This year, many states have continued to pursue federal approval for a range of proposals affecting Medicaid coverage, such as seeking modifications to the Affordable Care Act’s (ACA) Medicaid expansion or adding Medicaid work requirements.
Currently, nine states have implemented expansion through Section 1115 waivers to impose conditions such as monthly premiums, lock-out provisions for non-payment, and work requirements on certain Medicaid enrollees. While some Medicaid waivers approved by the federal government that include work requirements have faced legal challenges, other states — including those that have not implemented Medicaid expansion — are continuing to seek federal approval to condition Medicaid eligibility on work, with nine additional proposals currently pending.
The following is an overview of some of the current state Medicaid coverage waiver activity and other state actions affecting health coverage, including Tennessee’s recent block grant proposal.
State Changes to Medicaid Expansion Passed by Ballot Initiatives
Earlier this year, Idaho’s governor signed into law a number of changes to the Medicaid expansion ballot measure approved by voters in November 2018. One component of the law required the state to seek a 1332 waiver to enroll individuals eligible for expanded Medicaid who had income between 100 to 138 percent of the federal poverty level (FPL) in subsidized exchange coverage, although these individuals could opt for Medicaid coverage instead. However, in late August the Centers for Medicare & Medicaid Services (CMS) rejected the state’s waiver request, citing that it did not meet the deficit neutrality guardrails required of 1332 waivers. State officials have indicated that they will resubmit the application with additional information, although CMS noted in its letter that even a revised application would likely still not demonstrate compliance with those guardrails. Another aspect of Idaho’s law modifying the voter-approved Medicaid expansion directs the state to seek a waiver to implement Medicaid work requirements for most expansion enrollees, and the state recently submitted this 1115 waiver request for federal approval. If the waivers are not approved by Jan. 1, 2020, the state law requires implementation of traditional Medicaid expansion.
Similar to Idaho, voters in Utah passed a measure last November to implement Medicaid expansion, and in February state legislators enacted a law that significantly alters the voter-approved expansion in a number of ways. The law requires the state to seek a series of waivers, outlined in the state’s implementation toolkit, through a potentially four-step process, depending on what CMS approves. In March, CMS approved the state’s first request — the Bridge Plan — to expand Medicaid to only those earning 100 percent of FPL at the state’s regular federal medical assistance percentage (FMAP) rate, include an enrollment cap if projected costs exceed state appropriations, require individuals with access to employer-sponsored insurance (ESI) to enroll in that coverage with Medicaid premium assistance, and add work requirements in 2020. In May, the state submitted the second waiver proposal for the enhanced FMAP that the ACA provides for the expansion population while keeping the expansion eligibility level at 100 percent FPL, but CMS indicated that it would not provide the enhanced FMAP for a partial expansion. This second proposal also maintains the enrollment cap, work requirements, and ESI premium assistance from the initial waiver, adds in 12-month continuous eligibility and lock-out provisions for non-compliance with certain activities, and notably requests to implement a per capita cap model for receiving federal Medicaid funds for the new eligibility group. Although CMS did not approve the enhanced FMAP for the partial Medicaid expansion, the governor issued a statement that the state would move forward with requesting approval of the other proposal components, and the state submitted the waiver request in late July. If CMS does not approve this per capita cap proposal, the state plans to request permission to implement a “fallback” plan — the third step in the state’s implementation plan — that expands Medicaid to the ACA’s 138 percent of FPL eligibility threshold and provides the state with the enhanced expansion FMAP, and includes work requirements, an enrollment cap, and lock-out provisions. The final option – if this third plan is not approved – is implementing traditional Medicaid expansion through a state plan amendment, as was passed by the voters.
Nebraska was the third state in 2018 to pass Medicaid expansion through a ballot initiative, and while state legislators there did not follow the same route as Idaho and Utah, expansion in Nebraska has not yet occurred because the state intends to seek modifications to the expansion. State officials submitted a state plan amendment for expansion this past April, indicating the state would seek a waiver to modify its existing managed care program to include the expansion population and provide different benefit packages based on whether enrollees complete certain wellness requirements. Expansion will occur no later than Oct. 1, 2020, and the plan eventually will also incorporate work requirements for eligible individuals wishing to remain in the “prime” coverage option, which offers more robust benefits such as dental and vision services.
Activity in Medicaid Expansion States
Montana originally implemented Medicaid expansion through a waiver because the state requires certain individuals to pay premiums. The expansion was scheduled to sunset in July of this year, but in April the legislature passed a bill, signed by the governor in May, to continue expansion that added work requirements for most enrollees. The state’s waiver amendment also seeks to maintain the original waiver’s implementation of 12-month continuous eligibility and modify the monthly premium structure to be based on the amount of time an individual is enrolled. The federal comment period for the waiver amendment recently closed.
In Virginia, Democratic Gov. Ralph Northam and Republican state legislators negotiated a compromise to expand Medicaid with work requirements in 2018. Coverage became effective in January of this year, but the work requirements were not implemented as the state needed to seek federal permission through a waiver. The state is now negotiating to receive federal funding for employment supports, as Northam’s administration has indicated that the state cannot afford to implement the work requirements without these federal dollars. Some Republican state legislators are characterizing the request for this federal funding as an effort to backtrack on the compromise struck last year between them and the governor.
While New Mexico originally implemented the ACA’s traditional Medicaid expansion, the state sought and received approval in December 2018 to add premium and copayment requirements and waive retroactive eligibility for certain expansion enrollees. However, under Gov. Lujan Grisham, the state is now requesting to amend the waiver and remove the copayments, premiums, and waiver of retroactive eligibility.
Activity in Non-Medicaid Expansion States
Like last year, voters in some nonexpansion states will have the chance to consider expansion in 2020. Groups in Oklahoma indicated that they have gathered enough signatures to put expansion before voters in 2020. Medicaid expansion proponents in other states — specifically Missouri and South Dakota — are also attempting to place the issue before voters in 2020. Additionally, in Mississippi’s upcoming gubernatorial election in November, voters will decide between a Republican who opposes expansion and a Democratic who supports it.
North Carolina’s Democratic Gov. Roy Cooper vetoed the state budget in June in part because it did not include Medicaid expansion. However, in mid-September state legislators in the House voted to override the governor’s veto. While the Senate still needs to hold a vote on the veto override, a bill to expand Medicaid with work requirements and premiums has been added back to the legislative calendar.
Georgia is currently drafting two waiver proposals as part of a law signed by the governor in March. The state is expected to submit an 1115 waiver proposal to expand Medicaid to only those earning 100 percent of FPL, as well as seek federal approval through a 1332 waiver to implement a reinsurance program.
Beyond continuing efforts to expand Medicaid or modify laws to do so, block grants have surfaced again. Tennessee has developed a draft proposal to shift federal funding for most of the state’s Medicaid program into a version of a block grant, which would be a significant change and is based on a state law passed earlier this year. Under the plan, the state would receive a capped amount of federal Medicaid funding for low-income parents, children, and individuals with disabilities. Unlike a traditional block grant — which the state acknowledges its plan differs from — the state is requesting additional funding if enrollment rises above a certain threshold, but the funding amount would not be reduced if enrollment declined. Additionally, the funding cap does not include state spending on individuals dually eligible for Medicaid and Medicare, disproportionate share hospital (DSH) payments, outpatient prescription drug expenses, or administrative costs, and any savings achieved from the financing model would be divided evenly between the state and the federal government (the state’s current federal match rate is 65 percent). The state is also requesting additional flexibilities, such as modifying the amount, duration, and scope of benefits without federal approval or public comment and implementing a closed formulary for prescription drugs. The waiver request also proposes to exempt the state from federal regulations for managed care plans. Some policy analysts have identified that federal law does not allow Medicaid’s financing model to be restructured through the 1115 waiver authority, and if CMS does approve the waiver it is expected to face legal challenges. Tennessee also submitted a separate waiver request in December 2018 seeking to implement Medicaid work requirements for low-income parents and caretakers, which is still awaiting federal approval.
Legal Challenges to Medicaid Work Requirements
Medicaid waivers containing work requirements approved by CMS have been halted by court rulings earlier this year in Arkansas, Kentucky, and New Hampshire, and a legal challenge was recently filed against Indiana’s approved work requirements. Earlier this month, a three-judge panel heard oral arguments on the federal government’s appeal of the Arkansas and Kentucky rulings, and the judges noted that the administration had not considered the coverage losses resulting from work requirements. The ruling by this federal appeals court will have significant implications for Medicaid work requirements overall, and while they did not provide specific information about timing for the decision, it is expected before the end of the year. The court challenges are already beginning to have some implications — on Oct. 17, 2019, Arizona informed CMS that it would postpone implementation of the state’s approved Medicaid work requirements due to the litigation in other states. Additionally, a recent study conducted by the Government Accountability Office (GAO) recommended that CMS should improve its oversight of the administrative costs associated with work requirement waivers, which GAO found can be significant, ranging from under $10 million to over $250 million.
In addition to the next round of court decisions on Medicaid work requirements, states are waiting to see if federal guidance on Medicaid block granting will be issued soon — which is currently under review at the Office of Management and Budget. Similar to how states are seeking to implement Medicaid work requirements despite legal challenges, if CMS provides guidance and approves Tennessee’s block grant proposal, other states may also pursue this financing model, even if the block grant is challenged in court. Also, whether CMS and states that have been hesitant to expand will be able to find a middle ground on Medicaid expansion remains a question, and how decisions play out in Idaho and Utah in particular, will be significant for future actions. Similar to this past year, in 2020 states are expected to continue to seek new ways to test the boundaries of Medicaid coverage waivers and manage their Medicaid programs.
Dual Eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare and medical assistance from a state Medicaid plan. States cover some Medicare costs, depending on the state and the individual’s eligibility.
Many states already leverage Dual Eligible Special Needs Plans (D-SNPs ) to better manage care for individuals enrolled in both Medicare and state Medicaid programs. Recent changes to federal regulation, stemming the Bipartisan Budget Act of 2018, are expected to make D-SNPs more attractive for states seeking to better integrate care for this population.
The National Academy for State Health Policy (NASHP), with support from The SCAN Foundation, convened state policymakers at its recent annual conference to explore these new opportunities, highlight Medicare/Medicaid integration efforts in leading states, and explore what internal state capacity is needed to successfully address the needs of dual-eligible beneficiaries across programs.
The session, Maximizing Medicare: New Opportunities to Support State Policy Goals, featured examples of successful D-SNP models in Minnesota and Arizona, and highlighted lessons learned from states, detailing what internal expertise is needed to support these programs.
