Title V-Medicaid Partnerships
Interagency coordination is a statutory requirement for both state Title V and Medicaid programs. This collaboration differs from state to state and is described to varying degrees in each state’s interagency agreement (sometimes also known as a Memorandum of Understanding (MOU)). Title V’s expertise from working with CYSHCN and their families and its focus on direct, enabling, and public health services are assets for informing the content of effective interagency agreements. Statutory requirements for collaboration as described by the Maternal and Child Health Bureau include: coordination of EPSDT and other federal programs like supplemental food programs, Medicaid application and enrollment assistance, and shared data collection responsibilities. Medicaid must also reimburse Title V for direct services provided to Medicaid-enrolled children and can have arrangements to reimburse for administrative costs that benefit the Medicaid agency. The two agencies must collaborate to provide a toll-free number that offers information about Title V and Medicaid for families and work together on projects to encourage obstetricians and pediatricians to participate in Title V or Medicaid.1 The Catalyst Center’s resources Leverage Opportunities + Speak the Medicaid Language: A Workbook for Title V and Medicaid and CHIP: A Tutorial on Coverage for Children and Youth with Special Health Care Needs (CYSHCN) provide more information on these requirements.
The expansion of public program coverage for children through Medicaid and CHIP has reduced the role of Title V in providing direct services. There has been blurring of the respective roles of Title V and Medicaid programs due to both programs’ focus on similar issues, such as social determinants of health. It is important for Title V programs to understand the federal regulatory requirements for this collaboration and to have clarity about the unique value that they bring to this relationship.
In interviews with state Title V agencies, Title V staff identified several common intangible factors that contribute to effective partnerships with Medicaid. Many state Title V program staff identified that partnering on one project led to deepened relationships and continued collaboration. In addition to seeking opportunities to collaborate, Title V staff identified that co-location with their state’s Medicaid agency, either physically in the same building or organizationally within the same division or department, assisted with collaboration. Physical co-location allows for warm handoffs when making referrals between agencies and in-person relationship building, and placement within the same division encourages increased contact. Some states have also leveraged relationships when staff members move from positions within Title V to Medicaid or vice versa. A former Title V staff member might act as a ‘champion’ for Title V within Medicaid, increasing understanding of Title V’s role and unique value.
1 Items in this list adapted from: Rosenthal, J., Henderson, M., Dolatshahi, J., Hess, C., Tobias, C., Bachman, S., Comeau, M., Dworetzky, B., & Wilson, K. (2017). Public Insurance Programs and Children with Special Health Care Needs: A Tutorial on the Basics of Medicaid and the Children’s Health Insurance Program (CHIP). http://ciswh.org/resources/Medicaid-CHIP-tutorial; and United States Health Resources and Services Administration. (n.d.-a). Early Periodic Screening, Diagnosis, and Treatment. Retrieved August 2, 2022, from https://mchb.hrsa.gov/programs-impact/programs/early-periodic-screening-diagnosis-treatment
Title V As Subject Matter Expert
In 2019, Alabama Medicaid began implementing care coordination services through Alabama Coordinated Health Networks (ACHN). Alabama’s Title V care coordinators participate in joint trainings with ACHN care coordinators and communicate about clients who are eligible for care coordination through both programs. This partnership allows both groups to avoid duplication of services and find the program that is the best fit for each client.
New York Title V staff provide support to their state’s Medicaid agency on several initiatives, including the Health Home Serving Children (HHSC) Program and the Health Home Managed Care Organization (HHMCO) Sickle Cell Disease Subcommittee. For HHSC, Title V worked with Medicaid to develop policies and practices to facilitate timely referrals to the program and connections to local organizations. On the HHMCO, members discuss various strategies to identify, incorporate and further implement recently approved sickle cell disease single qualifying condition in HHSC to improve service delivery and care management to enrollees/members with SCD.
Through intentional relationship building, West Virginia Title V staff have become trusted subject matter experts for the state’s Medicaid agency. For example, when the Medicaid agency had a concern about pediatric dental billing, they were able to work with the state dental director, who works in the Title V office, to resolve the issue. Title V is also able to offer some of their state funding to Medicaid, and the two agencies collaborate to determine how to spend the funds. This aspect of their partnership has resulted in increased reimbursement rates for private duty nursing. Aside from billing and reimbursement, West Virginia Title V also provides expertise on epidemiology and data-driven decision making for the CYSHCN population. Title V additionally has a liaison within the Medicaid office who is able to advocate for Title V in Medicaid meetings.
Data Sharing and Analysis
In Arkansas and North Dakota, Title V uses the same electronic system to process claims for direct services as the state Medicaid agency. These shared databases help Title V track insurance enrollment for CYSHCN enrolled in their programs and provide gap-filling services to CYSHCN enrolled in Medicaid.
New Hampshire’s Title V agency has access to the enrollment management system for Medicaid, which allows them to confirm eligibility when enrolling children in the CYSHCN program. Title V staff indicate enrollment in the CYSHCN program in the system so that Medicaid is also aware of their involvement. Similarly, Missouri’s CYSHCN program sends monthly enrollment reports to their state Medicaid agency.
Each week, the Ohio CYSHCN program holds a case conference with the state’s Medicaid agency to discuss delays and denials of services for individual enrollees. The CYSHCN program tracks denials to identify patterns, and Medicaid can then use that information to drive system change by resolving issues with MCOs.
