Georgetown University Health Policy Institute Promoting Young Summary A child’s brain develops most rapidly in the earliest Children’s Healthy years of life, building the foundation for learning, behavior and health. Medicaid—as the primary source Development in of health coverage for young, low-income children— is a logical system to reach families with young Medicaid and children and set them on a path of healthy physical, social, and emotional development. Any effort to improve young children’s healthy development should the Children’s intentionally involve Medicaid and the Children’s Health Insurance Program (CHIP). Health Insurance Medicaid, along with CHIP, serves four out of five young children in poverty.1 Yet Medicaid can do more Program (CHIP) to elevate the needs of these children. Prioritizing young children in Medicaid through cross-sector, by Elisabeth Wright Burak innovative practice change has the potential to improve their lifetime trajectories, overall population health and long-run savings.2 Fourth in a series of briefs on the future This paper examines ways for state and federal of children’s health care coverage policymakers to use Medicaid and CHIP to more October 2018 effectively put young children on the best path for success in school and in life. These include: 1. Prioritize the health of parents and caregivers as key players in children’s healthy development. 2. Maintain continuous, consistent health coverage for young children and their families. Start by ensuring no newborn leaves the hospital without coverage. 3. Measure and ensure that young children receive the full range of preventive care and treatment they need under Medicaid’s comprehensive pediatric benefit (EPSDT). 4. Support expert-recommended, research-based interventions that meet the developmental needs of young children. 5. Invest in prevention and pediatric care innovation. 2 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Introduction A child’s experiences and environments early in life have a Health care coverage offers one important means to connect lasting impact on his or her development and life trajectory. families with providers and others who, by supporting positive The first months and years of a child’s life are marked by parenting and healthy development, can help to reduce rapid growth and brain development. Any parent can see this undue stress on families that can negatively affect a child’s firsthand, watching her children observe and interact with the trajectory. Coverage is a critical first step toward ensuring people and worlds that surround them. children can access routine preventive care through well-child visits and address health concerns as early as possible. Just While the brain can change and adapt throughout a person’s as important, coverage helps protect families from financial life, the foundations of the brain’s architecture are constructed insecurity that can come from an unexpected asthma attack early: Its capacity to adapt and change decreases with or injury at child care.9 Continuous, consistent coverage age.3 A strong foundation of positive early experiences with without disruptions is especially critical for young children, as caregivers in healthy, safe and nurturing environments greatly experts recommend 16 well-child visits before age 6, more influences a child’s resilience.4 Research even shows that heavily concentrated in the first two years, to monitor their a child’s early experiences—positive or negative—interact development and address any concerns or delays as early with their biology, ultimately determining how one responds as possible.10 These visits allow providers, to closely monitor to life’s inevitable challenges. A high incidence of adverse their a child’s development and address any concerns or childhood experiences, or trauma, in early years can delays as early as possible. negatively impact a child’s long-term physical health and well- being, also affecting learning and behavior throughout life.5 High quality health care is an important way to support young children and their families. But research is clear that many The health of parents, caregivers, and other adults in a child’s factors beyond medical care—income, access to healthy food life has a direct influence on his or her healthy development.6 and safe housing, education, and exposure to adversity—can Left untreated, maternal depression can impede a mother’s have a greater impact on health in the long run.11 For young ability to bond with and care for her child.7 Similarly, providing children and their families, the health care system can serve support and treatment to parents with substance abuse as a critical coordinating “hub” to improve linkages to other disorders, such as those affected by the growing epidemic social and economic supports. States and communities are of opioid dependence, is as important for children as their increasingly looking for innovative ways to address these caretakers.8 social determinants of health.12 Medicaid—serving nearly half of all young children—is an essential piece of the puzzle. Medicaid serves nearly half of all U.S. children Figure 1. Percentage of Children Under 6 with under age 6. Medicaid/CHIP by Federal Poverty Level, 2016 More than one-third of all children rely on Medicaid and 85.5 CHIP for health coverage13, but the programs play an even greater role for the nation’s youngest children. Among 65.9 children under age 6, 44 percent rely on Medicaid for their 44.1 35.7 health insurance. The percentage of young children covered by Medicaid grows as family income declines (See Figure 1) 11.7 and is highest for the youngest children.14 All Income < 100% 100-199% 200-299% ≤ 300% Levels Among children under age 6, 44 percent rely on Source: Georgetown University Center for Children and Families tabulations Medicaid for their health insurance. of the 2016 U.S. Census ACS data from IPUMS. 