As families face immense stress from the pandemic, states have rapidly reworked their home visiting programs to continue to support women and children. Because face-to-face services, including case management and family support and counseling, are no longer an option, health departments now deliver these vital services by telehealth. But with this new operating platform, states have needed to quickly address issues such as privacy requirements and billing, reimbursement, and enrollment processes as they launch their telehealth services.
Recently, the Centers for Medicare & Medicaid Services (CMS) released a toolkit in response to COVID-19 with guidance and steps for state Medicaid programs as they transition services to telehealth. The updated CMS guidance allows for greater flexibilities, including reimbursement for telephonic visits. To streamline the process, CMS stipulated that “no federal approval is needed for state Medicaid programs to reimburse for telehealth services in the same manner or at the same rate paid for face-to-face services, visits, or consultations.” However, a state plan amendment (SPA) is necessary to accommodate any revisions to payment methodology to account for telehealth costs.
Additionally, the Office of Civil Rights at the Department of Health and Human Services issued guidance that allows for enforcement discretion for noncompliance with the Health Insurance Portability and Accountability Act (HIPAA) regulatory requirements related to providers and telehealth, such as using non-HIPAA-compliant systems, such as the free version of Zoom.
How Michigan Converted its Home Visiting Service
Michigan, a state with a robust home visiting program prior to COVID-19, took quick action to support home visiting staff and the families they served to ensure continuation of services during the pandemic. The Maternal and Infant Health Program (MIHP) is administered and financed by the state Medicaid agency and is the largest home visiting program in the state. MIHP is available to all pregnant women enrolled in Medicaid and their infants up to age 12 months, with some exceptions. The program promotes healthy pregnancies and positive birth outcomes through a standardized, systemwide process of case management. When Michigan Gov. Gretchen Whitmer announced a state of emergency and stay-at-home orders in March 2020, the program quickly moved its home visiting services to telehealth.
The Michigan Department of Health and Human Services (MDHHS) updated guidance on telehealth visits for Medicaid beneficiaries. The provider bulletin allows for greater flexibilities on distant and originating sites and outlines the billing codes and modifiers providers should use. The MIHP operations team took numerous steps to ensure a smooth transition to telehealth services for their providers and families, including:
- Both the state Medicaid agency and the MIHP operations team had early and continued communication with providers, including making staff available to answer questions and provide support.
- The MIHP program created additional guidance specifically for MIHP providers. The guidance includes instructions on how to obtain and properly document verbal consent, billing procedures and codes specific to the MIHP program, and documentation procedures for all virtual visits.
- MDHHS held a provider webinar with detailed information related to telemedicine flexibility, including information targeted to MIHP providers and others.
- MIHP operations conducted a provider survey about how MIHP programs were continuing to provide services during this time, which netted a near 100 percent provider response rate. The survey revealed that a large majority of agencies adjusted successfully and quickly to the telehealth service delivery model. In addition, only a small number of agencies suspended services temporarily, primarily due to agencies shifting resources to cover COVID-19 emergency functions.
As states begin to reopen, many home visiting programs will begin to consider returning to face-to-face visits exclusively or as a part of their support programs. Considerations for the role of telehealth in home visiting is expected to factor into state decisions. While it is unclear how state home visiting programs will transition, some groups including The National Alliance of Home Visiting Models have encouraged all home visiting programs to continue to use telehealth to ensure the safety of women and their families, as well as home visitors. With the greater flexibilities allowed by CMS, states have the option to continue using telehealth for their home visiting programs during the pandemic. This allows for the continuation of important services for women and children and helps decrease the spread of COVID-19.
States will be weighing a number of considerations as they begin to open, including the benefits of telehealth for home visits and the costs associated with telehealth compared to in-person visits. These new policies will be important to monitor and will have implications for longer-term and possibly permanent use of telehealth to deliver essential services to families.