North Carolina Title V uses Medicaid’s enrollment dashboard to identify areas of the state with low enrollment. Staff then focus their outreach and promotion efforts in those regions.
Collaborating on Specific Programs or Projects
Vermont Title V and Medicaid work together to administer the state’s Disabled Child Home Care (DCHC) Waiver. Title V uses their subject matter expertise to inform Medicaid policy changes around the waiver, such as collaboration on research and refinement of the clinical assessment tool used to review DCHC eligibility. This highlights best practice and ensures nonbiased, objective, and consistent outcomes. Implementation of the proposed tool is planned for January 1, 2024, and will not change the legal standard for DCHC eligibility.
Tennessee Title V’s care coordination program for CYSHCN, called Community Health Access and Navigation in Tennessee (CHANT), is partially funded by their state’s Medicaid agency. The two agencies meet quarterly about this program, in addition to frequent meetings between Title V staff and the state Medicaid Chief Medical Officer, Assistant Director, Quality Assurance Director, and Managed Care Specialist.
In Rhode Island, Title V and Medicaid collaborate on the Pediatric Practice Enhancement Project (PPEP) and the Patient Centered Medical Home-Kids (PCMH-Kids) Program. PPEP places trained Parent Educators into pediatric practices to provide culturally competent, family-centered services that link families with medical homes and assist in coordinating their care. PCMH-Kids is a primary care payment and service delivery model reform initiative that began in 2015 and now engages 70 providers across the state in working toward a sustainable medical home model with a focus on quality measurement, accountability, population health, and data-driven quality improvement.
The Massachusetts Division for CYSHCN houses a Medical Review Team (MRT), which evaluates applications for long-term or short-term care for individuals under 22 years of age in pediatric nursing homes or skilled nursing facilities. A multidisciplinary team of professionals works with families and referring agencies to determine whether this type of placement is appropriate based on medical and developmental criteria. When a placement is approved, MassHealth, the Massachusetts Medicaid agency, covers these services.
Alaska’s Title V and Medicaid agencies work together with the All Alaska Pediatric Partnership (AAPP) on a statewide effort to revise the plan for pediatric specialty care to address provider shortages. AAPP is a nonprofit organization that brings together pediatric providers, the Alaska Department of Public Health, and community groups to improve systems of care for children.
Illinois’s CYSHCN program and Medicaid agency held focus groups with caregivers raising CYSHCN to develop recommendations and strategies for improving home nursing coverage and addressing financial challenges for medically fragile children and youth. They have also worked together to identify training opportunities and put together educational webinars for home nursing agencies. UIC-DSCC continues to operate the Home Care Program on behalf of Medicaid providing ongoing care coordination for children receiving in-home shift-based nursing care. In 2022, UIC-DSCC was asked to take on the role of providing care coordination to another Medicaid program, Interim Relief, serving individuals with complex behavioral health needs.
Dedicated Medicaid Liaison Role Within Title V
After Georgia’s Department of Public Health moved to a different department from the Medicaid agency, Title V developed a Medicaid liaison role. The person who serves in this role represents the CYSHCN program and Title V more broadly while working with Medicaid and develops policy-level relationships between the two agencies. In 2019, the liaison was able to work with Medicaid to increase reimbursement rates for well child visits conducted by local health departments, which has allowed them to expand their services.
Aligning Priorities Between Title V and Medicaid
After revising their Memorandum of Understanding (MOU), Oregon’s Title V and Medicaid agencies began meeting on a quarterly basis to collaborate on legislative and policy agendas and other topics of shared interest.
The Title V and Medicaid agencies in Wyoming collaborated to draft a crosswalk of their services for CYSHCN, pregnant individuals, and families with children. This crosswalk illustrated areas of overlap and helped to identify ways to improve coordination of services.
Providing Services to Children Enrolled in Title V CYSHCN Programs and Medicaid
Vermont Title V has partnered with Medicaid to improve incontinence supplies and resources for Vermont CYCHCN. This involved teaming to research, evaluate, and determine the need to contract with a primary vendor for Vermont Medicaid members. Nurse case managers employed by Vermont Medicaid contact each new Medicaid enrollee, regardless of their eligibility pathway, to discuss their benefits and ensure that they are enrolled in the best plan for them. Originally, nurses only contacted individuals 18 years and older, but after the Vermont CYSHCN program approached them and developed a script for outreach to youth and their families, the nurses have extended this outreach to younger enrollees. If a nurse identifies a special health care need during one of these calls, the enrollee can be referred to the CYSHCN program.
In 2019, the Maine Title V and Medicaid agencies worked together to improve access to and coverage of medical foods. Maine Medicaid had already covered medical formulas, and Title V advocated for the opening of a new billing code to allow for coverage of low protein foods. After the code was opened, Medicaid and the families enrolled in the CYSHCN program identified a durable medical equipment vendor to supply the food and enrolled families with the vendor.
Direct Service Provision
Mississippi’s Title V agency administers the state’s early intervention program. The state’s Medicaid agency reimburses for care coordination provided by Title V staff to families with children enrolled in this program, and for services delivered by physical therapists, occupational therapists, speech therapists, and special early intervention instructors.