3 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Medicaid requires comprehensive pediatric Ensuring all young children and their families access the benefits under Early, Periodic, Screening, preventive care and other services they need is challenged by Diagnostic, and Treatment (EPSDT). the following issues: EPSDT is the child health benefit in Medicaid—and in zz Where a child lives plays a large role in whether she or he many states, CHIP.15 It provides broader coverage as can get the care they need. Medicaid policies and their compared to private plans and Medicaid benefits for applications are inconsistent across states. As a federal- adults, and it has an explicit focus on prevention.16 EPSDT state program, a large share of Medicaid’s cost is paid by is designed to ensure that children’s developmental the federal government. States administer the program, with needs are met and that diseases or delays are addressed broad discretion in eligibility/enrollment, payments, delivery as early as possible. It seeks to ensure coverage for systems, and quality improvement above federal minimum services that are designed not only to treat a condition requirements.22 but also to prevent it from occurring or worsening. States zz Continuous, affordable health coverage for children and must provide each child with recommended preventive their parents is essential, but incomplete. While Medicaid, screens, follow-up diagnostic assessments and, in turn, CHIP, and the ACA have elevated coverage levels to all-time any resulting “medically necessary” services a medical highs, millions of children, their parents, and other adults professional considers essential to prevent, treat or in their lives remain uninsured or do not have access to improve the diagnosed condition. 17 consistent, reliable health coverage.23 More than 900,000 children under age 6 remain uninsured, many of whom are Medicaid serves a growing percentage of eligible for but not enrolled in Medicaid or CHIP. 24 In 2016, young children’s parents. One in five (20.4 seven states—Alaska, Arizona, Georgia, Nevada, North percent) parents of children 3 and younger Dakota, Oklahoma, and Texas—had significantly higher rates were enrolled in Medicaid in 2016.18 of uninsured children under 6 than the national average.25 Where a parent or adult caretaker lives ultimately An initial look at 2017 data show an increase in the rate of determines whether he or she can get Medicaid uninsured young children for the first time in many years.26 coverage. Rates of Medicaid coverage among parents Many other children experience gaps in coverage that can of children age 3 and younger range from less than 10 impact continuous access to care. Parents of young children percent (Texas, Kansas and Virginia) to 39 percent (New are also uninsured at higher rates. Nationally, 12.4 percent Mexico).19 Prior to implementation of the Affordable Care of U.S. parents of children ages 3 and under have no health Act (ACA), only the poorest parents qualified for Medicaid insurance. In non-expansion states, these parents are in most states. To date, 33 states and D.C. have adopted uninsured at double the rate of those in expansion states (18 the ACA Medicaid expansion, which covers all adults versus 8.7 percent).27 up to 138 percent of the federal poverty line (less than zz Medicaid’s promise of early and periodic screening, $29,000 for a family of three in 2018).20 In these states, diagnostic and treatment (EPSDT) benefits for children less than 10 percent (8.7 percent) of parents of children is not being fully realized. Almost 30 years after federal age 3 and younger are uninsured, compared to 18 Medicaid set a goal for 80 percent of all children to receive percent in non-expansion states.21 at least one well-child visit each year, few states met the threshold in 2017.28 At the national level, the goal has only Medicaid can help to drive system reforms been achieved for children under age one (see Table 1 below). that prioritize children’s development. State flexibility in program administration combined with Table 1: Percentage of Children in Medicaid the program’s purchasing power and large proportion of Receiving at Least One Well-Child Visit/Screen, 2017 children served, provide an opportunity to lead health All Under 1-2 3-5 system change that serves young children. Children Age 1 Years Years 58% 88% 78% 68% Source: EPSDT U.S. CMS-416 FFY2017, Participant ratio. 4 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT While most states exceeded the 80 percent goal for when they need it.32 For example, available data children under age 1, less than half of states met this does not show whether children accessed physician- rate for children ages 1 through 2, and only two states recommended referrals and treatment as a result of met the goal for ages 3 through 5.29 preventive screen, or their progress toward desired health outcomes. Other available, state-reported data provide additional zz The traditional health care system is not designed detail on preventive care gaps for young children to address a child’s family and community context. in Medicaid and CHIP. Figures 2 and 3 shows the Payments are often linked to treatment for individuals. geographic distribution of children under age 6 Yet for young children, a move toward “family-based receiving recommended well-child visits for 2017. Best primary care” and strong care coordination that links practices for young children during well-child visits, families to health and social supports is critical.33 such as developmental screenings, also fall short of the recommended standard: Of the 27 states reporting zz Multiple, fragmented systems—health, mental the measure for 2017, developmental screening for health, public health, education, social services— children under age 3 in Medicaid and/or CHIP ranged serve many of the same children and families. from less than 4 percent in Alaska 30 to 81.1 percent in While these systems often have overlapping goals, Vermont, with a median of 39.8 percent.31 they largely operate in isolation, creating confusion for families. Many children fall through the cracks zz Child health data is limited and/or inconsistent as uncoordinated systems are stretched by limited across states, child-serving systems, and payers. resources and lack of integration that could better This limits the ability to gain a comprehensive sense connect families and services. of whether children receive the care they need, Figure 2. Percentage of Children in Medicaid and/or CHIP Receiving Six or More Well-Child Visits in the First 15 Months of Life, 2017 Child Core Set WA MT NH ME ND VT OR MN MA ID SD WI NY WY RI MI CT IA PA NJ NV NE OH MD UT IL IN DE CO WV DC CA KS MO VA KY NC Did Not Report (2 states) TN AZ OK NM AR SC 31.2% – 55.6% (12 states) MS AL GA 55.7% – 59.2% (11 states) LA 59.3% – 66.0% (13 states, TX including D.C.) FL 66.1% - 88.9% (13 states) AK HI Source: CMS Child Core Set, Mathematica analysis of MACPro reports for the FFY 2017 reporting cycle. Adapted from Child Core Set Chart Pack FFY 2017 (p. 22). 5 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Figure 3. Percentage of Children in Medicaid and/or CHIP Receiving at Least One Well-Child Visit in the Third, Fourth, Fifth, and Sixth Years of Life, 2017 Child Core Set WA NH ME MT ND VT OR MN SD MA ID WI NY WY RI MI CT IA PA NJ NV NE MD UT OH IL IN DE CO WV DC CA KS MO VA KY Did Not Report (2 states) NC TN AZ NM OK 26.9% – 58.4% (12 states) AR SC GA 58.5% – 66.8% (12 states) MS AL TX LA 66.9% – 76.0% (12 states) 76.1% - 86.5% (13 states, FL including D.C.) AK HI Source: CMS Child Core Set, Mathematica analysis of MACPro reports for the FFY 2017 reporting cycle. Adapted from Child Core Set Chart Pack FFY 2017 (p. 24). New York’s One-of-a-Kind Initiative to Prioritize Care for Young Children in Medicaid In 2014, New York’s Medicaid agency set out a goal to move to value-based payment for up to 90 percent of all managed care payments by 2020. As stakeholders gathered to inform the system change, advocates and child development experts pointed to the fact that for children, more upfront spending on primary care, attention to healthy caregivers, and stronger linkages to non-health supports drive more value for children in the long term.34 Based on this input, Medicaid officials developed the First 1000 Days in Medicaid, a collaborative process to identify opportunities for the Medicaid program to improve health, educational and economic outcomes for children in close partnership with education and other state agencies. Recommendations were prioritized by a broad-based stakeholder working group and funded in the state’s 2018 budget to be implemented and evaluated starting in 2019. Highlights include: requiring all Medicaid managed care plans to adopt a children’s quality agenda, making changes to billing practices to increase access to services for parents and their children together, and creating a database to facilitate information- sharing across systems. 6 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Recommendations State Federal Child development experts tell us that to be most effective, public policies to improve outcomes for young children and their families should aim to support responsive relationships between children and adults, strengthen core life skills, and reduce sources of stress in the lives of children and families.35 Recommendations below offer a starting place for Medicaid to more effectively serve young children and their families. The table on page 14 summarizes these recommendations by federal and/or state actions. Prioritize health care for parents, future parents, caregivers, and early childhood educators as essential contributors to children’s healthy development. Providing health coverage helps to ensure all adults that In states that expanded Medicaid, adults have seen care for young children have their own health needs met improved access to treatment—including behavioral while providing additional economic security, which can and mental health care—which can only improve the help to reduce stress experienced by low-income families. positive, nurturing relationships children need for health development.40 