A new, 50-state analysis of Medicaid managed care programs by the National Academy for State Health Policy (NASHP) shows that in the past three years, state Medicaid managed care (MMC) programs have:
- Enrolled more children and youth with special health care needs (CYSHCN);
- Provided more services to them through managed care; and
- Launched more specialized initiatives serving CYSHCN in managed care.
These trends deviate from past approaches as, historically CYSHCN have often been exempt from MMC due to the complexity of their needs. CYSHCN represent nearly 20 percent of children younger than age 19 and have chronic and/or complex care needs that require physical and behavioral health care services beyond what children normally require. As states become more proficient in developing MMC programs, they are increasingly incorporating CYSHCN into their program designs in an effort to improve quality and reduce costs.
NASHP has updated a 50-state chart and map, originally published in 2017, highlighting new developments in states’ MMC programs that serve CYSHCN. The 2017 analysis found that 47 states use some form of MMC (risk-based, primary care case management, and prepaid health plans) to serve CYSHCN, a figure that remains true in 2020, with the same number of states and Washington, DC continuing to use MMC to serve some or all CYSHCN.
NASHP’s new analysis found a downward trend in traditional fee-for-service (FFS) models and a shift toward innovative delivery systems. Given that 47 percent of CYSHCN are covered by Medicaid, this analysis provides important insight into how states are designing services to meet the unique needs of CYSHCN.
The use of managed care delivery systems is widespread, with states contracting with managed care organizations (MCOs), which are paid on a per-member, per-month basis, to provide services for people enrolled in Medicaid. Thirty-eight states use a risk-based model to serve CYSHCN, in which the MCO assumes the financial risk. Ten states use a primary care case management (PCCM) model in which states contract directly with primary care providers and pay them a case management fee for each enrollee’s care coordination, and three states have a prepaid health plan (PHP) through which health plans are paid per-member, per-month for a limited set of services.
In this new analysis, NASHP identified several key trends among the 47 states and Washington, DC that use MMC to serve CYSHCN, such as the use of specialized MMC plans, MMC enrollment policies for CYSHCN, behavioral health service delivery systems, and quality assessment standards for CYSHCN.
MMC Contract Language for CYSHCN
Since 2017, six states have added a specific definition of CYSHCN to their managed care contracts – 29 states now clearly describe this population of children within their MMC program. Including a definition of CYSHCN in a managed care contract can support identification of CYSHCN and can be used to determine eligibility for specific services and supports. Some states align their definitions with the federal Maternal and Child Health Bureau, Health Resources and Services Administration definition, while others are based on specific health conditions or Medicaid enrollment categories (e.g., children enrolled in Medicaid through the aged, blind, and disabled eligibility category).
More states are also evaluating the quality of care that MCOs provide to CYSHCN using measures that account for their unique needs, as compared to 2017. States are required by federal Medicaid regulations to develop a quality assessment and improvement strategy and to contract with an external organization to evaluate the quality of care provided by their MCOs. In addition to meeting these regulations, 39 states now include specific language in their contract regarding measuring quality of care provided to CYSHCN through MMC delivery systems, an increase of seven states since 2017.
MMC Enrollment Policies for CYSHCN
CYSHCN may be eligible for Medicaid coverage through specific pathways to coverage, including those who are eligible for Medicaid’s aged, blind, and disabled (ABD) category, those receiving Social Security Income (SSI), and those who are enrolled in foster care or who are receiving adoption assistance. Additional subcategories of CYSHCN who may be enrolled in Medicaid include American Indian/Alaskan Native (AI/AN) children, those enrolled in Medicaid home- and community-based service 1915(c) waiver programs, and those enrolled in state Title V CYSHCN programs. States are increasingly mandatorily and voluntarily enrolling these subpopulations into MMC. The majority of states continue to enroll children that are eligible for Medicaid through ABD, SSI and youth in foster care or receiving adoption assistance in managed care. Over the past three years, the number of states that enroll AI/AN children and those enrolled in 1915(c) waiver programs has increased by more than 10 for each subgroup. Together, these trends may point to an increased understanding among state Medicaid programs of the diverse needs among CYSHCN subgroups.