Individuals covered by both Medicare and Medicaid present unique challenges for state policymakers. This population often has higher health care costs and poorer outcomes, including higher rates of chronic conditions and behavioral health diagnoses. For states, creating well-integrated and coordinated systems of care for this high-needs population can be hampered by the complex interplay of these two programs.
The Bipartisan Budget Act of 2018 permanently authorized D-SNPs, and final regulations require D-SNPs to coordinate Medicaid benefits for duals and assist them in navigating appeals. The new rule also requires D-SNPs – in some circumstances – to provide an integrated appeals process and discharge planning for some high-need members. All D-SNPs must meet certain minimum integration criteria by 2021.
Both Minnesota and Arizona have experienced improved integration of care for duals through use of D-SNPs. Both states leveraged the contracting requirements of the Medicare Improvements for Patients and Providers Act to align administration and improve consumer experience. Wisconsin has structured its program to provide a more integrated experience at every step, including one set of enrollment materials, aligned enrollment dates, and care coordination for primary, acute, and long-term care services. Arizona’s D-SNP plans must be contracted “companion” plans with the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid agency. This and other contract features help encourage member enrollment in the same health plan for both Medicare and Medicaid services.
What internal capacity is needed to make these programs work? Presenters offered the following key takeaways:
- Leadership is critical: Strong leadership is an important factor in providing more integrated care for duals. Leadership that understands the complexity of the population, and the need to mobilize specific resources and policies to address their unique issues and make long-term investment in these programs has been an ingredient for success in leading states.
- Build and nurture strong managed care organization (MCO) partnerships: Collaborative relationships with Medicaid MCOs are also central to integrating care across programs. To avoid misalignment, presenters suggested working with MCOs to review detailed descriptions of the services to be coordinated by D-SNPs, including behavioral health and long-term services and supports, and discussing enrollment, marketing, and appeals policies with them to identify and resolve issues.
- Engage stakeholders: Similarly, states found it helpful to regularly engage a range of stakeholders – providers, members, and advocates – to identify specific needs and areas of disconnect, and to allay consumer and provider concerns who may be impacted by policy changes.
- Focus on staff capacity and ongoing training: States emphasized the need to have subject matter expertise within a state Medicaid agency. One presenter noted, “integration is a process and not an event,” long-term capacity is necessary to be able to analyze and respond to the changing state and federal regulatory landscape on an ongoing basis. Having designated staff and facilitating clear lines of communication across offices within Medicaid with an “open door policy” can also help identify and troubleshoot issues. Important areas of expertise include accessing and using Medicare data, understanding covered services and payment, and familiarity with state policy options to better integrate care.
Presenters encouraged policymakers to make full use of available resources to help them better understand the policy issues and needs of dual eligibles. The federal Medicare-Medicaid Coordination Office (MMCO) was noted as an excellent resource. MMCO leaders recently released a State Medicaid Director Letter detailing how states can improve care for dually-eligible beneficiaries. Additionally, the Integrated Care Resource Center website also provides a host of state-specific materials and learning opportunities.
Additional information and copies of slide presentations from NASHP’s 2019 conference is available on this Conference Presentation page.
US Census Bureau data released this past week revealed 8.5 percent (27.5 million people) did not have health coverage at any point during 2018 – an increase from 7.9 percent (25.6 million people) in 2017. The latest census data also affirmed fears raised after reports of declining child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) that there was a rise in the overall uninsured rate for children – at 5.5 percent in 2018 – for the second year in a row.
Children’s uninsured rates have steadily decreased from 2008 when it was 9.7 percent to an all-time low in 2016 of 4.7 percent. However, the downward trend began to reverse in 2017 when the rate of uninsured children rose to 5 percent nationally and it has increased again in 2018. The resounding questions posed by state officials responsible for covering children in Medicaid and CHIP and other stakeholders are:
Why is children’s enrollment in public coverage programs declining and the uninsured rate increasing?
What is prompting an almost decade-long trend of increasing coverage for children to reverse?
According to the state officials who met and discussed children’s insurance enrollment at the 32nd annual National Academy for State Health Policy’s (NASHP) annual conference last month, there are no simple answers to these critical questions. They suggest that multiple factors, outlined below, are contributing to the decline.
Eligibility, Enrollment, and Retention Policies, Practices, and Systems
State officials explained that at the first indication of decreases in child enrollment in public programs, they looked inward to find a possible eligibility or enrollment system issue or policy problem to address. Although no one reported a major issue, many officials acknowledge that these policies and systems require continual updating and improving. Many officials want to further streamline the enrollment process for families by utilizing technology and existing data more fully, requiring less frequent renewals, and improving communication of what can be complex information for parents. Frustrating to many, these goals are not new and some are explicitly required by the Affordable Care Act (ACA), but still need attention. As states assess their systems and policies, there is a wealth of resources available to help them better target their investments.
This data suggests a strong economy does not guarantee access to health insurance. The 2018 data indicates that the percentage of people with private coverage (employer-sponsored, purchased, or Tricare) did not statistically change between 2017 and 2018. Therefore, even if the economy is helping families secure employment or increased income, it does not appear to guarantee access to health insurance.
The Strong Economy
It makes sense that during this time of job growth and low unemployment there would be a decreased need for public coverage programs. However, the data indicates that in 2018 the highest percentage of uninsured children (7.8 percent) were in families with incomes below 100 percent of the federal poverty level (FPL), which represents an increase over 2017. Also notable is the 0.7 percent increase between 2017 and 2018, of uninsured of children in families with incomes above 400 percent of FPL. This data suggests that a strong economy does not guarantee access to health insurance. Further, the 2018 data indicates that the percent of people with private coverage (employer-sponsored, purchased, or Tricare) did not statistically change between 2017 and 2018. Therefore, even if the economy is helping families secure employment or increased income, it does not appear to guarantee access to health insurance.
Changes to National Immigration Policies
State officials also suggested that changes to federal immigration policies have an effect on the decline in children’s enrollment in public programs and the increase in overall uninsured rates. According to a 2018 Urban Institute survey, the rule allowing the Department of Homeland Security to consider immigrants’ use of Medicaid when determining if they are or could become public charges has had a chilling effect on enrollment even before the rule became final. Although children’s use of Medicaid and CHIP is explicitly excluded from the final public charge rule, it is a complicated rule and is likely unclear to families who must determine how use of public coverage could affect their potential citizenship status. The data confirms that in 2018 naturalized citizens were 2.2 percent more likely to be uninsured. The data also indicates that in 2018, 8.7 percent of Hispanic individuals were uninsured, which is double the rate of other races or ethnicities in the report. All of which supports the speculation that immigration policy changes have had an impact on the rising rate of uninsurance.
Lack of Outreach and Marketing Funds
Outreach and marketing often take a backseat to other administrative and operational budget demands, particularly because state resources are already stretched thin. Instead, many state children’s coverage programs maintain active partnerships with community-based organizations and seek other low- or no-cost ways to get the word out about the availability of coverage. However, more and more state officials would like the opportunity to engage families to help them identify what messages resonate and the best ways to deliver them, such as social media or more traditional advertisements. State Medicaid and CHIP programs were benefiting from the federal navigator program that supported individualized health coverage application assistance, but in recent years, federal investment in that program has steadily declined.
Federal Policy Changes Affecting Affordability and Undermining the ACA
Finally, some state officials acknowledge that federal policies that supported the ACA have changed and may have impacted uninsured rates. Such policies include the elimination of the cost-sharing reductions and the federal reinsurance program, as well as others that have resulted in higher health insurance premiums and as a consequence lower enrollment. It is suspected there could be a relationship between parents’ loss of coverage and the decline in children’s enrollment. The ACA requires parents seeking coverage through health insurance marketplaces to enroll their eligible children in Medicaid or CHIP. If parents, who are no longer subject to the federal insurance mandate, are deterred by cost from seeking to enroll themselves in coverage, they may be missing the prompt to enroll their children during ACA’s open enrollment period and it could be a factor in the climbing child uninsured rate as well.
Without a clear cause and with multiple contributing factors for the declining children’s enrollment in public programs and the rising uninsured rate, states are challenged to identify how best to invest their limited resources to the address this issue, though many officials are deeply engaged in addressing this problem. NASHP will continue to work with states to understand better the emerging enrollment and uninsured data and to provide resources on tested and effective enrollment and renewal policies and practices to support state efforts to make sure eligible families have health coverage.
This toolkit highlights state initiatives to help older rural adults age in place by increasing services that help people remain in their homes, expanding and professionalizing the caregiver workforce, improving transportation access and services, and making delivery system reforms within Medicaid programs.
Download the toolkit.
Rural areas across the nation have higher concentrations of elderly residents than urban areas, 18 percent of rural populations are age 65 or older compared to only 13 percent in urban areas.1 These rural, older adults are poorer, have more complex health conditions, and experience the impact of health-related social factors such as lack of housing, transportation, and food more acutely than their urban peers.2 Rural adults are also more likely to be older (exceeding age 85), female, and white than their urban counterparts. Finally, rural older adults were also less likely to use home- and community-based services (HCBS) and more likely to use nursing facility services.3
State Medicaid programs, through HCBS waivers and the Medicaid nursing facility benefits, are the de facto long-term care system across the country. States are obviously committed to ensuring that older adults living in rural areas who need nursing facility care be able to access quality care in their communities. However, not only do more than 85 percent of older adults prefer to remain in their own homes and communities,4 but serving older adults in their homes is almost always less expensive than housing people in facilities.5 As a result, states are keenly interested in finding strategies that can help keep older, rural adults safely in their homes in their communities.
States can implement a wide range of strategies using differing combinations of policy levers to support rural older adults who age in place, including working across state agencies and with different partners. The strategies discussed in this toolkit were drawn from online research, as well as written correspondence and interviews with state officials. This toolkit showcases these three primary types of strategies that states are using to support aging in place:6
- Workforce and training;
- Facilitating access to services in rural areas; and
- Addressing the social determinants of health (SDOH).
This toolkit is designed to help state leaders, especially Medicaid officials, adapt and adopt existing strategies and develop new strategies that build on their peers’ experience and insights. While it does not offer a comprehensive compendium of state approaches, it instead provides examples of the types of strategies that states have implemented and presents emerging ideas for consideration. It also identifies and includes links to key documents used to implement these strategies, such as legislation, contracts, and program manuals. These are provided in order to offer officials a springboard for developing their own approaches and policies as they tackle the important issue of how to better support older individuals aging in place in rural areas.