Evidence also points to improved financial Expand Medicaid to all adults up to 138 percent security, as well as health coverage gains for children the federal poverty level (FPL). In non-expansion through the “welcome mat” effect—as parents gain states, the median income eligibility for parents is just 43 coverage for the first time, they also enroll their eligible percent FPL, ranging from 18 percent in Alabama and children.41 Children whose parents gain coverage are also Texas to at or close to 100 percent in Tennessee and more likely to access preventive care through regular Wisconsin.36 In most cases, adults without dependent check-ups.42 Medicaid expansion also supports healthy children remain ineligible for public coverage if their birth outcomes and can influence health equity. One study income falls below the poverty line.37 Parents and linked states with Medicaid expansion to significantly caregivers in this coverage gap are subject to added greater declines in infant mortality rates compared to stress of unmet health needs and financial insecurity that non-expansion states, which were even more dramatic for can directly impact the quality of interactions with young African-American infants.43 First-time mothers in Ohio were children in their care. significantly more likely to access prenatal care after the The benefits of the ACA’s adult Medicaid expansion state expanded Medicaid.44 for young children’s development are not limited to Ensure all eligible parents are enrolled in coverage for their parents. Children interact with many Medicaid. Regardless of Medicaid expansion adults in their early years, most often with caregivers at status, all states can do more to ensure eligible parents child care or family day care homes while parents work. are enrolled in Medicaid. In 2016, more than one in four Medicaid expansion could also benefit many of these uninsured parents were eligible for Medicaid but not early childhood educators who influence young children enrolled; two-thirds of these parents had a child who was daily. In 2017, the average annual salary for child care already enrolled in Medicaid.45 Just under 80 percent of workers in the United States was $22,290, just under the parents eligible for Medicaid were enrolled in 2016, with income threshold for Medicaid expansion (138 percent participation rates ranging from a low of 44 percent in FPL).38 Early childhood educators often do not have health Texas to 95.6 percent in Massachusetts.46 States can use insurance available through their small employers.39 targeted outreach efforts, as well as streamlined eligibility and enrollment policies, to reach these unenrolled parents (See #2 ). 7 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Maintain continuous, consistent health coverage for young children and their families. Medicaid/CHIP eligibility and enrollment policies can Make a newborn’s CHIP coverage effective have significant impact on both whether children and on their birth date. Regardless of when they are families access Medicaid and CHIP, and whether the enrolled in their first 90 days, a CHIP-eligible newborn’s coverage remains stable. Providing real-time eligibility coverage should be effective retroactive to their birth date. determinations and continuous coverage in Medicaid/ If a Medicaid-eligible newborn falls through the cracks and CHIP as long as a child remains eligible helps to prevent leaves a hospital without coverage, Medicaid’s retroactive unnecessary lapses in coverage and care, especially in the eligibility can pay for his or her health care during the early years of rapid development. three months prior to their enrollment.51 But this coverage Consistent coverage is also a key factor—a prerequisite, protection is not available in separate CHIP programs. even—in accurately measuring the quality of care States may elect to pre-date a newborn CHIP enrollee’s delivered to children in Medicaid. Quality measurement coverage eligibility to their birth date during their first three often excludes individuals who are not enrolled for at least months of age. 12 months.47 Until all Medicaid beneficiaries—especially Adopt presumptive eligibility in Medicaid children—have at least 12-month continuous coverage, it and CHIP for children, pregnant women, and is impossible to get an accurate, complete picture of how other adults. More and more states are moving toward many are getting the services they need and whether the real-time eligibility decisions52 but it can take up to a intended outcomes were achieved. month or more to determine Medicaid eligibility in some Federal and state technology upgrades are moving states cases.53 Presumptive eligibility helps children and families closer to real-time eligibility determinations for children enroll in health coverage on a temporary basis while and their families in Medicaid and other public programs. full eligibility is determined. States should fully adopt This not only cuts red tape for families but can also save presumptive eligibility until a real-time, seamless eligibility time and money for states by reducing administrative and enrollment system can be realized. Medicaid, CHIP, burdens. The following steps can further support and the ACA provide many tools to extend presumptive consistent coverage for eligible children. eligibility to new populations or in hospital settings.54 