Specialized MMC Plans for CYSHCN
Several states have developed specialized managed care plans to meet the unique needs of CYSHCN or subgroups. These plans typically offer tailored benefits that are often not available through their standard MMC plan. The number of states that have specialized MMC plans for CYSHCN has nearly doubled over the last three years.
- Thirteen states (DC, FL, GA, IL, IN, ND, TN, TX, UT, VA, WA, WI, and WV) operate 12 specialized health care plans to serve some or all CYSHCN, an increase of six states since 2017.
- Nine states’ (DC, GA, IL, IN, TN, TX, WA, WI, and WV) specialized plans serve youth in foster care and/or receiving adoption assistance, representing over half of the specialized MMC plans. In 2017, only two such plans existed.
- Six states (DC, IN, ND, TX, UT, and VA) have specialized plans that serve children who are eligible for Medicaid through the ABD category.
- Five states (ND, TN, TX, VA, and WV) enroll children who are enrolled in 1915(c) waiver programs in their specialized plans.
Behavioral Health Service Delivery for CYSHCN
States have historically been more likely to carve behavioral health services out of their MMC plans and deliver these services through distinct behavioral health organizations (BHO) or through FFS arrangements. As more states are shifting to integrate behavioral health and primary care services, they are increasingly providing behavioral health services through their MCOs. As of 2020, 41 states provide behavioral health services through MMC, an increase of eight states since 2017. Six states continue to provide behavioral health services through carve-out FFS and BHO arrangements.
Table 1: States’ MMC Program Design: 2017 – 2020
The table below summarizes key trends across states’ Medicaid managed care programs that serve CYSHCN, such as increases in the number of states that enroll CYSHCN in MMC, offer specialized health care plans that serve CYSHCN, and integrate behavioral health services with primary care for CYSHCN. These and other insights can be found in NASHP’s updated 50-State Chart and Map.
|Feature||Number of States – 2017||Trend||Number of States – 2020|
|Contract provides a clear definition of CYSHCN||23||↑||29|
|Specific quality measures for CYSHCN||32||↑||39|
|Subpopulation enrollment in MMC (mandatory or voluntary for at least one plan)|
|Aged, blind, and disabled||40||↑||42|
|American Indian/Alaskan Native||22||↑||36|
|Foster care youth/adoption assistance||39||↑||46|
|Social Security Income (SSI)||20||↑||33|
|Title V CYSHCN||14||↑||17|
|Specialized plans for CYSHCN*|
|Total states with specialized plans||7||↑||13|
|Includes aged, blind, and disabled||3||↑||6|
|Includes youth in foster care/adoption assistance||2||↑||9|
|Includes Social Security Income||2||↑||3|
|Includes Title V CYSHCN||1||↓||0|
|Behavioral health service delivery system for CYSHCN**|
|MCO provides behavioral health services||33||↑||41|
|Behavioral health services are carved-out into FFS||7||↓||6|
|Behavioral health services are carved-out of managed care and provided by a behavioral health organization||8||↓||6|
*Specialized plans may include more than one subpopulation.
**Some states use more than one approach to provide behavioral health services.
 Children with Special Health Care Needs.” Maternal and Child Health Bureau, December 17, 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs.
 See NASHP’s 2017 chart and map here: https://www.nashp.org/state-medicaid-managed-care-program-design-for-children-and-youth-with-special-health-care-needs/
 MaryBeth Musumeci and Priya Chidambaram, How Do Medicaid/CHIP Children with Special Health Care Needs Differ from Those with Private Insurance? (Menlo Park, CA: Kaiser Family Foundation, June 2019). https://www.kff.org/medicaid/issue-brief/how-do-medicaid-chip-children-with-special-health-care-needs-differ-from-those-with-private-insurance/
 Children with Special Health Care Needs.” Maternal and Child Health Bureau, December 17, 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs