process. Each VCO’s share of savings will depend on the VCO’s performance. A VCO’s share of losses will not be adjusted for performance. However, an accountable primary care organization’s liability for losses is limited to the total amount paid to the organization in care management fees. Importantly, because the model builds on the fee-for-service payment structure and limits accountable primary care organizations’ risk to the amount paid in care management fees, the model enables FQHCs to participate without placing their federally-mandated per visit payments at risk.
How Performance Determines Savings
Shared savings will be distributed to VCOs based on their performance on reducing growth in total cost of care and achieving specified quality measures goals. Idaho Medicaid chooses the measure set in conjunction with VCOs and updates the set each year. For the first year of the program, the set will include hospital re-admissions, emergency department visits, breast cancer screening, diabetes HbA1c test, well-child visits during the first 15 months, well-child visits during ages 3 to 6 years, and well-care visits for adolescents. Idaho publishes the measure specifications in its Healthy Connections website. If a measure does not apply to a practice, that measure is excluded from consideration when calculating share of savings (e.g., pediatric measures are only considered if the practice serves children). However, hospital-related measures apply to all VCOs as PCP performance affects those outcomes.
The Medicaid agency will retain 20 percent of savings produced by a VCO for administration. The VCO can earn the remaining 80 percent. The VCO will earn half of the available savings (40 percent of total savings) if it maintains quality of care, which is defined as maintaining baseline performance – the individual clinic’s performance on the measure in the previous year – on at least half of the measures in the quality measure set. This half is referred to as the efficiency pool. The other half of the available savings, referred to as the quality pool, can be earned by showing acceptable improvement on the measures in the set — improvement on more measures secures a greater share of savings. Acceptable improvements are either:
- Performing at 90 percent of the state or national benchmark established for the measure (aspirational goal); or
- Producing a 3 percent reduction in the gap between the VCO’s performance and the aspirational goal (individualized annual improvement target).
Supporting Participating Providers
Healthy Connections staff provide support to practices seeking to qualify for a higher tier. Idaho Medicaid plans to continue this support and to offer new types of support to help VCOs succeed. The state has structured other features of the program to encourage provider engagement:
Enrollment policies: On July 1, 2019, Idaho Medicaid implemented an annual fixed enrollment policy (enrollment lock-in). Previously Medicaid enrollees could change their PCCM provider at any time. Under the new policy, enrollee will have 90 days from enrollment with a PCCM provider to change providers. If an enrollee does not change providers within the 90 days, the individual will not be able to do so until that next annual enrollment period, which occurs from May 1 to June 30 of each year. Enrollees can request a change outside of the enrollment period due to special circumstances, such as moving out of the provider’s service area or poor quality of care. This new enrollment policy supports VCOs by creating a more defined and stable panel of patients for the VCOs to manage.
Information on provider performance: Once an FQHC indicates an interest in participating in the HCVC program, Idaho Medicaid generates a cost/quality dashboard showing the clinic’s current performance on both cost and quality. Idaho Medicaid also plans to establish an automated claims data portal for VCOs that will enable them to view their performance on selected qualify measures on an ongoing basis.
Community-level investments in patient health, including addressing the social determinants of health (SDOH). Idaho Medicaid plans to form and support two regional advisory groups to support the work of the VCOs in the region. Regional care collaboratives will consist of physicians who participate in the HCVC program and are responsible for identifying the health care needs in the region and seeking collaborations to improve cost and quality by addressing those needs. Community health outcomes improvement councils will be composed of community stakeholders and are responsible for identifying opportunities to improve health and wellness, including addressing SDOH in their communities.
A Medicaid Perspective
The Idaho Medicaid agency pursued VBP because it wanted to foster cost control, but not at the expense of quality. After reviewing their options, the agency chose to pursue the HCVC model because it allowed it to “begin where they are” by building on the existing PCCM payment structure. The existing Healthy Connections payment model is also well known to – and has the strong support of – PCPs. The agency developed the HCVC model with the input of both hospitals and PCPs, including FQHCs. As the agency sought feedback on successive iterations of the model, the model evolved. Early versions of the model proposed that accountable hospital care organizations would share both savings and losses, but accountable primary care organizations would share only savings. In early 2019, the agency added shared loss for the accountable primary care organizations at the suggestion of hospitals and after consultation with primary care providers.