Ensure no newborn leaves the hospital without Table 2: Number of States Adopting Presumptive health coverage. States can improve technology Eligibility in Medicaid or CHIP, by Population, and processes to immediately enroll newborns in available January 2018 coverage: In 2016, nearly 115,000 (3 percent) children under Medicaid CHIP 12 months of age were uninsured.48 Babies born to mothers Children 20 11 enrolled in Medicaid or CHIP are immediately eligible as Pregnant “deemed newborns” for one year.49 States should ensure Women 30 3 their enrollment systems reflect this requirement and easily Parents 9 n/a allow medical providers and staff to check on a child or All adults 6 n/a family members’ coverage and take steps to quickly enroll them if needed. Oklahoma uses an automated newborn Source: Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2018: Findings from a 50-State Survey” enrollment system, which allows hospital staff to enter (Washington. D.C.: Kaiser Family Foundation, March 2018). newborn information and receive an assigned Medicaid number before the mother and baby are discharged.50 8 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Adopt Express Lane Eligibility (ELE) for children. Table 3: Number of States Adopting 12-month ELE, used by nine states, allows Medicaid agencies Continuous Eligibility (CE) in Medicaid or CHIP for to consider findings from other public, income-based Children, January 201862 programs, such as Supplemental Nutrition Assistance Program (SNAP), to enroll a child in Medicaid or CHIP or All Children Limited to young renew their coverage. As of January 2017, nine states Medicaid Medicaid CHIP children used ELE for Medicaid/CHIP enrollment, renewal, or or CHIP both.55 Federal law allows states to use several means- 32 24 26 3 tested programs in ELE, including the Child Care and AR, DE, FL, NV, PA, TN, TX and UT FL: Under age 5 Development Block Grant, Head Start, and the Special provide 12-month continuous eligibility PA: Under age 4 Supplemental Nutrition Program for Women, Infants, and in separate CHIP programs, but not in (Medicaid) 63 Medicaid. IN: Under age 3 Children (WIC), which reach many young children.56 To date, other than WIC57, no state has used these programs Source: Medicaid and CHIP Eligibility, Enrollment, Renewal, and in ELE; most use SNAP.58 Cost Sharing Policies as of January 2018: Findings from a 50-State Survey” (Washington. D.C.: Kaiser Family Foundation, March 2018). Require 12-month continuous coverage for all children in Medicaid and CHIP. Continuous Extend the continuous eligibility period up to eligibility allows a beneficiary’s Medicaid or CHIP five years for children under age 6. Moving enrollment to remain stable for a set period of time, beyond a 12-month continuous eligibility regardless of changes in family size or income, which period for young children would recognize the can fluctuate from month to month, even as their annual significance of early childhood development, frequency income remains relatively low.59 Research shows that of recommended check-ups, and the higher share of 12-month continuous eligibility for children increases the young children in poverty and the income volatility faced coverage continuity and reduces churn, or the rolling on by many poor families.64 and off coverage that disrupts consistent care.60 zz Congress could give states the option to adopt Beyond the required 12 months of coverage available to up to five years of continuous eligibility for children deemed newborns, federal policy allows states to adopt under age 6. 12-month continuous eligibility for all children. Thirty- two states adopt the practice in Medicaid or CHIP for zz Absent Congressional action, states could pursue a all children (see Table 3). Eight states provide 12-month Medicaid Section 1115 research and demonstration continuous eligibility in separate CHIP programs but not waiver to test the practice.65 in Medicaid, potentially leaving children in families with lower income levels with less stable coverage than their higher income peers. States may also consider continuous eligibility for parents, caregivers and other adults.61 zz Congress should standardize children’s continuous eligibility by requiring all states to adopt a minimum of 12-month continuous coverage for children in Medicaid and CHIP. zz States should adopt 12-month continuous coverage for all children in Medicaid and CHIP. 9 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Measure and ensure that young children receive the full range of services they need under EPSDT. The first step is ensuring higher quality and more Policymakers should: consistent data. Ideally, data should be publicly and Implement a comprehensive focus on young consistently reported at multiple levels—national, state, children’s quality improvement. States should managed care plans, provider practices—to allow determine where gaps exist or where additional or revised policymakers, families, and others to assess Medicaid’s data may be necessary. For states with children served performance for children. A focus on children’s health in managed care, this means requiring each contracted quality improvement can improve data collection and Medicaid managed care organization (MCO) to have an reporting to inform and prioritize policies. Importantly, it explicit focus on pediatric quality, as