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Congress with regard to Medicaid have centered on shifting from the current federal—state funding partnerships to fixed block grants, fully giving states control of how Medicaid dollars are spent. Other states use criteria that are more restrictive or otherwise differ from those of the SSI program to determine Medicaid eligibility for their SSI residents; thus, not all children receiving SSI receive coverage under Medicaid, although most do.

In other words, for these states, meeting SSI eligibility criteria does not guarantee Medicaid eligibility. The net result of this variation is that the extent to which a child on SSI can secure Medicaid coverage to meet his or her needs is largely dependent on geography. States have wide latitude regarding which services are covered and what payments they make to providers, although coverage of basic preventive and routine services see Appendix D is required under the Patient Protection and Affordable Care Act ACA.

Although coverage of prescription drugs and specialty services e. Certain services are mandatory, however, including hospital care, physician services, and laboratory and X-ray services. States also have administrative and budgetary control over their Medicaid and CHIP programs, which results in disparate levels of spending and covered services.


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The federal—state funding structure for Medicaid and CHIP enables states to access federal matching funds based on per capita income. For Medicaid, wealthier states such as New York and New Jersey receive a 50 percent expenditure match from the federal government, while states with lower per capita incomes receive a higher percentage expenditure match e. Federal funding matches are similar for CHIP, but at an enhanced rate approximately 15 percent higher. The ACA has further increased this enhanced rate by an average of 23 percent through September 30, , as an incentive to enroll more children in the program see Appendix D.

An unintended policy.

Clinical Outcomes Department

States set their provider reimbursement rates, operate their own enrollment systems, and operate their own medical billing systems to process and pay claims GAO, States with Medicaid programs that contract with managed care organizations MCOs are required to evaluate the quality and appropriateness of care for services provided to children with special health care needs. MCOs that are compensated through state-paid monthly premiums require evaluation via an external quality review organization. One component of external review is assessing progress on performance improvement projects PIPs , where individual states choose areas to focus on improving.

Several states have committed to PIPs focused on children with special health care needs. Each state is required to list the quality measures it uses for evaluating its CHIP plan, and outcomes from the quality measures are reported annually to the U. States are also required to report data on access to primary and specialty care services and care coordination activities.

Quality measures for children with special health care needs are complex because states are not required to separate them out as a distinct population. That is, outcomes for children with special health care needs are blended with outcomes either for typically developing children or for adults eligible for Medicaid because of disability. One option is to extrapolate children who used long-term care services in the past year and to let this stand as a variable for children with special health care needs.

Other suggested metrics include medical home criteria, parent satisfaction surveys, and disease-specific quality measures Szilagyi, , p.

Epub Case Management And Care Coordination Supporting Children And Families To Optimal Outcomes

The EPSDT benefit guarantees comprehensive and preventive health care services for children under 21 who are enrolled in Medicaid. EPSDT screening services include comprehensive assessments of mental and physical health at developmental milestones, a routine schedule of physical exams, appropriate immunizations, necessary laboratory testing including blood lead level assessments if needed , and preventive and wellness educational materials CMS, Although these services are mandated, many children in actuality do not receive them.

In a follow-up, the OIG reported that CMS had engaged in a number of promising outreach efforts to encourage participation in EPSDT screenings and mental health assessments, encourage completeness of medical screenings, and work collaboratively with states and providers. As discussed throughout this chapter, access to a variety of quality health care services is critical for children with disabilities. For low-income families, public health insurance programs help children and their families access necessary care. However, some children with disabilities may not meet income requirements for Medicaid eligibility or may need services not traditionally covered by Medicaid.

Such programs have been used to increase access to health care services for children with disabilities. The increased flexibility provided by Medicaid waivers makes them attractive to states. As of February , 41 such demonstration waivers were in place, requested by 33 states Hinton et al. States have used their waiver authority in a variety of ways, including reforming how services are delivered; expanding Medicaid following passage of the ACA; managing long-term care; improving behavioral health care; and developing services for targeted populations, such as children with disabilities.

As of —, 33 states and the District of Columbia either included autism as a related clause or explicitly listed persons with autism under waivers for people with intellectual disabilities, while 11 states offered autism-specific waivers for children. HCBS waivers providing services for children with autism spectrum disorder have been found to differ substantially among states in a number of ways, including targeted populations, service cost estimates, cost control methods, and services covered Velott et al.

HCBS waivers for children with autism have been linked to decreased likelihood of hospitalization or use of long-term care and decreased expenditures during hospitalization Cidav et al. When HCBS waivers increase the limits on allowable costs for services and the number of enrollment slots, they have been found to reduce the likelihood that parents of children with autism spectrum disorder will be unable to engage in paid employment. Increased enrollment limits are most effective among higher-income households, whereas increased cost limits are most effective among low-income households Leslie et al.

