Medicaid Managed Care

Managed care is a health care delivery system that works to coordinate health services while managing utilization, quality, and cost. State Medicaid agencies contract with Managed Care Organizations (MCOs) to deliver Medicaid health benefits through a set per member per month payment. Medicaid Managed Care plans vary from state to state.

Potential benefits of managed care include increased coordination of services, improved health care quality and outcomes, and access to additional programs. Most MCOs focus on the general population and give limited attention to the many smaller special need Medicaid subpopulations including CYSHCN. For that reason, some state Medicaid agencies have also designed MMC programs to exclusively serve specific populations of Children and Youth with Special Health Care Needs (CYSHCN), allowing states to target services to the unique needs of CYSHCN. As of 2022, twenty-nine states include a definition of CYSHCN in their MMC contracts to support identification of CYSHCN and determine eligibility for specific services and supports, such as enhanced assessment and care coordination. Thirty-seven states also include specific MMC contract language regarding quality measures for services provided to CYSHCN. When state Title V agencies collaborate with Medicaid MCOs regarding care for CYSHCN, clarity around each organization’s role is necessary to prevent duplication of services and ensure the MCO is meeting their contract requirements.

In order for families to receive the most comprehensive services from managed care, education on each plan’s benefits, cost sharing, and provider networks is necessary. When state Medicaid agencies are determining which Managed Care Organizations (MCOs) to contract with, it may be beneficial to consider the MCO’s familiarity with state and local resources, as some states have found locally based MCOs to be more responsive to community needs.

Specialty/Focused Managed Care Plans

Florida offers a Medicaid Managed Care plan specifically for CYSHCN called the Children’s Medical Services (CMS) Health Plan. In addition to coverage for direct services for medical, behavioral, and developmental needs, the plan offers enhanced benefits for families including grocery stipends, non-medical transportation, and caregiver behavioral health services. Florida Title V has collaborated with CMS to review quality measures for the plan, and this initiative resulted in the inclusion of quality of life measures.

In the District of Columbia, the MCO Health Services for Children with Special Needs, Inc. provides insurance coverage for children and young adults up to age 26 who live in DC and receive Supplemental Security Income (SSI). Covered services include appointment scheduling support, medically necessary orthodontia services, early intervention programs, feeding programs, home health nursing and personal care services, and hospice care.

In South Carolina, all children and youth in foster care are enrolled in one Medicaid MCO health plan, First Choice by Select Health of South Carolina. This MCO provides additional resources to meet the needs of those in foster care, including Project ECHO sessions for providers focused on best practices for caring for children in foster care.

MCO Enrollment

Family Connection of South Carolina, the state’s Family-to-Family Health Information Center, assists families in choosing a Medicaid MCO for their child. Family Connection staff walk families through determining which MCOs their child’s current providers participate in and choosing the plan that includes all or most of those providers.

Specialized Care Coordination within an MCO

Each of the Medicaid MCOs in Pennsylvania has a Special Needs Unit with designated special needs coordinators and staff who provide case management, transition assistance, and referrals to CYSHCN.

CYSHCN Programs Offering Expertise to MCOs

In Ohio, the state Department of Health (ODH), which houses the Title V CYSHCN program, and the Department of Medicaid (ODM) meet biweekly to review cases in which families are experiencing challenges with coverage through MCOs. These meetings both solve problems for individual families and drive policy change by clarifying policies between the ODM and the MCOs. ODH also collaborated with ODM during the process of re-bidding agreements with MCOs and in orienting new MCOs to the needs of Ohio’s CYSHCN population.

Virginia’s CYSHCN program offers the Care Connection for Children (CCC) program, which assists families raising CYSHCN with services such as care coordination, medical insurance benefits evaluation and coordination, information and referral to resources, and family-to-family support. In order to increase collaboration and coordination between CCC and Medicaid MCO programs, representatives from the Virginia Department of Health provided a presentation about CCC to 280 care coordinators who work in Medicaid MCOs.

Kansas’s CYSHCN program, KS-SHCN, maintains a partnership with Kansas Medicaid and each of the state’s MCOs to ensure that the two programs complement one another. At the organizational level, the CYSHCN Program Manager educates MCO staff about the KS-SHCN program and its services. As a result of this partnership, both programs have improved their services, decreased denials of services, and reduced wait times for the appeal and approval process. Title V also presents information about maternal and child health measures to the MCOs, focusing on Medicaid population disparities.

The Rhode Island Department of Health participates on the Advisory Council of the MCO that enrolls most of the state’s CYSHCN. Participation on the council allows Department of Health staff and families of CYSHCN to bring forward issues for improved health care assistance.