Agency representatives report they have encountered two major challenges. The first was determining which federal authority to use to implement the model. It could have been implemented as managed care under Section 1932(a) of the act or as fee-for-service under 1905(t).* Idaho ultimately decided that 1905(t) would better support the HCVC model for a number of reasons. Implementing the model under 1905(t) enabled Idaho to avoid the need to require primary care organizations to secure agreements with the hospitals, specialists and other providers whose costs are included in calculations of savings/losses when using a TCOC approach. Idaho found the State Medicaid Director Letter on Policy Considerations for Integrated Care Models, as well as consultation with CMS staff, to be very helpful in guiding the decision. Reflecting on their experience, agency staff advise other states to consult with CMS early in the development of new VBP models. The agency also found it valuable to engage outside experts to help staff evaluate policy options and determine how each option would affect operation.
The second challenge was data. Idaho Medicaid is seeking to build a transparent model — one where participating providers can easily track their performance on cost and quality and have the information they need to improve on both. Idaho Medicaid has a small data team and has found it challenging to implement their data plans. For example, agency staff had hoped to have an automated claims data portal operating at program launch, but now anticipates that the portal will need to launch after January 2020. Similarly, the agency plans to give VCOs the information they need to make referral decisions on both quality and cost, but will not be able offer cost information at program launch.
FQHCs have already expressed interest in participating in the HCVC model as accountable primary care organizations. State officials believe the new model plays to FQHCs’ strengths in panel management and the efforts they have already made to become effective, efficient PCMHs for their patients. Officials, note, however, that in order to produce savings, FQHCs may need to change some aspects of their practice. For example, FQHCs may need to identify which providers in a group (e.g., labs or specialists) produce equally good health outcomes, but at less cost to the Medicaid program and then shift their referral patterns to increase referrals to the less-costly providers within the group.
The FQHC Perspective
FQHC representatives report they believe the new model is a move in the right direction. They expressed concerns about some specific aspects of the model, but overall, believe it will be good for their patients and that FQHCs will succeed under the new model. Idaho’s 16 FQHCs serve more than 50,000 Medicaid enrollees living in 54 communities throughout the state. In 2012, 14 FQHCs formed the Community Health Center Network of Idaho. This FQHC-owned network has engaged in VBP contracts with commercial payers since 2014 and also operates a Medicare accountable care organization. This experience and support give Idaho’s FQHCs several advantages that should help them thrive under the HCVC model. Because the network is statewide and HCVC was originally conceived as a purely regional model, initial FQHC interest in participating as a statewide network presented some challenges. But the Medicaid agency adapted the approach and the FQHCs are now interested in joining the program as accountable primary care organizations when the final VCO contract and data are available.
FQHCs also see gaining access to the Medicaid data they need to manage cost and quality as one of the greatest advantages of participation — but they also identified data as a challenge. Although the dashboards the FQHCs received from Medicaid were helpful, they did not provide sufficient detail to enable FQHCs to manage their population as they will need to under the HCVC model. The network anticipates that the Medicaid agency will soon share claims level data, and the network plans to use the data to produce patient registries, identify gaps in patient care, and inform participation decisions.
The FQHCs also identify sharing losses from the program’s inception as a challenge. They would prefer to have one to two years of shared savings-only before they had to also share losses with the Medicaid agency. Officials are confident that their strategy of increasing primary care expenditures to reduce TCOC will produce savings. However, it has been the FQHCs’ experience with other payers that it takes time to fully understand any VBP model and identify what they need to do to succeed under it. For example, because the individual FQHCs serve tend to be more high-risk than those served by other providers, FQHC representatives would prefer to test the Medicaid agency’s approach to risk-adjustment in TCOC for a year or two before being asked to live with the results of the approach. Limiting accountable primary care organizations’ risk just to the care management fee could make sharing in losses from the start of the program more palatable. However, FQHC officials remain concerned that any loss of the income from care management fees will endanger the care management programs that FQHCs have developed with that funding.