The ACA originally stipulated that state Medicaid programs would have until to meet federal standards for helping elderly patients and patients with disabilities access home- and community-based services. Recently, the deadline for meeting federal standards was extended to States are still required to submit a plan of action for complying with federal HCBS standards. Under TEFRA waivers also known as Katie Beckett waivers , states are allowed to count only the income of children with special health care needs when making Medicaid eligibility decisions and provide services to children in their homes rather than in institutions.

The waiver has been in place since , and as of served nearly 25, children with disabilities in 20 states. These programs extend Medicaid eligibility to a broader group of children with disabilities than would a TEFRA program. MCHB has as its main goal enhancement of the health and well-being of women and children, especially those of low income, across the country.

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Much of the MCHB funding goes to the states in block grants, allowing them to apply the grants as most needed to address state problems and opportunities in maternal and child health. States vary a great deal in their use of these funds, but common themes include efforts to increase use of prenatal care, decrease maternal morbidity and mortality, improve birth outcomes, enhance prevention through home visiting, screening, and some direct preventive activities , and increasingly implement community interventions to improve child well-being.

Approximately two-thirds of the funds go to general preventive efforts, while the other one-third is earmarked for programs for children with special health care needs. Here, too, state programs vary from screening programs, to efforts to provide or improve care coordination, to programs for specific conditions such as asthma or obesity or developmental disabilities.

Through its state block grants, MCHB supports a large number of national programs, many focused on children with special health care needs. A large effort addresses helping states develop systems of care for children with special health care needs, including through work on regionalizing services, developing referral and access programs, strengthening care coordination, and actively engaging parents, as well as building the evidence and research base needed to carry out best maternal and child health activities.


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  • Substantial amounts of research related to basic questions about the epidemiology of special health care needs, new strategies and experiments focused on organizing care and increasing collaboration, and ways to enhance family caretaking abilities have come from MCHB support. MCHB also has provided significant support for family groups to have major and increasing roles in program development and oversight. In addition to these general programs, which emphasize many of the commonalities among children with diverse chronic conditions and their families, MCHB supports specific initiatives in hemophilia, sickle cell disease, epilepsy, newborn genetic screening, and autism, mostly in response to specific congressional mandates.

    In recent years, that intergovernmental outreach has extended to the Departments of Education, Housing and Urban Development, and Justice. These programs promote the same healthy behaviors as those recommended for individuals without disabilities.

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    At present, 19 states receive one of three types of grants for the purpose of building capacity, implementing new core programs, or adding enhanced activities to existing programs CDC, Examples of how states use these grants to implement core programs or enhance activities are highlighted in Box CDC, Accomplishments in included publishing treatment recommendations for children with ADHD and tracking autism and the trajectory from evaluation to diagnosis and treatment.

    Stated future goals include implementing high-volume trainings to educate pediatric behavioral therapy providers on evidence-based treatments for ADHD, as well as helping to improve access to behavioral therapy programs for children with all types of mental illness. Children and youth with mental health conditions have a particular need for integrated care to address all of their chronic and immediate health care needs through the incorporation of primary care into mental health care, or vice versa.

    As discussed earlier in this chapter, integrated care is important to individuals with disabilities over the life span, as physical and mental health conditions often co-occur. The most common chronic physical health symptoms that co-occur with mental illness are high blood pressure, heart disease, diabetes, obesity, and asthma. Mental health conditions also often lead to substance abuse behaviors during adolescence and adulthood, including smoking, consuming alcohol, and using illicit drugs, all of which have negative effects on physical health.

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    These interrelationships among mental illness, chronic health conditions, and substance abuse necessitate an integrated approach to treating the whole patient SAMHSA, n. This program helps community behavioral health organizations build capacity for providing integrated services. A difference-in-difference analysis between intervention and control sites suggested that patients in. On the other hand, patients enrolled in nonintegrated programs were more likely than patients enrolled in the integrated programs to self-report that they had stopped smoking. The data did not suggest a clear relationship between integrated health services and improved behavioral health outcomes compared with the control programs, nor did functioning indicators, such as social engagement, differ significantly for patients between the two groups of sites.

    While patients receiving integrated health care showed decreased levels of substance abuse between pre- and postassessment, patients receiving nonintegrated health care showed lower rates of binge drinking relative to patients in the PBHCI programs DALTCP, Mixed results regarding behavioral health and substance abuse outcomes were not unexpected given that both sites provided high-quality mental and behavioral health services to patients.

    Moreover, future studies could be expanded to include acute, isolated, quantifiable episodes, such as the number of panic attacks, in addition to chronic measures of physical health. Finally, the committee thought it pertinent to highlight efforts at creating cross-disciplinary partnerships that engage in research and training on issues related specifically to childhood disability.

    UCEDDs are a national network of 68 university centers that conduct interdisciplinary training on working with people who have developmental disabilities and autism spectrum disorder, host community service opportunities, and support research with the goal of positively impacting the lives of individuals with developmental disabilities, as well as their families, by increasing their independence, productivity, and integration into communities.

    Care Coordination 101