recently adopted can also unify a variety of stakeholders around common in New York (see box above).71 In North Carolina, new goals, offering a concrete way to engage other child and Medicaid MCOs will be required to adopt three performance family-serving systems in the quest to improve child improvement projects based on a list of priority areas health, which Medicaid cannot do in isolation. for the state, one of which is early childhood health and Publicly available Medicaid data currently does not provide development. The state will also require plans that do not a full picture of whether children are getting the preventive meet a 75-percent threshold for well-child screenings during a and treatment services they need, when they need it.66 year to adopt an additional performance improvement project Data are also typically not disaggregated in a way that on EPSDT screening and community outreach.72 can allow for comparisons across race and ethnicity, States should also engage other child-serving systems in which could inform state efforts to improve health equity. quality improvement to identify shared goals and outcomes The Child Core Set (see box), as it evolves, offers one that can be addressed in partnership. For example, in Oregon important opportunity for consistent child measures across and New York, Medicaid and education agencies have states and over time, in conjunction with state-reported committed to use the shared goal of school readiness to EPSDT participation data.67 inform improvements and move toward shared accountability across sectors.73 State adoption of cross-system goals, or even common measures, could help provide a road map for Medicaid and CHIP Child Core Set: States Must these efforts, such as those detailed in federal guidance for Report All Measures Starting in 2024 cross-system early childhood and health alignment.74 Created in 2009, the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP Publicly report the Child Core Set quality measures offers a standard set of universal measures to allow for young children, with additional detail. Eleven tracking and reporting within and between states of the 26 measures in the 2018 Core Set focus on over time.68 State reporting is currently optional, with prenatal or early childhood health.75 Only 26 states all states reporting at least one measure in 2017, currently report the Core Set developmental screening ranging from one to 25 of the total 27 measures.69 measure, an important starting place to help drive Starting in 2024, states will be required to report on improvements in universally-recommended screens for all Core Set measures, including well child visits, young children. immunizations, developmental screenings and other zz Federal officials should require additional detail and key services for young children.70 Required reporting transparency in both EPSDT and Core Set reporting offers a significant opportunity for states to coalesce for states and MCOs alike.76 Federal officials can also child- and family-serving systems around Medicaid support development of new measures that seek to move quality improvement for young children. beyond screenings to capture follow-up referrals and treatment received by young children. 10 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT zz States can get a head start reporting additional Ensure EPSDT reporting, and outreach/ measures before they become mandatory in 2024, education, service requirements are explicit in creating cross-system learning communities to state agency agreements with Medicaid MCOs. For support the quality of data collection and measure states serving children in managed care arrangements, performance. The developmental screening measure agreements with MCOs must be explicit on data reporting, should be prioritized if not already reported. services, and family outreach responsibilities with regard State and federal officials should move toward systems to EPSDT to ensure clear lines of accountability when that can publicly report Core Set and EPSDT data corrective action is needed. aggregated by child demographics (e.g. race/ethnicity), service delivery type (e.g. managed care versus fee-for- service), and service location (e.g. region, plan, provider) to better understand specific areas of need. Support expert-recommended, research-based interventions that meet the developmental needs of young children. The American Academy of Pediatrics’ (AAP) Bright Futures Fully adopt AAP Bright Futures preventive Guidelines for Health Supervision of Infants, Children, care guidelines in Medicaid and CHIP. States and Adolescents77 sets the standard for preventive care. determine their own policies and guidelines for preventive Supported by multiple agencies of the federal Department care in Medicaid, including a periodicity schedule, or the of Health and Human Services, Bright Futures provides state’s reimbursement timetable for preventive screens. an evidence-based template for well-child visits and Full adoption of Bright Futures—including the periodicity screenings, including a recommended periodicity schedule schedule—can move toward a more uniform preventive for universal and periodic screens, which specifies the care framework across states and primary care settings. number and frequency of screenings that cover many Since these guidelines are updated regularly based on