There are a number of state agencies with responsibility for providing or overseeing services to older adults who live in rural areas — often this task is part of a broader scope of responsibilities. This situation creates the potential for cross-agency partnerships. Most of the strategies presented in this toolkit are led by Medicaid or include Medicaid as a partner, but other state partners include aging agencies and departments of rural health, licensing, and transportation. Some states also partner with colleges and universities as well as providers, families, and consumers. Finally, many of these strategies depend on engaging the support of community-based organizations.
States generally use three types of policy levers to implement their strategies — and implementing most strategies depend on more than one lever:
- States enact legislation that created or changed laws and authorized funding to better support older adults living in rural areas.
- States adopt regulations to implement legislation, including legislatively authorized programs such as Medicaid. This category includes guidance (e.g., Medicaid provider manuals) that states develop to share regulations with providers and other stakeholders.
- Sometimes states choose to contract for services through a process (e.g., request for proposals) that selects an organization or individual to deliver a service.
The state initiatives that informed this toolkit combined these tools in various ways to meet the needs of the target population. Sometimes they built strategies targeting only older adults in rural areas, but more often they developed strategies that addressed this group’s needs as part of a broader strategy. The table below draws on two of the strategies detailed in this toolkit to illustrate how states have used the resources at their disposal (partners, policy levers, and federal authorities) to build strategies that meet the needs of older, rural adults.
Table 1: Key elements of Minnesota and Georgia’s initiatives to meet the health needs of older, rural adults
|Strategy||Minnesota Community Emergency Medical Technician||Georgia Mobile Adult day Care Services|
|Trained emergency medical technicians deliver services, such as safe home evaluations, in the individual’s home.||Staff travel from a central location daily to provide adult day care services at various sites.|
|Legislation||Minnesota Session Laws 2015, Chapter 71, Article 9, Sec. 18. Community Medical Response Emergency Medical Technician (CEMT) services covered under the Medical Assistance Program||Georgia HB 318 Adult Day Center Licensure Act provides for licensure of adult day center.|
|Regulation and Guidance||The Medicaid provider handbook sets out provider qualifications and billing guidelines CEMTs must meet to receive Medicaid payment.||Section 1103 of the Medicaid provider manual outlines provider requirements, policies, and procedures required for mobile adult day centers to receive Medicaid payment.
The Department Of Community Health 111-8-1, Rules And Regulations For Adult Day Centers licensing requirements.
|Contracting||Medicaid managed care organization (MCO) contracts require MCOs to cover CEMT services.||The Area Plan for Aging Services, specifies the services area agencies on aging (AAAs) must provide under contract to the Division of Aging.|
|Partners||Medicaid, Office of Rural Health and Primary Care, Emergency Medical Services Regulatory Board, and the local colleges and universities that offer training.||Medicaid, Department of Human Services’ Division of Aging Services|
|Federal Authority||Medicaid State Plan Amendment for coverage of CEMTs||Medicaid 1915(c) waiver
State Plan on Aging
Because several of the programs serving older adults in rural areas are state-federal partnerships — financed by both governments and operating under federal guidelines – a final, important element of each strategy is the federal authority to implement the change. Under Medicaid, these are mostly state plan amendments (SPAs) and waivers.
- Medicaid state plans define the parameters of the Medicaid program in each state, including defining who is eligible and what services are covered. States change these parameters by gaining federal approval of their SPAs.
- Waivers, when approved by the federal government, allow states to establish Medicaid policies that would not otherwise be allowed under federal rules, such as providing long-term services and supports (LTSS) only to a subset of Medicaid beneficiaries or limiting beneficiary choice of providers. Different waivers allow the waiver of different requirements and are approved for different lengths of time.
One challenge is there are simply not enough providers in rural communities to serve older adults. In rural areas, there are only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 people in urban areas.7 There are often shortages of other critical service providers, such as home health providers.8 As people age they often become less able to drive safely, which make provider shortages even more problematic for this group as they become less able to travel to find care. States can implement strategies that increase access to providers, including increasing provider supply and enhancing the capabilities of existing providers.
Minnesota uses both community paramedics and community emergency medical technicians (CEMTs)9 to meet the health needs of Medicaid beneficiaries living in underserved areas. Both of these professions were established in Minnesota by legislation. One of the reasons for creating the CEMT profession was that a pilot program had demonstrated its potential in rural areas.10 Minnesota Medicaid pays both CEMTs and community paramedics to deliver services in a beneficiary’s home. The Medicaid managed care organization (MCO) contract also requires coverage of these services. CEMTs may deliver post-discharge visits when a beneficiary is released from a hospital or skilled nursing facility as well as safe home evaluation visits. Community paramedics may deliver a broader range of services, including health assessments, medication compliance management, chronic disease monitoring and education, immunizations, lab specimen collection, and minor medical procedures. To qualify for payment, services must be provided by a qualified CEMT or paramedic under the direction of a primary care provider (PCP). Required qualifications for both providers include minimum experience, specialized training, and certification by Minnesota’s Emergency Medical Services Regulatory Board.
Minnesota officials report that building these new professions took time. Although legislation creating CEMTs passed in 2015, in 2017 the Medicaid agency reported that no CEMTs were billing for delivery of their services.11 However, state officials report that CEMT billings have steadily increased since early 2018 when the first technicians completed their training and became certified CEMTs. The Department of Health reports that more community paramedics are needed — as of May 2019 there were 127 certified community paramedics, half of whom worked in the urban Twin Cities and the other half in greater Minnesota.12
How Minnesota Created its Community Emergency Response Technician and Paramedic Programs
· Department of Health, Office of Rural Health and Primary Care
· Emergency Medical Services Regulatory Board
· The state’s ambulance association
· Colleges and universities that offer training
|State policy levers:||Federal authority:|
· Minnesota Session Laws 2015, Chapter 71, Article 9, Sec. 18. Community Medical Response Emergency Medical Technician Services Covered Under the Medical Assistance Program
· Minnesota Statutes 256B.0625, subdivision 60 Community Emergency Medical Technician Services and Community Paramedic Services
|Medicaid State Plan Amendment for coverage of CEMTs and community paramedics|
|Regulation and guidance
· Medicaid provider manual CEMT and community paramedic sections
· Community Paramedic Toolkit
· CEMT and Community paramedic coverage was incorporated into all three types of contracts that served families and children, seniors, and people with disabilities.
Idaho also sought to use emergency medical personnel in new ways, but took a different approach to implementation and payment. Idaho leveraged the State Innovation Model (SIM) award it received from the Centers for Medicare & Medicaid (CMS) in 2015 to establish a training and technical assistance program for community health emergency medical services (CHEMS) agencies. The Bureau of Rural Health and Primary Care, in partnership with the Bureau of Emergency Medical Services (EMS) and Preparedness, was responsible for developing the program. The program sought to prepare existing EMS agencies in rural and underserved areas to take on new roles in the state’s health care delivery system, such as providing vaccinations and transitional care after hospital stays, performing medication inventories, and serving as a health care navigator or advocate. Idaho’s EMS bureau made changes to the code governing licensure to support the expanded EMS role and is continuing to support CHEMS agencies, for example, developing CHEMS clinical integration protocols through its EMS advisory committee and maintaining an online resource center. The SIM award also enabled Idaho to reimburse the patient-centered medical homes (PCMHs) that participated in SIM up to $2,500 toward the cost of integrating CHEMS into their practices. As of July 2019, there were 11 CHEMS agencies in the state, several serving rural areas.13 Although the program does not target older adults, the CHEMS visit may include a fall risk assessment in the home. Also, agencies do not gather data about patients’ ages but do serve patients with conditions that indicate they are likely to be older adults (e.g., certain chronic diseases, dementia, falls, congestive heart failure, and chronic obstructive pulmonary disease – COPD).
Although SIM funding has ended, the Medicaid agency continues to encourage PCPs to work with CHEMS agencies. PCPs that integrate a CHEMS agency can qualify for Tier 3 (of four total tiers) of Medicaid’s Healthy Connections program, which features per member per month (PMPM) payments for PCMH services. Those who qualify for higher tiers receive higher payments. No payer, however, yet pays for CHEMS services and Idaho has found that to be a challenge. As one state official explained, “Providing training and technical assistance supports program development and implementation, however, additional elements, such as funding, reimbursement, and on-going active engagement with primary care clinicians and the local hospital, are critical to sustainability.”
How Idaho Created its Community Health Emergency Medical Services (CHEMS) Agencies
|· Division of Public Health’s Bureau of Rural Health and Primary Care and Bureau of EMS and Preparedness)
· Division of Medicaid
· Office of Healthcare Policy Initiatives
· University of Idaho
· Ada County paramedics
|State policy levers:||Federal authority:|
· Legislation not required
|Medicaid State Plan Amendment for the Healthy Connections program.|
|Regulation and guidance:
· IDAPA 16.01.03 and Idaho Code 56-1012
· Healthy Connections Tier III Requirements
Each agency seeking to use SIM resources to become a CHEMS agency signed a contract with the Idaho Department of Health and Welfare (IDHW), which administered the SIM award.
In 2007, Minnesota passed legislation officially establishing community health workers (CHWs) as a profession in Minnesota. In 2010, the Medicaid agency obtained state plan amendment approval enabling the agency to pay for diagnosis-related patient education services provided by qualified CHWs under the direction of a physician, advance practice registered nurse, certified public health nurse, dentist, mental health professional, or other registered nurse. Medicaid’s MCO contract also requires MCOs to cover these services. Minnesota’s provider manual defines CHWs as “a trained health educator who works with Minnesota Health Care Programs (MHCP) recipients who may have difficulty understanding providers due to cultural or language barriers.” CHWs work as part of a team to help patients learn how to manage their conditions and help them access services. Minnesota Medicaid specifies that it will only pay for provision of education services that support delivery of medical services.14 The CHW cannot bill for services directly, rather an enrolled medical or dental provider must bill for the service. To qualify to deliver Medicaid services, CHWs must, among other requirements, complete an approved curriculum and identify the medical professionals with whom they are affiliated.
Minnesota officials hoped CHWs would extend the reach of existing providers into underserved communities, including rural communities. Although state officials reported that start-up was slow, the number of members in this new profession is growing. CHWs have established both a peer network and a state-level organization to aid their efforts – the Minnesota Community Health Workers Alliance. CHWs operate in rural areas and some have developed expertise in gerontology — enabling them to better meet the health needs of older, rural adults.