The HCVC payment model is Idaho’s next step on its path to:
- Ensure that Medicaid enrollees are served by effective PCMHs; and
- Reward practices that produce savings while maintaining or improving quality with increased payments.
Some challenges, particularly in ensuring that primary care providers have the data they need to manage their patients’ care, remain. However, stakeholders who were interviewed indicated that Idaho was on the right path and were optimistic about the new model’s success.
*A July 2012 letter from CMS indicates that states can also operate integrated programs under other federal authorities, including waivers, but Idaho eliminated these options early in program development
Acknowledgements: The National Academy for State Health Policy wishes to thank Matt Wimmer and Meg Hall of Idaho’s Division of Medicaid and Yvonne Ketchum-Ward of the Idaho Primary Care Association for their contributions. The author also wishes to thank Trish Riley and Kitty Purington of NASHP, as well as NASHP’s Health Resources and Services Administration project officer, Lynnette Araki, and her colleagues for their review and guidance. Finally, the author thanks Kristina Long of NASHP for her assistance in the preparation of this case study.
In the face of rapidly rising prices, state Medicaid programs are asserting their prescription drug purchasing power through more active oversight of the administration of prescription drug benefits. As major drug purchasers, state Medicaid programs have leverage to lower costs without action from state legislatures. Ohio, Washington, and West Virginia have recently deployed a range of strategies to curb drug costs:
- Ohio requires Medicaid managed care plans to adopt transparent, pass-through payment models with their pharmacy benefit mangers (PBMs).
- To maximize rebate potential and reduce administrative burden, Washington State is implementing a single preferred drug list (PDL) across Medicaid fee-for-service and managed care plans.
- West Virginia carved out the prescription drug benefit from its managed care contracts and now acts as its own PBM to increase oversight of drug purchasing and reduce costs.
Below is a detailed explanation of how these three states have implemented innovative purchasing strategies for their Medicaid pharmacy purchases.
Ohio Requires a Transparent, Pass-Through PBM Payment Model
A 2018 report found that PBMs retained profits of $224 million by creating a “spread” between what Medicaid paid PBMs for pharmacy claims versus what PBMs paid pharmacies. In response, Ohio mandated that managed care plans switch to contracts with transparent, pass-through payment models with the PBMs. With a transparent, pass-through model, states can ensure PBMs do not profit off this spread-pricing practice and pass through drug discounts and rebates to managed care plans. PBMs are instead reimbursed more directly through fees. Wisconsin’s state employee health plan requires a similar, fully transparent, pass-through payment model. Through this change in contract terms, Wisconsin’s per member, per month drug costs were more than 10 percent below industry averages from 2016 to 2018.
Ohio state officials report making significant changes to managed care contracts to increase transparency, reporting, and accountability pertaining to their PBM contracts and drug payments. Through enhanced reporting from managed care plans, officials have been able to confirm the successful implementation of the pass-through model. Ohio’s 2020 budget goes a step farther, requiring all managed care plans to contract with a single PBM, which will be selected by Ohio’s Medicaid department, giving the state more authority over drug purchasing.
Washington State: Implementing a Single, Standard Medicaid PDL Across MCOs
In January 2018, the Washington Healthcare Authority implemented a single PDL – a list that indicates which drugs are “preferred” by the state and do not require prior authorization. Washington’s Medicaid program transitioned from six different PDLs across managed care organizations (MCO) to one. A single PDL provides a number of advantages, including:
- Administrative ease for providers, patients, and pharmacies;
- Rebate maximization by selecting drugs with the lowest cost or maximum rebate potential;
- Rebate transparency for more accurate cost management; and
- Fewer disruptions for patients who may switch between managed care plans.