New Mexico’s Title V program, with support from the New Mexico Quality Improvement Partnership (NMQIP), worked with Medical Directors of the four state Medicaid MCOs to develop a consistent set of Patient Centered Medical Home (PCMH) standards. This state’s Title V program shares its expertise in delivering care coordination services and supports for CYSHCN to the Medicaid programs, supporting the transition of CYSHCN to sustainable and coordinated medical homes. As a result of New Mexico Title V’s outreach to MCOs, MCO care coordinators rely on Title V staff for assistance with complex cases.

Collaboration on Care Coordination

The Virginia CYSHCN Unit meets on an as-needed basis with Virginia Medicaid to strengthen the partnership between CYSHCN program care coordinators and Medicaid care coordinators. They aim to have meetings between both types of care coordinators so that they can collaborate to better support families in understanding their insurance benefits and accessing care.

The District of Columbia’s School Based Oral Health Program, which is overseen by Title V-funded staff, has launched an MCO notification function that activates the MCO’s care coordination services when school based oral health vendors identify a child with follow-up dental needs.

New Jersey Title V and Medicaid Managed Care representatives participate in quarterly Medical Assistance Advisory Committee (MAAC) meetings to share information on access to care for CYSHCN through MCOs and discuss program planning objectives related to care coordination for CYSHCN. These public meetings also incorporate representation from governmental, advocacy, and family representatives. This collaboration has led to New Jersey’s progress in the implementation of managed long-term services and supports (MLTSS), along with the restructuring of services to CYSHCN through cross-agency collaborations.

In 2018, Colorado Title V staff developed the Colorado Care Coordination Collaborative, which focused on increasing efficiency and reducing duplication of care coordination services for CYSHCN provided through MMC programs, the state EPSDT benefit outreach program, and Title V. The Title V program used the lessons learned from this collaborative to provide input to the state Medicaid agency as they developed phase II of the Accountable Care Collaborative Program and the state’s MMC delivery system, as well as the state’s medical home action plan.

Reimbursement from MCOs for Care Coordination Provided by Title V or Family Support Organizations

The University of Illinois Chicago Division of Special Services for Children (UIC-DSSC), Illinois’s Title V CYSHCN division, contracts with Medicaid Managed Care plans to provide care coordination services. UIC-DSSC provides care coordination services that are reimbursed by these MCOs for children who were previously enrolled in UIC-DSSC’s Core Program. A new program was created called, UIC-DSCC Connect Care, to serve CYSHCN in one of the contracted MCOs.  The Core Program continues to serve children in private insurance or who are exempt from managed care.

Family Voices of Tennessee, the state’s Family-to-Family Health Information Center, contracts with the state Medicaid program and the Medicaid MCOs to receive reimbursement for parent-to-parent support services. The parent-to-parent program remains free of charge for all families, and the Medicaid reimbursement funds add to the overall budget for the organization.

Title V Expertise Contributing to Health Plans and MCO Contracts

Missouri’s Title V agency has a strong relationship with the state’s Medicaid program around in-home services for children with medical complexity. When the state shifted to managed care statewide, Title V described their processes for authorization of in-home services and shared tools with the MCOs to provide consistency in authorization processes.

When New Mexico renewed their Medicaid Section 1115 Waiver that authorizes managed care, the state’s Title V agency provided comments on the waiver to encourage specific considerations for CYSHCN, especially around health care transition. The Title V program has also contributed to the policy manual that Medicaid distributes to each of the MCOs.

Several state Title V programs have participated in state Medicaid processes to select and contract with MCOs. Louisiana implemented 6 MCO contracts in 2023, and under the new contracts, MCOs are required to offer tiered case management services to special needs populations based on a health needs assessment or special need referral. The Title V Family Resource Center serves to connect families with case management service when a need for these services is identified. In 2019, Michigan’s Title V CYSHCN program joined the state Managed Care Plan Division. The state’s Title V program was involved in the contracting process and included language encouraging MCOs to discuss medical transition with clients transferring from pediatric to adult care in the new managed care program. Additionally, during the procurement of the Virginia’s largest MMC program, the Medicaid agency invited Title V representatives to participate in the procurement review panel that selected the participating MCOs.

Title V and Quality Improvement for MCOs

Connecticut does not have Medicaid Managed Care but has an Administrative Services Organization (ASO). The Connecticut MOU with the ASO includes a data sharing agreement with specific data reporting and service delivery requirements.

Michigan’s CYSHCN program has a strong relationship with Medicaid, and as a part of their partnership, Children’s Special Health Care Services (CSHCS) staff participate in site reviews of Medicaid MCOs and the annual review of contracts. Being involved in site reviews allows CSHCS to directly evaluate compliance and quality of the MCOs specifically for CYSHCN.

Additional Resources