How Minnesota Established its Community Health Worker Profession
· Department of Health’s Office of Rural Health and Primary Care
· Community and technical colleges
· Minnesota Community Health Workers Alliance
· Minnesota Community Health Worker Peer Network
|State policy levers:||Federal authority:|
· Minnesota Statutes 256B.0625, Subhead. 49., defining community health worker (CHW)
|Medicaid State Plan Amendment|
|Regulation and guidance
· Medicaid provider manual, CHW section
· Office of Rural Health and Primary Care CHW Toolkit
· CHW services were incorporated into all three types of managed care organization contracts that served families and children, seniors, and people with disabilities.
Project ECHO (Extension for Community Healthcare Outcomes), using multi-point video conferencing, enables primary care providers in remote areas to better manage their patients’ chronic conditions by working with and learning from academic specialists. New Mexico is applying this approach to support nursing facility staff who serve people with complex conditions, including behavioral health conditions. In August 2018, the Medicaid agency, in partnership with the University of New Mexico (UNM), launched the 11-member pilot of the Medicaid Quality Improvement and Hospitalization Avoidance ECHO, which seeks to improve care delivered to Medicaid enrollees residing in rural and remote skilled nursing facilities (SNFs). New Mexico Medicaid plans to expand this program to include all SNFs in the state by 2023. The pilot included two ECHOs:
- Quality measures related to pain control, urinary tract infections, and antipsychotic use; and
- Hospitalizations, including SNF readmissions and long-term care admissions.
The pilot will be completed in the summer of 2019, after which project leaders will evaluate and if necessary recalibrate their approach.15 Medicaid MCO contracts require MCO participation in Project ECHO, including in this project and in working with the UNM’s Department of Geriatrics.
How New Mexico Used Project ECHO (Extension for Community Healthcare Outcomes) to Support Nursing Facility Staff
· University of New Mexico
|State policy levers:||Federal authority:|
· No legislation required
|Section 1115 Research and Demonstration Waiver, authorizes Medicaid managed care programs and commits to use of Project ECHO|
|Regulation and guidance
· None required
· Section 220.127.116.11.4 of the Centennial Care 2.0 MCO contracts
Alaska developed a comprehensive, multi-sector partnership for health workforce planning. An explicit goal of this process was to address rural workforce needs — several of the plan’s initiatives are designed to benefit older adults and people with long-term care needs. The Alaska Health Workforce Coalition was formed in 2008 by a broad group of organizations and individuals representing state agencies, health care employers, education providers, and professional associations, among others. The coalition was launched with funding from the departments of Health and Social Services (DHSS) and Labor and Workforce Development (DOLWD), and the Alaska Mental Health Trust Authority, a state agency governed by an independent board and functioning like a foundation. The Alaska Workforce Investment Board (AWIB) asked the coalition to develop a coordinated approach to addressing the state’s health workforce shortages. The Alaska Health Workforce Plan was presented to the AWIB in May 2010. Based on that plan, the coalition developed an action agenda that was updated in 2017 to cover the period 2017-2021. The coalition also maintains a “scorecard” that tracks progress on the agenda’s items. The coalition merged with the trust in 2017 and, under the trust’s leadership, coalition partners continue to work together to advance the strategies included in the plan. Key strategies include:
Apprenticeships: Alaska has leveraged the federal registered apprenticeship program to recruit Alaskans into the health care field, particularly in rural areas. In August 2018, about 300 Alaskans were in health care-related apprenticeships.16 There are apprenticeships for behavioral health counselors and aides, medical assistants, and others. Of particular relevance, the Alaska DHSS serves as an employee sponsor for a certified nurse assistant (CNA)-registered apprenticeship at its state-owned assisted living facilities. CNA apprentices receive on-the-job training specializing in dementia care over six to twelve months.
Non-traditional providers. Alaska Medicaid pays for services delivered by non-traditional providers, including behavioral health peer support specialists, community health aides,17 behavioral health aides, and dental health aide therapists. Some in these professions qualified as Medicaid providers through the apprenticeship program. According to state officials, many in these positions work in the frontier regions of the state.
Collaboration across organizations: One critical element of the plan was to more effectively deploy resources by helping participating organizations understand and build on each other’s work. For example, the trust and DHSS collaborated with the Alaska Training Cooperative to develop core competencies documents and a corresponding assessment tool for direct care workers. These resources are designed to give employers the information they need to build and assess the skills of direct care workers.
How Alaska Developed its Multi-sector Health Care Workforce
|· Departments of Health and Social Services, Labor and Workforce Development, and Education and Early Development
· Alaska Mental Health Trust Authority
· Alaska Workforce Investment Board
· University of Alaska Anchorage
· Alaska Area Health Education Centers
· Alaska Native Tribal Health Consortium
· Alaska Primary Care Association
· Alaska State Hospital and Nursing Home Association
· Alaska Behavioral Health Association
· Alaska Alliance for Developmental Disabilities
|State policy levers:||Federal authority:|
|· Implementing the plan has required the use of many state policy levers including legislation to establish a loan repayment program and, more recently, new legislation to expand that program to all areas of the state.||Each strategy engaged federal authorities relevant to the approach, including Medicaid State Plan Amendments to allow payment for non-traditional providers and Apprenticeship Program Registration with the US Department of Labor.|
Emerging Ideas: Tennessee and Washington Offer Distance Learning and a Career Pathway to High School Students
Tennessee and Washington are implementing statewide initiatives to enhance the home- and community-based services and the LTSS workforce. While neither initiative explicitly focus on older adults living in rural areas, both have potential to benefit this group.
Tennessee is launching a statewide LTSS workforce development initiative focused on competency-based learning and career pipeline development. Medicaid developed this initiative because it was experiencing escalating challenges in the recruitment and retention of LTSS workers in HCBS waiver programs. It also knew developing competent staff capable of delivering high-quality services as key to successful implementation of the managed LTSS program for people with developmental disabilities. The state plans to incentivize completion of the training program by establishing value-based payment (VBP) arrangements that reward workers with higher wages for increased competency and also rewards providers for employing a more highly trained workforce. Tennessee worked with experts to design this initiative to correspond to the set of core competencies for direct service workers produced by CMS in 2014. The Medicaid agency worked with the Tennessee Board of Regents to create a post-secondary certificate program and to leverage state last dollar funding programs to help cover training costs. Steps taken to ensure that the initiative would benefit rural areas included:
- Delivering training through Tennessee’s statewide system of community colleges and Colleges of Applied Technology;
- Distance learning; and
- A virtual assessment environment that allow for reliable and valid demonstration of competencies to be completed remotely in a more cost-efficient manner.
In Washington, many home care aides (referred to as individual providers or IPs) are hired and supervised by the person needing LTSS, but are paid by the state. The state is experiencing a shortage of aides, which it expects to grow. In September 2019, Washington plans to launch its High School Home Care Aide training program, which targets high school juniors and seniors. This program will allow high school students to take state-required courses before graduating and learn how to apply their new knowledge through practicums in facilities. Those who complete the course become certified by the state’s health department and will be eligible to work as aides starting when they are 18.18 State officials see this not only as a way to address the shortage of home care aides it currently faces, but as offering young people an opportunity to start a health care career.
State agencies can implement strategies that increase the availability of existing services in rural areas. Most of these strategies focus on modifying billing policies to make it easier for providers to deliver services in rural areas. But at least one state has also modified its Medicaid eligibility policies to begin serving older adults in rural communities before they need LTSS in hopes of delaying or preventing the need for such services.
Georgia pays for mobile adult day health services, which are provided by staff who travel from a central location on a daily basis to various sites, primarily (but not limited to) rural areas. The Department of Community Health (DCH) licenses adult day care, including mobile adult day care. The Medicaid program will pay for the service under two Medicaid 1915(c) waiver programs that serve the elderly and younger adults with disabilities. According to the Medicaid provider handbook, the purpose of these services is “to allow caregivers in rural and/or underserved areas a respite from 24-hour-a-day, care-giving responsibilities and to allow members the opportunity to participate in social, health, and rehabilitative services.”19 The Department of Human Services’ (DHS) Division of Aging Services will also pay for mobile day care services for older adults (60 and older) who do not qualify for Medicaid services. In Georgia, local Area Agencies on Aging (AAA) deliver non-Medicaid services under contract to the Division of Aging Services and at least one AAA that serves a largely rural area (Coastal Georgia AAA), provided the service during fiscal year 2019.
How Georgia Developed Mobile Adult Day Care and Health Services
· DHS Division of Aging Services
|State policy levers:||Federal authority:|
· HB 318 Adult Day Center Licensure Act
|Medicaid 1915(c) waiver|
|Regulation and guidance
· Department Of Community Health 111-8-1, Rules And Regulations For Adult Day Centers (defining licensing requirements)
· Medicaid provider manual
· Area Plan for Aging Services, which specifies the services AAAs provide under contract to the Division of Aging.
The Arizona Health Care Cost Containment System (AHCCCS), which is Arizona’s Medicaid program, uses differential payments to reward providers “who have committed to supporting designated actions that improve patients’ care experience, improve members’ health, and reduce cost of care growth.” For example, nursing facilities that have fewer than average patients with pressure ulcers are eligible for a 2 percent increase in their reimbursement rates. Most relevant for older adults living in rural areas is a differential payment for Critical Access Hospitals – among other requirements, these hospitals must be more than 35 miles from any other hospital20. These providers qualify for a 0.5 percent increase in payments by joining the State Health Information Exchange, allowing them to access more complete information about the services their patients receive which, in turn, supports quality improvement and care coordination. MCO contracts require the MCOs to make these payments. The state, however, will reimburse MCOs for the added costs of the differential payments.
How Arizona Medicaid Implemented its Provider Incentive Program
|Arizona Health Care Cost Containment System|
|State policy levers:||Federal authority:|
· No legislation required
|Medicaid State Plan Amendment
Note: Although Arizona operates its Medicaid program under a Section 1115 Research and Demonstration waiver, it did not need to amend the waiver to make these payments.
|Regulation and guidance
· R9-22-712.35, R9-22-712.61, and R9-22-712.71 govern standards for payments
· MCO contracts, Section D.81 for all programs, including those serving people with long-term care needs
Utah Medicaid implemented the Rural Home Health Travel Enhancement, under which higher rates are paid to those providers who deliver home health services in rural areas. In most of Utah’s rural counties, Home Health Service payment enhancements are offered for cases in which the provider must travel more than 50 miles. However, enhancement payments for services provided to residents of San Juan and Grand Counties vary by location within the county, with the largest enhancement offered for services delivered to residents of San Juan County’s Monument Valley region.