To transition to a single PDL, Washington submitted two State Plan Amendments – one for the single PDL and one to include managed care plans in its supplemental rebate contracts through a multi-state purchasing pool for drugs on the PDL. Washington also added and amended contracts with a number of vendors to ensure the Medicaid agency and managed care plans had access to the same drug data sources to allow seamless collaboration – an important detail for ensuring care coordination. Officials met with managed care plans weekly to plan and roll out the three phases of implementation, ensuring that drugs added to the PDL were clinically appropriate and cost-effective for the state and the plans. Implementation began with 27 drug classes and is expected to be complete by April 2020 with almost 400 different drug classes included in the PDL.
West Virginia: Carving Prescription Drugs Out of Managed Care
In 2017, West Virginia Medicaid began acting as its own pharmacy benefit administrator under a fee-for-service model, after carving out prescription drug benefits from its managed care contracts. To accomplish the prescription drug carve-out, West Virginia:
- Added an additional pharmacist to its staff;
- Stress-tested its existing claims processing system;
- Increased its capacity for prior authorizations; and
- Educated the public and its help desk staff about the program change.
West Virginia’s Medicaid program now covers over 550,000 enrollees through a fee-for-service model. State officials report they are able to effectively manage the pharmacy benefit and maintain care coordination across MCOs, while obtaining savings for the state. The prescription drug carve-out led to a savings of $54.5 million in 2018. Additionally, changes to the state’s reimbursement methodology during the carve-out process led to an infusion of $122 million in dispensing fees to the state’s pharmacy community.
While West Virginia is acting as its own PBM, California is carving out the prescription drug benefit from its managed care contracts and contracting with a single PBM to leverage the state’s immense purchasing power. California will use strict contracting terms to ensure greater transparency and cost savings with the contracted PBM. Michigan is currently considering a drug carve-out and legislatures in Louisiana and Nevada prompted their Medicaid programs to explore a potential carve-out of prescription drugs from managed care.
As states strengthen their oversight of drug purchasing, the National Academy for State Health Policy (NASHP) has created and will soon release a model PBM contract for states. Informed by Ohio and Minnesota’s contracts, NASHP’s model contract is designed to help states ban spread pricing and better understand rebate arrangements with their PBMs. To learn more about other administrative actions to curb rising drug costs, read the Administrative Action section of NASHP’s Prescription Drug Pricing website.
While state policymakers across the country grapple with oral health care access challenges, California, Pennsylvania, and Connecticut are incentivizing their Medicaid plans and providers to deliver pediatric oral health services in innovative ways, with a special focus on community-based solutions.
- Under its Medicaid section 1115 waiver, California incentivizes dental care coordination by community health workers and the use of telehealth.
- Pennsylvania has a number of Medicaid managed care strategies in place to foster innovation, including making dollars available to managed care organizations (MCOs) to engage public health dental hygiene practitioners.
- Connecticut similarly includes oral health in its statewide Medicaid payment and delivery reform.
Through these incentives and performance measures, explored below, Medicaid agencies are supporting workforce innovations to address children’s oral health.
The Case for Oral Health Workforce Innovation in Medicaid
Dental decay is preventable, yet it is the most common chronic condition among children. Because oral health and overall health are interconnected, unmet oral health needs can negatively affect overall health by making chewing difficult, leading to lost school days, and damaging self-esteem.,, Inability to access dental care can be fatal – in 2007 Deamonte Driver, a 12-year-old boy enrolled in Medicaid, died after an untreated tooth infection spread to his brain.
Medicaid is a key lever in addressing oral health care needs, particularly for children, because the Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit requires dental coverage for children and adolescents. The Centers for Medicare & Medicaid Services (CMS) encourages state Medicaid agencies to increase children’s access to dental services through Medicaid and the Children’s Health Insurance Program (CHIP). The Child Core Set of measures that Medicaid agencies can report to CMS includes dental and oral health. The 2011 CMS Oral Health Strategy outlines options for state Medicaid agencies to increase children’s access to care, including workforce strategies, such as provider outreach and recruitment, and reimbursement for services provided by additional types of providers to deliver preventive services.
