Provider Adequacy

Even when CYSHCN have health insurance, they may face difficulties accessing healthcare services due to narrow provider networks. Standards for provider network adequacy vary from state to state. Not all states require the full range of pediatric specialty care to be included in Medicaid, CHIP, employer-based, or Marketplace insurance managed care networks. In 2023, the Centers for Medicare and Medicaid Services (CMS) will begin enforcing time and distance standards for Qualified Health Plan provider networks offered in the federal Marketplace.

In public insurance, measuring access to providers can be complicated by “ghost providers,” who are listed in Medicaid/CHIP networks but do not actually see any publicly insured patients. A study published in Health Affairs in 2022 that analyzed Medicaid provider networks and claims across four states from 2015-2017 found that on average, 11 percent of pediatric primary care providers listed in Medicaid networks were ghost providers. An additional 10 percent of pediatric primary care providers saw very low numbers of patients (fewer than 10).

Although most hospitals and health systems with highly specialized resources are able to partner with Medicaid to increase reimbursement rates for their services, differential rates between private and public insurance can still complicate access to care.

To help address provider adequacy, some state Title V agencies collaborate with Medicaid and community partners to expand access and training or provide direct services through local health departments.

Increasing Provider Adequacy Through Financing Models

Georgia’s Title V agency collaborated with Medicaid to increase reimbursement rates for child wellness visits provided at local health departments. This has allowed health departments, especially in rural areas, to provide more services to children, and as a result, link more children to the state Title V CYSHCN program. Once enrolled in the program, care coordinators assist families in switching from Medicaid Managed Care to fee-for-service Medicaid so that CYSHCN can access direct services such as care coordination, specialty care clinics, and health care transition services provided through state public health districts.

Vermont’s Title V office helped ensure that visiting nurse associations and designated county agencies that provide care coordination and other services for CYSHCN were included in the state’s Medicaid Accountable Care Organization (ACO) network. The ACO provides a financial incentive to the agencies to provide certain care coordination services, and the agencies can use this funding to support staff retention and training, as well as hiring highly trained staff.

Increasing Size of Provider Network Through Training and Consultation

After recognizing a need for improved training for home care nurses for CYSHCN, the Illinois Title V agency partnered with Ann and Robert H. Lurie Children’s Hospital of Chicago to develop a training conference for nurses providing care in the home. The conference, titled “Nitty Gritty Nursing: Improve Your Community Nursing Skills for Children who are Medically Fragile and Technology Dependent,” offered training in tracheostomy care, ventilator management, skin care and enteral feeding, and central line and infusion care. Continuing education credits incentivized attendance. After the initial conference, the program was replicated in another part of the state and was recognized by Health Affairs as an effective model of targeted nursing education.

As New Hampshire has moved toward utilizing Title V funds for enabling services and infrastructure as opposed to direct services, they have created a statewide nutrition, feeding, and swallowing provider network. Through a contract with a Federally Qualified Health Center, Title V also funds a complex care clinic that provides one-time assessments with a team of providers including a developmental pediatrician, physical therapist, educator, and other specialists as requested. This consultative model of care addresses pediatric specialty provider shortages while assisting families with health concerns and educational needs.

New Jersey uses a consultative model to increase access to child and adolescent psychiatric services. Through this program, the Primary Care Child Psychiatrist Consultation Collaborative, pediatric primary care providers can contact regional hubs to consult with psychiatrists across the state at no charge. The program began as a one-county pilot project supported by SPAN Parent Advocacy Network and after showing success, has been expanded statewide with additional grant funding and funding from the state legislature. This program supports primary care providers in offering behavioral health services and shortens child and adolescent psychiatrists’ wait lists.