Opportunities & Challenges for Children with Complex Health Care Needs in Medicaid & CHIP Cindy Mann

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1 Opportunities & Challenges for Children with Complex Health Care Needs in Medicaid & CHIP Cindy Mann Designing Systems that Work for Children with Complex Health Care Needs Lucile Packard Foundation for Children s Health December 7, 2015

2 Agenda 2 Coverage Gains for Children Challenges Providing Care to Children with Complex Health Needs Promising Delivery System Reform Initiatives

3 Coverage Gains for Children 3

4 Current State of Medicaid Coverage for Children 4 Medicaid is the largest public health insurance program in the United States, covering more than a third of children. Insurance Coverage for Children (0-18) in 2014 Uninsurance Rate of Children (0-18) Source: (1) 2014 National Health Interview Surveys (2) 2013 and 2014 National Health Interview Surveys and Early Release of National Health Interview Survey 2015

5 New Coverage Paradigm 5 Medicaid expansion for adults is voluntary with states 400% FPL 241% FPL Coverage gap in median nonexpansion states 133% FPL 100% FPL Exchange Subsidies Medicaid/CHIP Children Varies by State 48% FPL 33% FPL Adults Children Other Adults Jobless Parents Working Parents Pregnant Women Sources:

6 Improvements to Medicaid Coverage 6 Streamlined application process Electronic data verification to ease enrollment process Timely eligibility determinations Automated renewals process Goal: Increase enrollment and retention of eligible children in Medicaid Expanded coverage for the parents and families of children

7 Additional Ways to Support Enrollment & Retention 7 States have options to further simplify enrollment and renewal, and promote continuity of care for children. State Options to Help Children Enroll & Stay Enrolled No Federal Approval Required Requires Federal Approval Enlist Managed Care Organizations to assist with renewals Adopt Automated Renewal for children unlikely to have changes in income Use Data from Food Assistance and Other Sources to automatically enroll in Medicaid/CHIP Implement Off-Cycle Renewals Adopt 12-Month Continuous Coverage for Children Make broad use of Population-Based Presumptive Eligibility

8 8 Providing Care to Children with Complex Health Needs

9 Children with Special Health Needs 9 Children with special health care needs are defined as those who have, or are at increased risk for, a chronic physical, developmental, behavioral, or emotional condition that requires health and related services of a type or amount beyond that required by children generally. Children with Special Health Needs Children with More Complex Needs 20% of children in the United States have special health care needs 23% of children with public insurance have special health care needs 17% of children with special health needs have 4 chronic conditions 60% of children with special health needs have more complex needs Children with medical complexity account for 34% of Medicaid spending on children 47% of Medicaid spending for children with medical complexity is tied to hospital care; only 2% to primary care Source: Lucile Packard Foundation for Children s Health; Children with Medical Complexity and Medicaid: Spending and Cost Savings, Health Affairs, 33, no. 12 (2014)

10 Access & Unmet Needs 10 In general, children have good access to services in the Medicaid program. However, some children with special health care needs face barriers and have unmet needs. Barriers to Access 35% of families with a child with special health needs had trouble accessing community-based services 22% of families had problems getting referrals to specialists Unmet Needs 19% of families with a child with special health needs reported at least one unmet need (e.g., preventive care, specialist care, prescription medicine, etc.); this number increased to 44% when the child was medically complex Medicaid families reported 32% more unmet needs compared to families with private insurance; uninsured families reported four times the number of unmet needs Source: Lucile Packard Foundation for Children s Health; Inequities in Health Care Needs for Children with Medical Complexity, Health Affairs, 33, no. 12 (2014)

11 Particular Groups with Complex Health Needs 11 Foster Care Over 400,000 children are in foster care nationally Justice-Involved 70,800 youth are in the juvenile justice system 60% of children in foster care have a chronic medical condition; 25% have more than % have moderate to severe mental health issues Under the Affordable Care Act, former foster care children retain Medicaid coverage up to age 26 Over two-thirds of youth reported a health care need; 50-75% have a mental health or substance use disorder 9-29% of youth in the justice system are also in the child welfare/foster system States are pursuing opportunities to improve continuity of coverage for this population Source: (1) A Children s Health Policy Blog, Georgetown University Health Policy Institute: Center for Children and Families, available here: (2) Health Coverage and Care for Youth in the Juvenile Justice System: The Role of Medicaid and CHIP, Kaiser Family Foundation, May 2014.

12 Comprehensive Coverage for Children in Medicaid 12 The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides comprehensive coverage for children under 21 in Medicaid. Promotes the early identification and treatment of health issues in children, including mental health and substance use disorders. Provides all treatment services that children need and that Medicaid can cover, even if Medicaid does not cover the service for adults. Covers necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. SSA 1905(r)(5)

13 Turning the Promise of Coverage and Care into Reality for Children with Complex Needs 13

14 Care Management 14 The Center for Medicare and Medicaid Innovation (CMMI) announced Round Two of the Health Care Innovation Awards in 2014, which included several awards focused on improving care management of children with complex health needs. IL MA University of Illinois CHECK (Coordination of Healthcare for Complex Kids) Project Sponsor: Board of Trustees of the University of Illinois Project: Build a medical neighborhood to bring care to patients where they live, work and attend school Establish care management teams with embedded navigators Massachusetts Alliance for Complex Care (MACC) Project Sponsor: Boston Medical Center Project: Develop Comprehensive Care plans for children and families through comprehensive assessment Assign families a Family Navigator Provide behavioral health services Source: CMMI website, Health Care Innovation Awards Round Two Project Profiles.

15 Care Management, continued 15 The Center for Medicare and Medicaid Innovation (CMMI) announced Round Two of the Health Care Innovation Awards in 2014, which included several awards focused on improving care management of children with complex health needs. WI Coordinating All Resources Effectively (CARE) for Children with Medical Complexity Project Sponsor: National Association of Children s Hospitals and Related Institutions Project: Improve care for medically fragile and intense needs children by: 1) Creating tiered system of care 2) Designing new payment system/models 3) Creating a learning system for providers and payers Special Needs Program for Children with Medical Complexity Project Sponsor: Wisconsin Department of Health Services Project: Enhance and expand the Special Needs Program (SNP) currently in place at Children s Hosp of WI Establish multi-disciplinary care teams Expand SNP to ambulatory setting Source: CMMI website, Health Care Innovation Awards Round Two Project Profiles.

16 Spotlight on Additional Reform 16 New York State Building a Medicaid health home program tailored to serve the unique needs of children who have complex physical and/or behavioral health conditions 174,00 children statewide may be eligible for health home enrollment in addition, many foster children may be eligible The Children s Hospital of Philadelphia (CHOP) Piloting the Compass Care program to improve care management and coordination of children with the most complex health needs Develops comprehensive care plan for each child with his/her unique needs in mind Facilitates communication between doctors, payers, and the family to clearly define roles and ensure that appropriate decision-makers are at the table Source: CHOP website, available here:

17 Behavioral Health Integration 17 Recognizing the strong relationship between physical and behavioral health, there has been an increased focus on integrating behavioral health and primary care Waivers in New York and New Hampshire seek to: Build behavioral health capacity; Screening Assessment Warm Hand-off to Specialists Improve integration with primary care; and Strengthen behavioral health transitions from acute care settings to community settings Care Coordination Integrated Care Interdisciplinary Care Teams Individualized Care Plans

18 Kids are a critical part of the high needs population and need to be a focus of delivery system reform. 18

19 19 Thank You! Cindy Mann