Workforce strategies are critical to address children’s oral health needs in part because oral health care provider shortages persist across the country. Health Professional Shortage Areas (HSPAs) for dental care exist in 49 states. Rural communities have significantly fewer oral health providers than urban communities and therefore less access to services. To offset shortages, states are introducing new provider types or expanding the services existing providers can deliver. Dentists and dental hygienists (working independently or under dentist or physician supervision) practice in every state. Pediatricians and other primary care medical providers deliver preventive oral health services and refer children to dentists. In 10 states, dental therapists can provide preventive and restorative care. Five states have introduced legislation for advanced dental hygiene practitioners, and 21 states allow community dental health coordinators to assist in community-based care coordination and prevention outreach.,
To address children’s oral health needs and access to care, Medicaid officials in California, Pennsylvania, and Connecticut use payment and performance-based strategies to engage the providers authorized to deliver oral health services in their states in the continuum of care.
California’s Dental Transformation Initiative
California’s current 1115 waiver focuses on transforming health care service delivery and quality for Medicaid (Medi-Cal) members, and it includes the Dental Transformation Initiative (DTI). The DTI aims to increase pediatric preventive dental service utilization, diagnose early childhood caries through caries risk assessment (CRA) and disease management, and continuity of care for children enrolled in Medicaid. The DTI budget is up to $740 million over five years (through 2020) for provider incentive payments in four domains: pediatric preventive dental service utilization, caries risk assessment and disease management, continuity of care, and local dental pilot programs (LDPPs).
DTI incentives include:
- Semi-annual payments to dental service office locations or safety net clinics that provide preventive services to more children;
- Payments to dentists for performing pre-identified treatment plans for children ages 6 and younger (where treatment plans include CRA with motivational interviewing, nutritional counseling, and antimicrobials; fluoride varnish application; toothbrush prophylaxis; exams; and increased frequency of services depending on risk level);
- Annual, tiered payments to dental service office locations that provide exams to an enrolled child (up to age 20) for continuous years (e.g., tier one payments are provided on a per-child basis for those with two or more exams from the same service location for two consecutive years); and
- Payments specific to each LDPP program.
The LDPPs use innovative strategies to address the primary DTI aims of pediatric preventive dental service utilization, risk assessment and disease management, and/or continuity of care. Community organizations submitted applications for LDPPs, and as of July 2019, the state Medicaid agency had contracts with 13 LDPPs. Many LDPPs employ workforce strategies such as telehealth and care coordination or case management to meet the DTI goals.
- Five LDPPs are piloting a virtual dental home (VDH) — in this system children receive preventive and other oral health services in community settings, such as schools. Dental hygienists and assistants with special training collect information and provide preventive services. Using technology, dentists in a different physical location review the information and may direct provision of additional services. The VDH also connects children with complex dental needs to a local dentist. The VDH model began at The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry. A Health Resources and Services Administration (HRSA) State Oral Health Workforce Grant to the California Department of Public Health enabled expansion of the VDH to additional sites.,
- The Sonoma County LDPP (“Cavity Free Sonoma”) is training and integrating community dental health workers (CDHWs) into dental teams at seven federally qualified health centers (FQHCs) to decrease dental disease among Medicaid-eligible children ages six and younger. The CDHWs provide culturally appropriate oral health information to caregivers and children, assist with caries risk assessment, track patient data, and provide dental case management. CDHWs help caregivers navigate medical and social service systems, and they follow up with caregivers to ensure children complete appointments.
A number of state policies underpin and support the DTI. The VDH was initially tested under the state’s Health Workforce Pilot Projects Program, which allows organizations to test or evaluate new or expanded provider roles before changing licensing laws. Based on the VDH results, the state made scope-of-practice changes for dental hygienists and dental assistants, amended the state Medicaid plan to allow allied dental professional enrollment and billing, and to cover the technology used in VDH. These changes facilitated additional VDH piloting and implementation.