How Utah Implemented Enhanced Rural Home Health Rates
|State policy levers:||Federal authority:|
· No legislation required
|Medicaid State Plan Amendment, page 10|
|Regulation and guidance
· Medicaid home health provider manual, p 15
In January 2017, the Washington Health Care Authority, which includes the state’s Medicaid agency, launched its Medicaid Transformation Project that operates under a Section 1115 Research and Demonstration Waiver. Through this waiver, Washington established two new Medicaid benefits designed to help older adults delay or avoid the need for LTSS – primarily by supporting older adults’ unpaid caregivers. The Medicaid Alternative Care (MAC) benefit is targeted to older adults (55 and older) who qualify for Medicaid-financed LTSS, but have chosen to wrap services around their unpaid caregiver rather than receive traditional Medicaid-funded services, such as personal care. The Tailored Supports for Older Adults (TSOA) benefit targets older adults who are not currently Medicaid-eligible but are at-risk for future Medicaid-financed LTSS use. TSOA offers two packages of services:
- If the older adult has an unpaid caregiver, the adult receives a package that consists solely of supports for the benefit of the caregiver, such as respite care or training in dementia care. Caregivers qualify for the support based on the financial and functional status of the older adult for whom they care.
- If the older adult does not have an unpaid caregiver, the package offers services, such as personal care, adult day services, home-delivered meals, and personal emergency response systems.
Both MAC and TSOA are administered by the Department of Social and Health Services’ (DSHS) Aging and Long-Term Support Administration (ALTSA). The ALTSA contracts with the AAAs to determine eligibility for services and help caregivers access approved services. This local presence helps ensure that staff determining eligibility are familiar with the caregiver resources available in their areas — a benefit for both rural and urban caregivers. Both benefits also feature presumptive eligibility that enables eligibility staff to begin delivering services quickly.
As of July 2019, state officials report that 2,493 people were participating in TSOA and MAC and almost 5,000 had participated since the start of the program in September 2017. Officials report that major challenges included developing and implementing a new eligibility system for the new benefits. They also found that many informal caregivers (who are often family members) do not think of themselves as caregivers until they become very stressed and, as a result, delay seeking these supports.21 MAC and TSOA are modeled after Washington’s Family Caregiver Support Program, which produced significant savings.22 State officials are optimistic that these new benefits will prove their value, enabling Washington to continue to fund the services after the end of the waiver.
How Washington Launched its Initiative to Help Older Adults Avoid or Delay the Need for LTSS
|· Health Care Authority’s Healthier Washington Initiative and Medicaid agency
· Department of Social and Health Services’ Aging and Long-Term Support Administration (ALTSA)
|State policy levers:||Federal authority:|
· WAC 182-513-1600 (MAC) and WAC 182-513-1610 (TSOA)
|Section 1115 Research and Demonstration Waiver|
|Regulation and guidance
· WSR 17-12-019
· Long-Term Services and Supports Manual for MAC, TSOA, and Presumptive Eligibility
· The ALTSA AAA contract
Since 1997, the Texas legislature has enacted multiple bills that support the use of telehealth, telemedicine, and telemonitoring. Recently, in 2019, Texas enacted to remove barriers to the use of telehealth and telemedicine. Among other things, SB 670 directs the Health and Human Services Commission (HHSC) to ensure Medicaid MCOs do not deny reimbursement for a covered service solely because that service was not provided in an in-person consultation. A study by the state’s Health and Human Services Commission found that the use of telehealth services in Medicaid increased by 30 percent between FY 2016 and 2017 and that the use of telemonitoring services more than doubled.23 Texas Medicaid plans to implement its new legislation through medical policies, administrative rule-making, and MCO contract changes, which it plans to develop with the input of stakeholder workgroups that will include MCO representatives.
One technology-based service that may provide benefit to older adults is telemonitoring. Texas Medicaid will pay for telemonitoring provided by a hospital or home health agency to beneficiaries with diabetes or hypertension who also exhibit specified risk factors, such as two or more hospitalizations within the previous 12 months. In fiscal year 2017, 5,961 Medicaid beneficiaries received this service, which covers daily or weekly monitoring of a patient’s clinical data transmissions. Texas has developed extensive guidance material for providers of these services. Some expressed concern that older adults might not be comfortable using the telehealth equipment, so Texas established some requirements that could mitigate those concerns. Providers are required to have written protocols defining service provision that must discuss the provider’s process to ensure, “The client is able to operate the equipment or has a willing and able person to assist in completing electronic transmission of data.”24 Currently Texas’ MCO contracts, including those for programs serving older adults in rural areas, specify these services are covered as described in the Texas Medicaid Provider Procedures Manual.25
How Texas Launched its Telehealth, Telemedicine, and Telemonitoring Initiatives
|· Health and Human Services Commission (HHSC)|
|State policy levers:||Federal authority:|
· SB1107, defining scope-of-practice requirements and delivery modalities
· SB670, most recent legislation, containing multiple changes to support use of telehealth and telemedicine
· And others
|Current Medicaid State Plan authority will support these changes.|
|Regulation and guidance
· Medicaid provider procedures manual
· Telehealth, telemedicine, and telemonitoring is specified as a covered benefit in all MCO contracts (page 8-195)
Emerging Ideas: Arizona Plans to Use Electronic Visit Verification System for Planning and MCO Oversight
Federal statute requires states to implement electronic visit verification (EVV) systems for all Medicaid-funded personal care services by Jan. 1, 2020 and home health services by Jan. 1, 2023.26 EVV systems must be able to verify specific information about each in-home visit, including type of service provided, person receiving the service, date of service, and start and end times of the service. 27 AHCCCS is leveraging this new requirement to gather data for planning and MCO oversight. MCOs are required to initiate home health services within 30 days of identifying the need for the service for new members or in 14 days for existing members in need of new services. The system will also allow better monitoring of the population’s access to care (i.e., gap reporting28) by tracking at a system level how often providers fail to arrive for their visits. For individual patients, AHCCCS intends for this new system to enable real-time resolution of missed visits — improving patient care by ensuring receipt of critical services.29 Finally, state officials plan to use the system to analyze provider networks by geographic region. Officials view this capability as particularly beneficial for older adults living in rural areas as they have anecdotal evidence that access to care is a large problem in rural areas and this system will enable them to assess the accuracy of the anecdotal information.
Transportation is one of the major barriers to care in rural areas. It particularly impacts older adults, as 21 percent of Americans age 65 or older do not drive.30 In addition, older adults in rural areas have other social concerns that affect their health, such as food insecurity. Many states are working to address transportation needs and some are moving to a more comprehensive approach to identify and address these social determinants of health (SDOH).
North Carolina’s Department of Health and Human Services (DHHS) entered into a public/private partnership with the Foundation for Health Leadership and Innovation (FHLI) to build the North Carolina Resource Platform, a secure shared technology platform that manages referrals for social services (e.g., housing and food assistance), with the capability to “close the loop” on referrals. In 2018, FHLI selected NCCARE36031 to build a statewide, coordinated care network using this platform. NCCARE360 also includes a statewide resource directory (building on the state’s 2-1-1 program) and a call center. NCCARE360 plans to succeed by empowering the communities it serves to be key leaders in building the system. Therefore, NCCARE360 assigns a community engagement manager to each region in the state. The manager works with the community to implement NCCARE360 and then continues to work in that region to update the system and, along with a customer success team, ensures smooth operations. As of May 2019, one health system had embedded this platform into its electronic health records (EHR). As of August 2019, NCCARE360 was operating in eight rural counties and four urban/suburban counties. Implementation was underway in an additional 17 counties, 16 of which are rural. State officials anticipate NCCARE360 will be fully operating statewide by the end of 2020. Prepaid Health Plans (North Carolina Medicaid’s managed care organizations) are required to use the “NC Resource Platform” (NCCARE360) to identify and connect their members to community-based resources. While the system is not targeted specifically to older adults it was developed with a consideration of their needs and contains information about the resources available to them.
How North Carolina Launched the NCCARE360 Resource Platform
|· Department of Health and Human Services (DHHS)|
· Foundation for Health Leadership and Innovation
· And many others
|State policy levers:||Federal authority:|
· No legislation required
|Section 1115 Research and Demonstration Waiver allows implementation of managed care and Healthy Opportunities.|
|Regulation and guidance
· Part of DHHS’ Healthy Opportunities Initiative and the State’s IT Roadmap
· Prepaid Health Plan contract requires contractors to use NCCARE360, page 125
Rhode Island’s SIM Initiative fostered the growth of community health teams (CHTs) in Rhode Island as a way to address the SDOH of high-risk patients, including those with behavioral health needs. A CHT must include at least one licensed, community-based health professional (often a behavioral health clinician) and two certified CHWs, but they often include additional staff, such as a Screening, Brief Intervention, and Referral to Treatment screener.32 These multi-disciplinary teams work as extensions of PCPs in the community to provide comprehensive care plan development and coordination to high-risk patients, including identification and management of physical, behavioral, substance use, and social needs. CHTs conduct health assessments, develop and implement care plans, facilitate referrals, assist with medical appointments, and link patients to community resources. As of July 2019, there were eight CHTs operating in Rhode Island, some of whom serve rural areas. Most CHTs negotiate partnerships with multiple practices, including negotiating patient referral criteria and processes. The CHTs are designed as a “place-based” intervention, working in identified geographic regions, and CHT members do work within PCPs’ offices, but spend much of their time visiting patients in their homes or finding patients in community settings. An additional benefit is CHT members know local resources and have established relationships in the community.
One recent study found that over a six-month period in 2018, eight CHTs served 2,202 patients. Researchers examined detailed information about a subset of patients33 and found they:
- Ranged in age from 18 to 96;
- 60.1 percent were female; and
- 90 percent had at least one SDOH challenge.
CHT engagement lowered health risk and other screening scores.34 Four of the CHTs were established with the support of braided funding from the state’s SIM award, which ended in June 2019. Moving forward, CHTs are supported by braided funding that includes funding from:
- Medicaid Health System Transformation Project to enable CHTs to be a place-based support for accountable entities (AEs are Rhode Island Medicaid’s ACO-like provider organizations);
- State Opioid Response (SOR) grants to bolster the opioid related substance use response provided by the CHTs; and
- Commercially licensed health plan spending facilitated by the Office of the Health Insurance Commissioner (OHIC). (Note: Insurance regulations in Rhode Island incentivize health plans to make investments in primary care, and when primary care investment targets are missed by health plans, OHIC can assist with directing remaining funds toward activities, such as CHTs.)
How Rhode Island Launched Community Health Teams to Address SDOH
|· Rhode Island Department of Health
· Executive Office of Health and Human Services (EOHHS)
· EOHHS Division of Medicaid
· Office of the Health Insurance Commissioner (OHIC)
· Department of Behavioral Healthcare, Development Disabilities and Hospitals
|State policy levers:||Federal authority:|
· No legislation required.
|SIM award authorized funding to support CHTs
SOR grant funds support CHTs
Section 1115 Waiver (Rhode Island operates its Medicaid program, including the Medicaid Health System Transformation Project, under the waiver but did not need to amend it to begin paying for CHTs)
|Regulation and guidance
· OHIC’s Regulation 2 establishes the requirement for health plans to invest in primary care
· Contract for CHT support
· MCO Contract
Tennessee enacted legislation in 2015 (Public Chapter #152) to limit the liability of volunteer drivers who provide rides for older residents through a charitable organization or human services organization. The state’s Commission on Aging and Disability worked to facilitate the formation of these programs, which offer rides to medical appointments as well as for other purposes, such as going to grocery stores. Among these programs are MyRide TN, which is sponsored by the Tennessee Commission on Aging and Disability and serves multiple counties in the state, including eight rural counties. The volunteer programs leverage the legislation when recruiting volunteer drivers. They also leverage Older Americans Act funding. In addition, riders who must be at least 60 years of age, pay a small fee for rides. According to state officials, 40 percent of the trips provided by the volunteer services are for doctor visits.35
How Tennessee Launched MyRide TN
|· Tennessee Commission on Aging and Disability|
|State policy levers:||Federal authority:|
· Public Chapter No. 152 (Senate Bill No. 117)
|Tennessee State Plan on Aging|
|Regulation and guidance
Ohio estimates that five state agencies (including Medicaid) spend about $228 million each year on client transportation.36 Ohio has taken several steps to better coordinate these transportation networks at the regional level, including providing tools and resources to help rural counties develop coordinated transportation plans. These plans are a requirement for three grant programs, including the federally funded Specialized Transportation Program, the Ohio Coordination Program, and the Ohio Mobility Management Program. These plans all consider the needs of older adults. State officials point to the mobility management program as particularly beneficial to older adults in rural areas. The state Department of Transportation oversees this program, which distributes federal funding authorized under the Elderly Individuals with Individuals with Disabilities (Section 5310) Program to private non-profit, as well as, designated state and local government authorities to support mobility management activities. This program supports local mobility managers across the state. These managers work with stakeholders to meet the transportation needs of older adults and people with disabilities by connecting individuals to available resources, promoting transportation resources, and working with stakeholders to identify and develop plans to meet local needs.
How Ohio Used Federal Transportation Funding
|· Ohio Department of Transportation|
|State policy levers:||Federal authority:|
· No legislation required
|Section 5310 Funding|
|Regulation and guidance
· State program guidance for mobility management program
Effective May 1, 2019, AHCCCS (Arizona’s Medicaid agency) allowed Transportation Network Companies (i.e., ride-share companies such as LYFT and Uber) to register to provide non-emergency medical transportation (NEMT) to Medicaid beneficiaries. The first ride-share company completed registration in June 2019. These companies may only provide medically necessary rides to beneficiaries who do not need personal assistance, which enabled AHCCCS to establish reduced training requirements for drivers (e.g., CPR training is not required for ride-share drivers). In Arizona, MCOs are responsible for delivering NEMT and they have, in turn, contracted with brokers to deliver the service. Therefore, the ride-share company will need to develop payment arrangements with the MCO’s broker before it can be paid for delivering NEMT services and the ride will need to be scheduled by the broker. One state official described the potential benefit to older adults living in rural areas this way, “Over a quarter of members reside in rural areas, and half of utilization occurs in rural areas. That would predict that there is disproportionate benefit [in this new NEMT option] for rural areas.”
North Carolina Medicaid is implementing the Healthy Opportunities pilot program in several, yet-to-be-determined, areas of the state. As part of this pilot, North Carolina will contract with competitively selected Lead Pilot Agencies that will serve as the connector between managed care entities and local social services agencies. These agencies will implement and test evidence-based interventions to address the SDOH needs of Medicaid beneficiaries, including housing, food insecurity, and transportation. North Carolina is implementing this program under its Section 1115 Waiver for Medicaid Transformation and has earmarked up to $650 million over five years for the pilot projects. If the pilots prove effective, the Medicaid agency anticipates establishing them across the state. As of August 2019, the Medicaid agency anticipated completing its Lead Pilot Agency selection process in early 2020.
Providing appropriate and timely patient care in the home along with assessment of other needed services can support older adults’ desires to remain in their homes and communities, support families, and limit more costly care in nursing facilities. This toolkit provides examples of state policies and programs that address the health care needs of older, rural adults. Many of these programs also facilitate older adults’ access to social services, which can bolster the health of the population. Several lessons learned and key findings emerged from this research and discussions with state officials and others involved in program implementation:
Designing strategies based on community-defined needs and involvement leads to success. Both Tennessee’s voluntary transportation program and North Carolina’s technology platform to address SDOH, for example, are implemented on a region-by-region basis as stakeholders are engaged. One Minnesota official observed that, “…Usually, that results in a faster uptake of the service if the provider community is driving the development.”
Using pilot programs to field-test strategies enabled states to gather data for building the case for wide-scale implementation and improve operations before expansion. Washington State’s new programs to support caregivers, for example, were built on the success of their Family Caregiver Support Program (FCSP) which, state officials report, was “found to have positive ROI [return on investment] when caregivers are supported and care receivers delay or avoid Medicaid LTSS.” Minnesota’s Community Paramedics program, Tennessee’s voluntary transportation program, and Georgia’s mobile day care program were each built on the success of a single local pilot.
While technology can facilitate service delivery, it still requires human resources and community engagement to be effective. North Carolina is implementing its shared technology platform that manages referrals between health and social services providers, which states that, “NCCARE360 will only be successful if it is built by the community it serves.”37 To turn that sentiment into action, NCCARE360 hires a locally-based community engagement manager to implement the system in each region. The manager brings together stakeholders to plan and work with health and social services providers to incorporate them into the system and, in turn, help them incorporate the platform into their workflows. A community-based organization in Missouri operates a transportation program (without state agency involvement) that relies on a cloud-based, similar platform to enable providers to book rides for their patients within two minutes. The leaders of these programs agree that the technology only succeeds in engaged communities where providers, transportation providers, and other stakeholders work together to populate and use the platform with the facilitation of a local coordinator.38
Professionalizing the caregiver workforce benefits both the people receiving services and the workers. Both Washington and Tennessee have made efforts to ensure that HCBS workers have a career path and are rewarded for increasing their capabilities through training. Washington State focuses on formal caregivers (those who are paid to provide personal care services). It offers caregivers who become certified as a home care aide training, health care coverage, paid time off, and retirement benefits. Aides are also represented by the Service Employees International Union (SEIU 775). State officials report they believe that building the knowledge of caregivers, who act as the eyes of the delivery system, results in better care. Also, offering aides a career path, including increased payment for increased capabilities, reduces caregiver burnout and, in some cases, serves as a stepping stone to other careers in health care.
States have chosen to keep the broad delivery system and payment reforms they implement focused on improving health outcomes statewide, including older adults living in rural areas. Some states did implement reforms that focused on LTSS providers and the Medicaid beneficiaries they serve, but none had a rural focus.39 Some states also implemented complementary strategies to ensure that the statewide programs operate with local knowledge, which would help ensure that the statewide reforms met rural needs. For example, Washington created regional Accountable Communities for Health (ACHs) throughout the state. The ACH’s bring together local leaders to plan for and support local implementation of statewide payment and delivery system reforms.
The Medicaid program offers states flexibility to design and implement a wide variety of strategies designed to support older adults living in rural areas. Nearly all strategies presented in this toolkit were implemented within Medicaid programs. States had to amend their Medicaid State plans or obtain a waiver to implement some of these strategies. Many, however, were implemented under the state’s existing federal authority — and Arizona leveraged the new federal requirement for electronic visit verification to create a new tool for planning. Most of the strategies however, required partners, drew on the resources and expertise of other agencies (e.g., aging), and relied on contractors (such as MCOs) and local agencies for implementation.
Not only are there higher concentrations of elderly residents in rural areas than in urban areas, but compared to their urban peers, older, rural adults are poorer, have more complex conditions, and experience the impact of health-related social factors more acutely. Older adults living in rural areas are also less likely than those in urban areas to use home- and community-based services and more likely to use nursing facility services. These factors, combined with provider shortages in rural areas, make it difficult for older adults to remain in their homes and communities as they age. States want to help older adults remain in their communities both because it is what older adults want and to contain cost. In recent years, states have implemented a number of strategies to help older adults remain in their communities. These strategies have been implemented by different agencies working with a wide variety of partners and leveraging multiple federal authorities. The examples presented are designed to help states learn from each other as they continue to work to meet the health needs of older adults living in the nation’s rural regions.
 “Shrinking share of Americans in rural communities,” Pew Research Center’s Social & Demographic Trends Project, Pew Research Center, May 22, 2018, https://www.pewsocialtrends.org/2018/05/22/demographic-and-economic-trends-in-urban-suburban-and-rural-communities/psd_05-22-18_community-type-01-00/ . (Accessed August 19, 2019).
 “Older Adults and Unmet Social Needs Prevalence and Health Implications,” AARP, November 2017, https://endseniorhunger.aarp.org/wp-content/uploads/2017/11/SDOH-among-older-adults-2017_IssueBrief_COR-Final.pdf .(accessed August 19, 2019).
 Andrew Coburn, Eileen Griffin, Deborah Thayer, Zachariah Croll, Erika C. Ziller. “Are Rural Older Adults Benefiting from Increased State Spending on Medicaid Home and Community Based Services?” Maine Rural Health Research Center, June 2016, https://muskie.usm.maine.edu/Publications/rural/Medicaid-Home-Community-Based-Services-Rural.pdf (accessed August 19, 2019).
 “Baby Boomer Facts on 50 Livable Communities and Aging in Place,” AARP, 2014, https://www.aarp.org/livable-communities/info-2014/livable-communities-facts-and-figures.html . (Accessed August 19, 2019).
 Karen Marek, Frank Stetzer, Scott Adams, Lori Popejoy, and Marilyn Rantz. “Aging in Place versus Nursing Home Care: Comparison of Costs to Medicare and Medicaid,” Research in Gerontological Nursing. U.S. National Library of Medicine, April 2012, https://www.ncbi.nlm.nih.gov/pubmed/21846081. (Accessed August 19, 2019).
 Although the primary focus of this paper is on the services that help older adults remain in their homes, some examples of state strategies to support nursing facilities are included as it is also important to ensure that older adults in rural areas that need that level of care can access high quality care in their own communities.