- NASHP Infographic: How State Medicaid Programs Can Use Telehealth to Serve Pregnant Women during COVID-19, May 2020
- NASHP Blog: States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment, April 2020
- Institute for the Advancement of Family Support Professionals: Rapid Response Virtual Home Visiting Collaborative
To tackle the opioid epidemic, which has been the leading cause of unnatural deaths since 2013, Virginia recently developed an integrated physical and behavioral health continuum of care, which spans multiple treatment settings and includes case management and peer recovery support. The initiative, combined with increased access to naloxone and other efforts, has helped reduce fatal overdoses by 3.3 percent between 2017 and 2018.
In March 2016, with support from Virginia Gov. Terry McAuliffe, the Virginia General Assembly passed appropriations mandating transformation of the SUD Medicaid benefit entitled the Addiction and Recovery Treatment Services program or ARTS, which was implemented on April 1, 2017. Early results from Virginia’s ARTS program indicate success in increasing access to care for Medicaid-eligible pregnant women with SUD and opioid use disorder (OUD).
Data obtained from pre-ARTS implementation (covering April 2016-March 2017) compared to post-ARTS implementation (April 2017-March 2018) indicate that the percent of Medicaid-enrolled pregnant women with SUD who received treatment increased from 2 percent to 21 percent, while the rate of pregnant women with OUD who received treatment increased from 4 percent to 31 percent. In addition to increasing treatment rates, the number and types of treatment providers and treatment programs available to pregnant women with SUD and OUD also increased significantly in the post-ARTS implementation period.
Ashley Harrell, senior program advisor with Virginia’s Department of Medical Assistance Services (DMAS), recently shared the goals and highlights of the program with the Maternal and Child Health Policy Innovation Program (MCH PIP) Policy Academy, hosted by the National Academy for State Health Policy (NASHP). The academy, made up of eight cross-sector state teams, focuses on the mental health needs of pregnant and parenting women, particularly those with or at risk of substance use disorder (SUD). The ARTS program has six major goals:
- Expand the short-term SUD inpatient detox benefit to all Medicaid/FAMIS enrollees (FAMIS is Virginia’s health insurance program for uninsured children);
- Expand short-term SUD residential treatment to all Medicaid enrollees;
- Increase reimbursement for existing Medicaid/FAMIS SUD treatment services;
- Add peer support services for individuals with SUD and/or mental health conditions;
- Require SUD care coordinators for DMAS-contracted managed care plans; and
- Organize provider education, training, and recruitment activities.
The Virginia state Medicaid agency has made additional policy changes to improve access to care for pregnant enrollees with SUD. Some of these changes include:
- Allowing and encouraging same-day billing of medical and behavioral health services;
- Requiring access to medication-assisted treatment (MAT) along the addiction care continuum; and
- Removal of prior authorization requirements for up to 24 mg/day of Suboxone film for in-network buprenorphine-waivered practitioners.
Additionally, the Virginia Medicaid MEDALLION 4.0 has an embedded High-Risk Maternity Program that includes comprehensive care management and family planning services to women with SUD. MEDALLION 4.0 is a statewide, fully capitated, risk-based, mandatory managed care program for Medicaid and Family Access to Medical Insurance Security (FAMIS) members that operates under the authority of a §1915(b) waiver. MEDALLION 4.0 covers pregnant women, infants and children and provides acute and primary health care services, prescription drug coverage, and behavioral health services for their members.
Harrell’s presentation spurred much discussion among academy participants, who quickly shared their concerns about access to care, integration of services, health equity, and the long-term health outcomes of women, children, and families affected by SUD.
Over the next two years, NASHP academy participants will continue to learn from each other and from subject matter policy experts as they strive to develop, support, and advance state-level policy innovations for pregnant and parenting women with or at risk for SUD and/or mental health conditions. Understanding state innovations is key to identifying new strategies to leverage change. As one policy academy participant observed during the meeting, “No one [state] has all the answers, but we have a lot of resources in each other.”
For more information on the academy, read NASHP’s blog, New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD. For more information about the Virginia ARTS program, visit the Virginia DMAS ARTS website or email questions about the ARTS program to email@example.com.
The opioid epidemic has heightened states’ efforts to prevent and treat of substance use disorder (SUD) in pregnant and parenting women. The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration, interviewed Colorado, Pennsylvania, and Texas officials about the unique interagency approaches they are using to promote recovery for this population. This new report explores:
- State coverage, care delivery, and financing strategies to support pregnant and parenting women with SUD;
- Available state and federal funding sources for these initiatives; and
- Key considerations for states working to promote recovery.
- Download webinar slides and listen to the webinar that explored how Colorado supports pregnant and parenting women with SUD. The speakers were:
- Amy Cooper, Women’s Services Coordinator, Office of Behavioral Health, Colorado Department of Human Services;
- Susanna Snyder, Maternal Child Health Policy Specialist, Health Programs Office, Colorado Department of Health Care Policy and Financing; and
- Dr. Kaylin Klie, Physician, Denver Health; Assistant Professor, University of Colorado Department of Family Medicine
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
- Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
Karen Palombo is the substance use disorder (SUD) team lead in the Texas Health and Human Services Commission’s mental health and substance use division who helps shape state intervention and treatment policies. Before joining state government, she worked in hospital, mental health, and SUD treatment settings for nine years as a licensed chemical dependency counselor. Her first-hand knowledge of SUD treatment challenges in a state with an expansive mix of rural and urban gives her a unique perspective into how a state policymaker can use data, relationships, and grassroots connections to design and promote effective programs.
How did you come to work in SUD treatment in direct care, and then at a state policy level?
During my undergraduate and graduate years, I worked at a short-term residential treatment center for kids removed from their parents. About 80 percent were over age 12 and they talked a lot about seeing their parents drunk and high all the time. They were often prescribed depression and anxiety medications, but what they were really dealing with was trauma. They talked about how when they became parents they would do things differently.
My next job was in child protective services, where I worked with grown-up versions of those same traumatized kids, who still didn’t have the skills to do things differently. They had limited support, a mistrust of government resources, inappropriate social skills, and none or few coping skills. I wanted to work on a policy level to address that.
How did you come to focus on women and children?
I thought if I could keep women and children together during recovery, it would have the most impact. When women and kids don’t stay together, we know kids are safe, but are they secure? Unfortunately, children going through the child welfare system learn not to trust adults because if they tell them about their parents’ relapse and abuse, their family is separated and they are removed. My goal is for health care providers to have the community resources they need available so they know who to call and how to respond when a pregnant woman with SUD walks in the door to make sure her whole family is treated.
Like many rural states, Texas has inconsistent state data on opioid overdose deaths. As a policymaker, how do you make the case for more targeted resources to improve opioid prevention and treatment when data is unreliable?
In some areas, we have very good data, for example, we’re one of only two states that track if alcohol and other substances were involved — even if it was not the direct reason for a child’s removal. When we don’t have data, we rely on relationships with the people on the ground who know the things we need to know. I make tours around the state all the time and have the luxury of sitting on lots of committees where I’m always making the case for data collection. If I’m talking to a hospital, I know to talk about poison control, emergency department data, and hospital costs. It makes us better data collectors and sharers, but it’s done on a regional basis and relies on relationships.
I also know that when I call our Medicaid office and say, ‘I’m trying to find out how long newborns with neonatal abstinence syndrome stay in NICUs at the hospitals where I have given a community presentation,’ my contact knows what code to use and she can tell me from her data indicators what is happening on a statewide basis vs. on a regional basis. When individual staff persons see why they collect the data they do — when they see it in a report — it starts to matter.
Is regional information critical in order to fine-tune program design in such a large state?
When you work in a state the size of Texas, with its diverse rural and urban populations, knowing what’s happening on a regional level is critical. The types of [illegal] drugs used vary between regions. In some areas, opioids never really arrived and cocaine never left. From a public health perspective, we need programs that work no matter what drug is used. When I’m talking to officials in Odessa, they don’t care about a statewide picture, they only care about what will work in Odessa.
Your state legislature meets every two years, how do you get the resources you need to redesign or launch programs for a rapid response to this epidemic?
As part of legislative recommendations, Behavioral Health Services division moved from the Department of State Health Services to the Health and Human Services Commission, which has led to better collaboration and communication to address behavioral health alongside primary health. We have been able to reconfigure our programs, and now have a foothold so our workgroups now touch all of these government programs that affect women. For instance, Texas Medicaid now reimburses for SBIRT [Screening, Brief Intervention, and Referral to Treatment] and postpartum depression screenings. We were able to assist in writing language about the Medicaid benefit, which screenings would be reimbursable, and suggested at one meeting that it would be important at well-child visits to be able to screen for postpartum depression. This is now a benefit in Texas. We probably would not have been involved in this process if not for the state agency re-organization.
How are you breaking down traditional siloes that impede a collaborative response to this crisis?
I have attended monthly workgroup meetings for four years waiting for someone to turn to me and say, ‘don’t you do that?’ If we’re not there to share what we do and learn how to collaborate, nothing happens. Our team members work with child welfare, public health, maternal child health, community health workers, train-the-trainer programs in local communities, homelessness, housing, and recovery programs, education departments, and workforce development. Serving on those committees makes us better data collectors and sharers. Data is everything, you never know what the scope of a problem is until you identify the data you need.
Can you give me an example of how has data collection has resulted in better state policy?
At our workgroups, we started hearing anecdotal information about women with SUD miscarrying in jails. [Pregnant women are at high risk of miscarriage if they go into withdrawal and do not receive medication-assisted treatment (MAT), such as methadone.] The Texas legislature instructed the Texas Commission on Jail Standards to collect data on miscarriages starting in 2016. When data collection began, we started to get more calls from jail nursing staff asking how to get methadone to pregnant women. The data collection led to awareness and to development of new policies to address the problem. Most jails that have nearby methadone clinics are developing standard protocol for when [incarcerated] pregnant women report opioid use disorder.
We’re also collecting data for the MOM – Maternal Opiate Mortality study. We know opioid overdose is the leading cause of death for women after childbirth in Texas. We’re looking at what happens that made women relapse, we’re interviewing these women and their families, and identifying how the state can make sure women who leave Medicaid after childbirth continue to receive MAT. In 2020, we’ll use the findings to develop guidelines for providers to screen more high-risk women and work to reduce maternal deaths.
What would you recommend to other states that are working to develop more effective SUD programs?
What I’ve learned is you never stop going back into communities and asking them what they want and need. When you work at a state level, you often stop doing community outreach, asking questions, or attending forums. If people in the community don’t agree with what you’re trying to do on a state level, it’s not going to work.
The biggest issue for us is getting treatment to rural areas. Communities with more people have more money and more access to health care. Rural communities will tell you they know that people don’t care about them. That’s hard to hear when you’re sitting in a room listening to them, but as a state official, you really need to know what’s going on if you’re going to develop effective policies.
Low birth weight and preterm birth carry substantial human and financial costs; they also are associated with health problems that can have long-lasting effects. Renewed state and national commitment to improving birth outcomes and the quality of maternal and infant care are evident in states across the country as well in federal initiatives such as the Health Resources and Services Administration (HRSA)’s Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality and Healthy Start program, as well as the Centers for Medicare and Medicaid Services (CMS)’ Strong Start for Mothers and Newborns and Maternal and Infant Health Initiative. These federal initiatives engage state policy makers, providers, and other stakeholders.
States can make important strides in eradicating cervical cancer deaths. This report features promising state and federally qualified health center policies that support high performance in cervical cancer screening within the context of the medical home. Drawing from Colorado, Maine, Maryland, New York, Texas, Vermont, and Virginia, this report summarizes innovative programs, practices, and partnerships that facilitate improvement in cervical cancer screening. Experiences in these states offer examples for adoption by others to ensure high-quality preventive care for women. This publication was made possible through the support of the Health Resources and Services Administration.
|Download the Publication||497.1 KB|
Through regular screening cervical cancer is a highly preventable disease, yet thousands of women are newly diagnosed with the cancer each year. This brief features best practices from 14 FQHCs across 7 states that have made significant strides to reduce the incidence of cervical cancer enabled by adopting core attributes of the patient-centered medical home (PCMH). Their lessons will help other providers improve care for women. This publication was made possible through the support of the Health Resources and Services Administration.
|Click for the Publication||255 KB|