Additionally, the state legislature directed a portion of state tobacco tax revenue to be used for supplemental payments to dentists for certain services, and a $30 million loan repayment program for dentists who commit to serve Medicaid patients for five or ten years. (The American Dental Education Association maintains a list of loan repayment programs by state). Dentists in California can receive up to $300,000 through the loan repayment program, and awardees must agree to ensure Medicaid beneficiares comprise 30 percent of their patient caseload. In July 2019, the Medicaid agency announced $10.5 million in loan repayment awards to 40 dentists.
The Medicaid agency and public health department collaborate through these efforts and the statewide oral health plan, which complements and references the DTI. As part of the oral health plan, California aims to support community-clinical linkages by maximizing the use of trained personnel, such as community health workers and public health nurses, as well as co-locating medical and dental providers.
DTI results to date indicate improvement. The statewide pediatric preventive service utilization rate increased 7.48 percentage points from 2014 to 2017, and continuity of care increased 2.6 percentage points from 2015 to 2017.
Pennsylvania’s Medicaid Managed Care Strategies
Pennsylvania also encourages MCOs and providers to increase access to dental care for children in a number of ways that promote workforce innovation. Two specific strategies are performance-based incentives and allocating a portion of MCOs’ capitated payments to initiatives that focus on community-based care management, including for oral health.
Pennsylvania has a carved-in (or comprehensive managed care) Medicaid dental delivery system in which MCOs (physical health – PH – MCOs in the state) are responsible for medical and dental services. The state has an MCO and provider dental pay-for-performance (P4P) measure with related performance improvement projects (PIPs) to improve access to pediatric oral health services.
The measure is annual dental visit for youth ages 2 to 20. The PH-MCO receives an incentive payment for meeting the state benchmark and an incremental improvement compared to past performance on the measure. PH-MCOs are eligible to earn a double payout for meeting certain benchmarks or being responsible for a double offset if they do not meet those benchmarks. PH-MCOs also must include an incentive for the dentist as part of provider P4P for the measure. The dental P4P consists of two age bands, 0-5 years and 6-20 years. There is an emphasis placed on the lower age band and children who have not received a preventive dental service within the previous calendar year in order to increase education and obtaining early preventive dental care.
To improve access, some PH-MCOs offer incentives to pediatricians who make dental referrals for children who then receive a dental service (as evidenced by a dental claim). Some PH-MCOs partner with FQHCs to improve access by supporting co-location of primary medical and dental care. Examples of other innovative plan efforts to increase access include the use of a mobile dental unit with pediatric dental providers and the implementation of a small dental home pilot project.
The P4P dental measure and related dental PIPs have been successful. From 2016 to 2018, annual dental visit rates increased by 3.09 absolute percentage points, making the annual dental visit rate 63 percent statewide. Every Pennsylvania plan is currently above the 50 percent national benchmark, and while there is still room for improvement, each plan has improved since the inception of these projects. The state will continue to monitor progress in these areas and especially look at demographics and oversight of the managed care program. A specific area of focus is examining racial/ethnic or geographic disparities in dental care.
Another managed care strategy in Pennsylvania is the availability of Community-Based Care Management (CBCM) dollars for PH-MCOs to implement innovative initiatives that increase access to oral health services. CBCM dollars must be used for community-based projects, either for staffing or for the initiatives themselves. With this funding, PH-MCOs have embedded registered nurses or community health workers (CHWs) in care settings, helped enrollees with transportation to appointments, and conducted public education. Some PH-MCOs use CBCM dollars for oral health services, including mobile dental vehicles, and working with public health dental hygiene practitioner (PHDHP) initiatives. MCOs can enroll PHDHPs, and CBCM guidance specifically requires PHDHP initiatives. In this way, CBCM dollars assist plans in meeting P4P benchmarks and PIP goals.
An Emerging Model: Connecticut’s Oral Health Focus in Medicaid Payment and Delivery Reform
Connecticut’s State Innovation Model (SIM) initiative aims to improve overall community health, access to and quality of care, and health equity through payment and delivery reform. One component of SIM, the Community and Clinical Integration Program (CCIP), provides technical assistance to help provider organizations and FQHCs improve primary care delivery and patient outcomes. CCIP has three core standards: comprehensive care management, health equity improvement, and behavioral health integration, as well as three elective standards, one of which is oral health. This standard includes screening for oral health risk factors and symptoms, developing treatment plans, providing treatment, and tracking oral health outcomes and improvement over time. Although implementation is in the early stages, one participating FQHC has chosen this oral health elective standard. Connecticut recognizes the importance of oral health as it relates to overall health and this awareness will be a consideration in any future practice transformation and payment reform efforts.
Considerations and Conclusion
Some lessons from these state efforts to promote pediatric oral health care access through workforce innovation include:
- Engage the dental community. States with comprehensive managed care can elevate dental care within MCOs, for example, by requiring each plan to have a dental director. Pennsylvania has seen increased dental provider engagement since implementing this change.
- Consider pilot programs. Pilot programs offer the opportunity to start small, build buy-in, and receive early input. They also can help states determine possible impact and address challenges on a small scale before rolling out statewide.
- Leverage multiple funding streams, when possible, and consider a multi-pronged approach for oral health workforce innovation. California has leveraged tobacco tax revenue and federal grants to support innovations across Medicaid and public health, and with an academic partner.
- Consider the unique needs of FQHCs and safety net providers. FQHCs often can lead the way in co-location of dental and overall health services and providers, but some safety net facilities/organizations establish contracts for dental care with the private sector. Additionally, due to federal law, FQHCs bill Medicaid agencies for services differently than other providers. These realities can create challenges tracking utilization or other data. A contractor and a dental consultant have provided assistance engaging and supporting safety net providers who opt in to participate in the California DTI.
Dental decay is preventable, yet unmet oral health needs persist. Payment and quality measurement policies in California, Connecticut, and Pennsylvania demonstrate how Medicaid agencies — often in collaboration with public health agencies — can promote oral health workforce innovation to help Medicaid-eligible children access needed dental and oral health care. While states often face financial and data barriers, emerging efforts to engage providers, such as community dental health workers, or dental hygienists and assistants, with advanced training, and to leverage telehealth show promise.
 Centers for Disease Control and Prevention. “Dental Caries (Tooth Decay).” Hygiene-related Diseases. September 22, 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html.
 Jackson, Stephanie L., William F. Vann, Jonathan B. Kotch, Bhavna T. Pahel, and Jessica Y. Lee. “Impact of Poor Oral Health on Children’s School Attendance and Performance.” American Journal of Public Health 101, no. 10 (2011): 1900-906. doi:10.2105/ajph.2010.200915. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222359/
 Kelekar, Uma, and Shillpa Naavaal. “Hours Lost to Planned and Unplanned Dental Visits Among US Adults.” Preventing Chronic Disease 15 (2018). doi:10.5888/pcd15.170225.
 Health Policy Institute, American Dental Association. “Oral Health and Well-Being in the United States.” https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/OralHealthWell-Being-StateFacts/US-Oral-Health-Well-Being.pdf?la=en.
 CMS recently completed the Medicaid Innovation Accelerator Program Children’s Oral Health Initiative Value-Based Payment Technical Support Opportunity for states focused on selecting, designing, and testing a value-based payment approach to improve children’s oral health outcomes. See https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-functional-areas/value-based-payment/index.html
 National and State-level Projections of Dentists and Dental Hygienists in the U.S.: 2012-2025. Washington, D.C.: U.S. Deparment of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Information and Analysis, 2015. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nationalstatelevelprojectionsdentists.pdf
 National Advisory Committee on Rural Health and Human Services, Improving Oral Health Care Services in Rural America: Policy Brief and Recommendations. December 2018. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2018-Oral-Health-Policy-Brief.pdf
 For example, see: Centers for Medicare and Medicaid Services. “Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children & Adolescents.” September 2013. https://www.medicaid.gov/medicaid/benefits/downloads/keep-kids-smiling.pdf; Cantrell, Chris. “Engaging Primary Care Medical Providers in Children’s Oral Health” (National Academy for State Health Policy, 2009). https://www.nashp.org/engaging-primary-care-medical-providers-childrens-oral-health/.