 Ester Hing, Chun-Ju Hsiao. “State Variability in Supply of Office-based Primary Care Providers: United States 2012. NCHS Data Brief” US Department of Health and Human Services, May 2014. https://www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/PDFs/db151.pdf (Accessed August 19, 2019)
 Susan Jaffe. “Aging In Rural America,” Health Affairs, January 2015, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1372 . (Accessed August 19, 2019).
 Paramedics have more training than EMTs and are, therefore, licensed to perform a broader range of services.
 “Community Emergency Medical Technician Services: Purchasing and Service Delivery,” Minnesota Department of Human Services, March 2016, https://www.leg.state.mn.us/docs/2016/mandated/160410.pdf . (Accessed August 19, 2019).
 “Community Emergency Medical Technician Services: Purchasing and Service Delivery,” Minnesota Department of Human Services, October 2017, https://mn.gov/dhs/assets/2017-12-cemt-report_tcm1053-319648.pdf . (Accessed August 19, 2019).
 “Minnesota In Need Of More Community Paramedics,” CBS local news, May 2019, https://minnesota.cbslocal.com/2019/05/20/minnesota-in-need-of-more-communit-paramedics/ . (Accessed August 19, 2019).
 Dawn Juker. “Community Health EMS.” CHEMS Roundtable Discussion, Idaho Office of Healthcare Policy Initiatives, https://ship.idaho.gov/WorkGroups/CommunityHealthEMS/tabid/3050/Default.aspx. (Accessed August 19, 2019).
 Note: Federal Medicaid rules allow Medicaid agencies to pay for care coordination services provide by CHWs, but Minnesota did not implement that policy.
 “Medicaid Quality Improvement and Hospitalization Avoidance (MQIHA),” MQIHA, Project ECHO. https://echo.unm.edu/teleecho-programs/mqiha. (Accessed August 20, 2019).
 “Alaska Apprenticeship Plan,” Alaska Department of Labor and Workforce Development, October 2018, https://labor.alaska.gov/awib/Alaska_Apprenticeship_Plan-10-2018.pdf. (Accessed August 20, 2019).
 Community Health Aides are certified by the Alaska Community Health Aide Program Certification Board, hired by their local community and, under the supervision of a licensed medical provider, serve as the primary source of health care in over 170 rural Alaska villages. (Source: www.akchap.org).
Patti Killingsworth. “Shore It Up: Strengthening the LTSS Workforce,” TennCare, August 2018, https://custom.cvent.com/024D0492CF3C4ED1AEDC89C0490ECDEE/files/event/E097A8FCDDD34B0CAFD1DC01FFFFC9B8/d95885cf9327410683d59a030fb77136tmp.pdf . (Accessed August 20, 2019).
 “Policies and Procedures for CCSP and SOURCE Adult Day Health Services,” Georgia Department of Community Health, Division of Medicaid, July 2019, https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/CCSP%20and%20SOURCE%20Adult%20Day%20Health%20Services%2020190625135647.pdf . (Accessed August 20, 2019).
 “Critical Access Hospital,” CMS, July 2019, https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/critaccesshospfctsht.pdf . (Accessed August 20, 2019).
 Additional resources to help identify caregiver needs include the Caregiver Self-Assessment Questionnaire developed by the American Medical Association and Selected Caregiver Assessment Measures: A Resource Inventory for Practitioners produced by the Family Caregiver Alliance.
 “Long Term Services and Supports FAQs,” Healthier Washington, Washington State Health Care Authority. August 2017, https://www.hca.wa.gov/assets/program/mtd-i2-faq.pdf . (Accessed August 20, 2019).
 “Telemedicine, Telehealth, and Home Telemonitoring Services in Texas Medicaid,” Texas Health and Human Services Commission, December, 2018, https://hhs.texas.gov/sites/default/files/documents/laws-regulations/reports-presentations/2018/sb-789-telemedicine-telehealth-hts-medicaid-dec-2018.pdf . (Accessed August 20, 2019).
“Texas Medicaid Provider Procedures Manual,” The Texas Medicaid & Healthcare Partnership, August 2019, https://www.tmhp.com/Manuals_PDF/TMPPM/TMPPM_Living_Manual_Current/2_Telecommunication_Srvs.pdf . (Accessed August 20, 2019).
 “STAR+PLUS MRSA Contract Terms and Conditions,” Texas Health & Human Services Commission, April 2019, https://hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/programs/contracts/starplus-mrsa-contract.pdf . (Accessed August 20, 2019).
 “Electronic Visit Verification (EVV),” Medicaid.gov, https://www.medicaid.gov/medicaid/hcbs/guidance/electronic-visit-verification/index.html . (Accessed August 20, 2019).
 “21st Century Cures Act,” Public Law No: 114-255. https://www.congress.gov/bill/114th-congress/house-bill/34/text
 “Chapter 400 – Operations,” AHCCCS Contractor Operations Manual, Arizona Health Care Cost Containment System, June 2018, https://www.azahcccs.gov/shared/Downloads/ACOM/PolicyFiles/400/413_Gap_in_Critical_Services.pdf . (Accessed August 20, 2019).
 “Chapter 500 – Care Coordination Requirements,” AHCCCS Medical Policy Manual, Arizona Health Care Cost Containment System, Unpublished, https://www.azahcccs.gov/PlansProviders/Downloads/RFPInfo/YH19/EVV/540_EVV.pdf . (Accessed August 20, 2019).
 Linda Bailey. “Aging Americans: Stranded Without Options,” TRID, March 31, 2004, https://trid.trb.org/view/697686 . (Accessed August 20, 2019).
NCCares360 is a joint-venture of United Way of North Carolina; Unite Us, Expound Decision Systems, and Benefits Data Trust. (Source: https://foundationhli.org/2018/08/21/ncccare360-selected-to-build-a-new-tool-for-a-healthier-north-carolina-the-nc-resource-platform/)
 Screening, Brief Intervention, and Referral to Treatment (SBIRT) screeners are trained to use a standardized tool to quickly assess the severity of substance use and determine the appropriate level of treatment.
 The sample consisted of all new patients seen between October 1 and January 31, 2019 by seven of the eight CHTs. Source: https://www.rimed.org/rimedicaljournal/2019/04/2019-04-42-health-rajotte.pdf
 Rajotte, James C, Colleen A Redding , Catherine E Hunter, and Shayna S Bassett. “Initial Findings: Rhode Island’s Community Health Teams Address Complex Physical, Behavioral, and Social Needs of Patient Populations.” Rhode Island Medical Journal , April 2019, https://www.rimed.org/rimedicaljournal/2019/04/2019-04-42-health-rajotte.pdf . (Accessed August 20, 2019).
 “Aging and Transportation as a Necessity,” American Society on Aging, March 2018, . https://www.asaging.org/blog/aging-and-transportation-necessity . (Accessed August 20, 2019)..
 The Ohio Department of Transportation estimated this number based on reports from the state agencies. These reports covered different time periods between 2010 and 2014. Source: https://www.dot.state.oh.us/Divisions/Planning/Transit/TransitNeedsStudy/Documents/InitiativePaper-HumanServiceTransportation.pdf
 “NCCARE 360 Quarterly Report,” FHLI and DHHS, March 2019,https://foundationhli.org/wp-content/uploads/2019/05/NCCARE360-Quarterly-Report-January-March-2019.pdf (Accessed August 20, 2019)
 Missouri HealthTran is operated by the Missouri Rural Health Association without state agency involvement. Therefore it was not featured in this toolkit, but more information is available at: https://www.healthtran.org/
 We did not include these statewide reforms in this toolkit due to the lack of focus on older adults living in rural areas. The VBP programs we identified as having a focus on LTSS providers or the patients they serve were: Tennessee’s Quality Improvement in Long Term Services and Supports (QuILTSS) program, Arkansas’s Provider-led Arkansas Shared Savings Entity (PASSE) program, and Arizona ALTCS’ Alternative Payment Model Initiative.
Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. Once common, deadly diseases such as polio, measles, and mumps are preventable and smallpox no longer exists outside of a laboratory. According to research estimates, of 4.3 million infants born in the United States in 2009, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 spent on immunizations.
Despite these successes, states are working to improve their immunization rates, which hovered at 68.4 percent nationwide in children ages 19 to 35 months in 2012. California is using an assortment of strategies and inducements to boost its immunization rates.
How Can States Increase Immunization Rates through Medicaid?
Medicaid plays a key role in the delivery of vaccines, especially among vulnerable populations including children and pregnant women. Because Medicaid covers a large percentage of US children (39 percent), increasing childhood immunization rates among Medicaid beneficiaries can generate significant long-term savings. US Centers for Disease Control and Prevention (CDC) officials estimate that vaccinating children born between 1994 and 2018 has saved the United States about $300 billion in direct medical costs and $1.38 trillion in total costs, and protected millions from serious diseases.
State Medicaid programs can employ a variety of levers to increase immunization rates among their beneficiaries, from ensuring access and coverage for vaccines to tracking targeted metrics that inform provider incentive payments and reimbursement. These levers include:
- Providing comprehensive coverage: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s benefit for children and adolescents younger than 21, as described in Sec. 1905(r) of the Social Security Act. The EPSDT benefit requires that states provide all vaccines recommended by the Advisory Committee on Immunization Practice (ACIP) to all children eligible for EPSDT benefits.
- Making vaccine available: Through the Vaccines for Children (VFC) program, the CDC purchases vaccines at a discount and distributes them to state health departments and other local and territorial public health agencies. These entities distribute the vaccines to private and public health providers who are registered as VFC Children are eligible for VFC-funded vaccines if they are younger than 19 and Medicaid-eligible, uninsured, American Indian or Alaska Native, or underinsured and vaccinated in certain settings. VFC-eligible children receive recommended vaccines at no cost when administered by a registered VFC provider.
- Using metrics: The US Department of Health and Human Services sets annual Medicaid and Children’s Health Insurance Program (CHIP) health care quality measures to ensure providers deliver appropriate care to their patients. The 2019 Medicaid and CHIP Core Set of Children’s Health Care Quality Measures includes the Healthcare Effectiveness Data and Information Set (HEDIS) Childhood Immunization Status measure.* Monitoring and measuring changes in vaccine delivery through this metric is a critical step to improving targeted immunization rates.
- Using incentive measures: State Medicaid programs can use incentive payments to increase immunization uptake. For example, evidence shows that incentive payments to providers through Medicaid pay for performance programs increases childhood immunization rates.
- Performance improvement projects (PIPs): State Medicaid programs can encourage managed care organizations (MCOs) to focus on improving immunization rates by including it as one of their PIPs. Medicaid MCOs participate annually in PIPs.
- Form partnerships to strengthen immunization efforts: Multiple state agencies play an important role in increasing immunization rates. Medicaid and public health agencies can partner with other stakeholders to address mutual goals.
- Data sharing: States have various data sources from different agencies that may include information on vaccination status. This includes immunization information systems (IIS), which are confidential, population-based computerized registries that record vaccination doses and are usually maintained by public health departments, and Medicaid Management Information Systems (MMIS), which contain Medicaid claims data. Data exchanges between IIS and MMIS can help identify missed opportunities for vaccination, monitor gaps in immunization coverage, and improve vaccination rates.
A Healthy People 2020 immunization target is to increase the percentage of children ages 19 to 35 months who receive the recommended doses of diphtheria, tetanus, and pertussis (DTaP), polio, mumps-measles-rubella (MMR), Hib (meningitis), hepatitis B, varicella and pneumococcal conjugate vaccine (PCV) to 80 percent, from the 2012 average of 68.4 percent. As of 2017, California’s combined seven-vaccine series coverage rate among children ages 19 to 35 months was 68.6 percent. California’s health-related agencies have been working over the last several years to increase the state’s childhood immunization rates. Medi-Cal, California’s Medicaid Program, covers 43 percent of children in the state, so Medi-Cal has strong incentives to work to improve vaccination rates among its beneficiaries. Medi-Cal uses the following levers to reach this goal.
- Comprehensive coverage: The California Department of Health Care Services (DHCS) administers the EPSDT benefits to all low-income youth enrolled in Medi-Cal consistent with the federally mandated benefit. Pregnant women (of any age) and all children younger than 21 are eligible for Medi-Cal if they meet income limits.
- Vaccine availability: Medi-Cal participates in the VFC program to ensure that vaccines are eligible at no charge to public and private providers for eligible children. DHCS reimburses enrolled providers the administrative fee per dose of vaccine. In 2018, the California Department of Public Health (CDPH) distributed approximately $665 million worth of ACIP-recommended pediatric vaccines through the VFC program. Immunizations are also a medical and pharmacy benefit for all adult Medi-Cal members, including pregnant women.
- Metrics: California’s Medi-Cal program collects the HEDIS measure “Childhood Immunization Status” from all of its MCOs, which requires the administration of the 10 ACIP-recommended vaccines by age two. MCOs are required to meet a minimum performance benchmark on the childhood immunization measure – 50 percent of all Medicaid health plans nationally, as determined by the National Committee for Quality Assurance). When MCOs do not meet the benchmark, quality improvement work is required, sanctions are imposed, and corrective action may be imposed. MCOs are contractually required to document each member’s need for ACIP-recommended immunizations as part of all regular health visits, and to ensure that all children receive ACIP-recommended immunizations at any health care visit.
- Incentive measures: California’s Medi-Cal program operates a directed payment Quality Incentive Program (QIP) that directs MCOs to make QIP payments to designated public hospital systems tied to performance on specific performance metrics, including the Childhood Immunization Status and Immunization for Adolescents measures. As part of California’s 1115 Waiver, Medi-Cal provides incentive payments to designated public hospital and district and municipal hospital systems tied to performance on specific performance metrics, including the Influenza Immunization measure for members ages six months and older [California’s Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program]. In addition, California’s Medi-Cal Value-Based Payment Program provides an incentive payment to providers for administration of several vaccinations, including the pertussis vaccine to women who are pregnant (supporting the HEDIS Prenatal Immunization Status Measure), the influenza vaccine to adults 19 years and older, and the last dose of any of the multiple-dose vaccine series given on or before a child’s second birthday (DTaP, polio, hepatitis B, Hib, pneumoconccal conjugate, rotavirus, and influenza), supporting the Childhood Immunization Status measure.
- Performance improvement projects (PIPs): In 2016, DHCS identified improving childhood immunization rates as one focus topic for its PIP because less than three-quarters of young children enrolled in Medi-Cal were fully immunized, and immunization is an area with quantified health disparities, especially within the Medicaid program. Between 2015 and 2017, five health plans participated in PIPs to improve immunizations of two-year-olds. In 2018, health plans with low or declining performance on the HEDIS childhood immunization indicator were required to participate in a childhood immunization-focused PIP. Between 2017 and 2019, 15 health plans participated in PIPs to improve childhood immunization rates. Beginning in the fall of 2019, health plans will embark on their third round of PIPs, one of which will focus on childhood and adolescent health. To date, seven health plans have submitted PIP-focused proposals to improve childhood immunization rates. Separate from the PIPs, as noted above, when health plans do not meet the required performance benchmark for the childhood immunization measure, DHCS requires those plans to conduct a rapid cycle quality improvement project to improve their immunization rates. DHCS is striving to increase its overall managed care childhood immunization rate to at least 80 percent coverage.
- Partnerships that strengthen immunization efforts: Medi-Cal partners with multiple stakeholders, including CDPH and other state agencies, health care providers, and other private entities. CDPH provides technical assistance to public and nonprofit health clinics, participates in the multi-sector California Immunization Coalition, and assists schools and childcare centers in complying with state immunization requirements.
CDPH continues to develop and support efforts to address disparities in immunizations of minority and uninsured children, including a focus on increasing prenatal immunization with the TDaP vaccine among pregnant Latina women. In 2015, CDPH undertook several initiatives, including the DHCS National Governor’s Association Learning Collaborative, to increase prenatal immunization rates.
- Data sharing: California’s IIS – the California Immunization Registry (CAIR) – supports immunization by:
- Providing a comprehensive immunization record that can adapt to changes in the medical home or health insurance;
- Calculating which shots children need and minimizing under- or over-immunization;
- Issuing reminders of upcoming visits; and
- Identifying individuals and populations with low immunization rates.
The Medi-Cal program requires its MCOs to ensure that immunizations are reported to the registry. California physicians’ offices, clinics, families, and schools are estimated to have saved several millions of dollars annually as a result of the registry.**
California uses strategic levers to increase immunization rates in its Medicaid population, including identifying the target populations’ EPSDT benefits, identifying metrics for quality improvement programs, and developing strategies to incentivize providers to improve their immunization rates. These levers enable the Medicaid agency to contribute as a critical partner to a strong state partnership supporting a comprehensive strategy for improving immunization rates.
* Percentage of children age two who received four diphtheria, tetanus and acellular pertussis (DTaP); three polio; one measles, mumps and rubella (MMR); three haemophilus influenzae type B; three hepatitis B, one chicken pox; four pneumococcal conjugate; one hepatitis A; two or three rotavirus; and two influenza vaccines by their second birthday. This measure calculates a rate for each vaccine and nine separate combination rates.
** California Immunization Registry (CAIR) users include health care providers, public health departments, schools, childcare facilities, family child care homes, WIC service providers, foster care agencies, welfare departments, juvenile justice facilities, and other programs that provide, track, or promote immunization.
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Mary Beth Hance at the Center for Medicare and Medicaid Services, Megan Lindley and Aaron Borrelli at the Centers for Disease Control and Prevention (CDC), Sarah Royce at the California Department of Public Health and Linette Scott at the California Department of Health Care Services for their time and insights, which made this blog possible. The author also wishes to thank Trish Riley and Jill Rosenthal for their contributions to this case study. Any errors or omissions are the author’s. This project is supported by the CDC. This information or content and conclusions are those of the authors.
Addressing lead hazards today generates future economic benefits and improved health outcomes for children. In partnership with the Health Resources and Services Administration, NASHP is publishing a series of case studies highlighting state initiatives to promote lead screening and treatment. This study explores Indiana’s efforts to address this issue within its Medicaid and Children’s Health Insurance Program.
- View or download: State Levers to Promote Lead Screening and Treatment: Maryland’s Strategies
- View or download: Medicaid and Children’s Health Insurance Program Levers to Promote Lead Screening and Treatment: Indiana’s Experience
- To learn about other state initiatives, read NASHP’s 50-State Scan of State Health Care Delivery Policies Promoting Lead Screening and Treatment.
Care coordination has long been a core component of state efforts to improve health outcomes, reduce caregiver and patient burden, decrease health care costs, and strengthen systems of care for children and adults with chronic and complex conditions.
The National Academy for State Health Policy (NASHP), with support from the Lucile Packard Foundation for Children’s Health, is developing National Care Coordination Standards for Children and Youth with Special Health Care Needs (CYSHCN). These voluntary standards are designed to help states develop robust, high-quality care coordination programs for children with chronic and complex conditions.
NASHP’s work to develop care coordination standards is shaped by key informant interviews, a comprehensive literature review of evidence-based child and adult models, and a National Care Coordination Standards National Work Group comprised of representatives from state Medicaid agencies and public health programs, health services researchers, health plans, families of CYSHCN, federal agency representatives, and others.
States typically place greater focus on care coordination models for adults as compared with children. That trend, however, is changing as a result of state efforts to integrate health care delivery systems for Medicaid-eligible pediatric and adult populations. Federal rules such as the Medicaid Managed Care Final Rule and new investments including the Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation Integrated Care for Kids model underscore the critical role of care coordination.
Despite widespread recognition about the importance of care coordination for families of CYSHCN, its use varies across the country and is often not well aligned with need. Nearly one-third of families of CYSHCN report that they have not received care coordination services.
On the other hand, many families of children with medical complexity often report an abundance of care coordinators from varying health and social support systems, to the point they reporting having to “‘coordinate the care coordinators.” Furthermore, many states report common challenges in providing care coordination services to CSYHCN and have asked for guidance and resources to help their work.
These challenges include the need to identify the unique needs of CYSHCN, involve families in care coordination design and delivery, measure the quality of care coordination services, provide training to the care coordination workforce, and determine adequate payment for care coordination.
The benefits of providing care coordination to CYSHCN and their families are widely recognized. Care coordination programs have been shown to reduce emergency department visits and hospitalizations, decrease costs, avoid delivery of fragmented and duplicative care, improve family well-being, and reduce unmet needs. When provided effective care coordination, families of CYSHCN also report lower financial burden, less impact on their employment, and fewer school absences. In particular, children with medical complexity experience significant benefits from a team-based approach to care coordination, particularly when there is close collaboration with community partners in other sectors.
In the coming months, NASHP will convene the national work group to guide development of the National Care Coordination Standards for CYSHCN and achieve a consensus on the focus and content of the standards. The standards will be finalized and disseminated nationally in spring 2020.
For more information about the National Care Coordination Standards for CYSHCN, please contact Karen VanLandeghem, NASHP senior program director, firstname.lastname@example.org or Kate Honsberger, NASHP senior policy associate, email@example.com.
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.