 “New Mexico’s Passage of Dental Therapy Law Builds National Momentum for Changing Provision of Dental Care Amid Oral Health Crisis.” Community Catalyst. March 29, 2019. https://www.communitycatalyst.org/news/press-releases/new-mexicos-passage-of-dental-therapy-law-builds-national-momentum-for-changing-provision-of-dental-care-amid-oral-health-crisis.
 American Dental Hygienists’ Association. “The Benefits of Dental Hygiene-Based Oral Health Provider Models.” April 2016. https://www.adha.org/resources-docs/75112_Hygiene_Based_Workforce_Models.pdf.
 American Dental Association. “Solutions: About CDHCs.” Action for Dental Health. https://www.ada.org/en/public-programs/action-for-dental-health/community-dental-health-coordinators.
 Early childhood caries is the presence of one or more decayed, missing, or filled tooth surfaces in a primary tooth in children younger than six years of age. See American Academy of Pediatric Dentistry, “Definition of Early Childhood Caries” https://www.aapd.org/assets/1/7/D_ECC.pdf
 California Department of Health Care Services, “Medi-Cal 2020 Waiver Dental Transformation Initiative, Domain 4 Summary of Local Dental Pilot Program Applications,” March 8, 2018. https://www.dhcs.ca.gov/provgovpart/Documents/DTI/Domain%204/Medi-Cal_2020_DTI_D4_LDPP_Summary_030818.pdf
 University of the Pacific, Arthur A. Dugoni School of Dentistry. ”About Virtual Dental Home” https://dental.pacific.edu/departments-and-groups/pacific-center-for-special-care/innovations-center/virtual-dental-home-system-of-care
 University of the Pacific, Arthur A. Dugoni School of Dentistry. “Pacific Center Receives More than $3.5 Million in New Grants for Virtual Dental Home Projects,” October 13, 2017.
California Department of Public Health Office of Oral Health. “Oral Health Program Projects.” https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/Pages/OralHealthProgram/OralHealthProjects.aspx
 See www.CalHealthCares.org to learn more about loan repayment program eligiblilty and requirements.
 California Department of Public Health Office of Oral Health, Statewide Oral Health Plan 2018-2028, January 2018. https://www.cdph.ca.gov/Documents/California%20Oral%20Health%20Plan%202018%20FINAL%201%205%202018.pdf
 Kumar, Jayanth. “Public Health and Dental Care Collaboration in California.” Webinar presentation for the National Academy for State Health Policy. July 30, 2019.
 Jackson, Alani. “California Oral Health Innovations.” Webinar presentation for the National Academy for State Health Policy. July 30, 2019.
 To learn more about relevant PIPs, see Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for States. Centers for Medicare & Medicaid Services Oral Health Initiative, 2015. https://www.medicaid.gov/medicaid/benefits/downloads/pip-manual-for-states.pdf
 Connecticut State Innovation Model (SIM) Report of the Practice Transformation Taskforce on Community and Clinical Integration Program Standards for Advanced Networks and Federally Qualified Health Centers. Core Elective Standards. CT.gov, 2016. https://portal.ct.gov/-/media/OHS/SIM/PracticeTransformationTaskForce/CCIP-Reports-and-Publications/ccip_report_standards_updated_12_30_16.pdf?la=en
 To learn more, see for example, Medicaid and CHIP Payment and Access Commission. Medicaid Payment Policy for Federally Qualified Health Centers, December 2017. https://www.macpac.gov/publication/medicaid-payment-policy-for-federally-qualified-health-centers/
The authors wish to thank the state officials in California, Connecticut, and Pennsylvania who graciously shared their experiences and reviewed a draft of this publication. Trish Riley, Kitty Purington, and Elinor Higgins of NASHP provided helpful guidance or assistance. Finally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.