aspects of child development. research, states should also ensure that state policy reflects or refers to Bright Futures recommendations and Once a problem is identified, effective treatment is key. subsequent updates.81 Yet policy discussions around EPSDT often focus on screenings and preventive care, rather than whether As of 2018, Medicaid programs in 40 states children ultimately receive interventions necessary to and Washington, D.C., use Bright Futures as address conditions identified.78 the preventive care standard or use a similar standard.82 Policies in 11 states (Alabama, States have quite a bit of latitude in how they deliver Arizona, Arkansas, Delaware, Massachusetts, EPSDT services and set payment rates for providers. Minnesota, Missouri, New Jersey, Utah, In particular, states have wide discretion, under federal Washington, Wisconsin) do not align with Bright parameters, to decide who is able to be reimbursed and Futures. These states specify fewer well-child where a service may be provided.79 Yet a lack of clear billing visits for young children and/or do not reflect policies and procedures, sometimes influenced by limited preventive screening guidance.83 awareness of interventions and services young children need, can mute service delivery in practice.80 Policymakers Even among states with recommendations similar can employ the following strategies to help more young to Bright Futures, specific screening schedules and children get the services they need, when they need them. reimbursement policies vary.84 11 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Prioritize the ‘T’ in EPSDT by reviewing and referrals and follow-up care when a screen identifies a updating state policies and procedures where need. Thirty-three states promote standardized referral necessary. States should review current policies and processes to connect children or families to follow-up procedures to address barriers to treatments. Any updates services such as early intervention.90 should be accompanied by a robust education and training zz Delivery system barriers. Colorado recently started efforts for providers, on top of ongoing training and allowing all Medicaid beneficiaries to receive mental education on existing processes. Examples of areas to health treatment, such as parent-child therapy, in review include: the primary care setting for up to six visits without a zz Definition and application of pediatric “medical diagnosis.91 Other states, including North Carolina and necessity.” EPSDT should account for preventive care Oregon, also use pre-diagnosis codes to provide mental as well as comprehensive child development services, health interventions to young children at risk of mental including a child’s family and environmental factors.85 health disorders.92 This should be done in light of the requirement for Support interventions that recognize the role medical necessity decisions to be based on an of parents and caregivers in a child’s healthy individual child’s condition, not on arbitrary cutoffs or development. Experts and policymakers are condition lists.86 increasingly identifying ways to promote two- As of 2018, 40 states and Washington, generation approaches in Medicaid that nurture parent or D.C. incorporate a preventive care purpose caregiver-child relationships through federal guidance and in Medicaid’s pediatric medical necessity state policy.93 definition, while nine states did not (Hawaii, zz Issue federal guidance to states. This is one Illinois, Indiana, Iowa, Kentucky, Mississippi, important way the federal agency signals its priorities Nebraska, North Dakota, South Carolina). for states to address young children’s healthy Arizona does not have a pediatric medical development and clarifies promising strategies and necessity definition.87 practices in Medicaid. In 2016, the federal Department of Health and Human Services (HHS) provided zz Payment policies, procedures, and codes. In guidance to states on the ways Medicaid can support some cases, new and/or underutilized services home visiting—a service with clear evidence of cost- and treatment may require explicit billing policy or effective positive outcomes for mothers and their guidance for providers. State or MCO policy and children.94 Also in 2016, HHS guidance clarified that procedure manuals should explicitly signal an ability maternal depression screening during a child’s well- for providers to bill for certain services, including how child visit—a Bright Futures recommended practice and where a child or their parent may be served. For for new parents—can be billed to a child’s Medicaid example, several states have adopted new diagnosis number, along with any resulting parent-child therapy.95 criteria and billing codes for infant-early childhood A follow-up information bulletin issued in 2018 built on mental health services.88 States can also improve earlier guidance, outlining ways Medicaid can support developmental and other preventive screenings infants experiencing opioid or other substance abuse through increased reimbursements or financial withdrawal. Referencing the previous administration’s incentives to plans or providers that improve rates or efforts, the bulletin from HHS Centers for Medicare and exceed a standard.89 Medicaid Services (CMS) clarified the opportunity for zz Standardized referral/follow-up tracking. states to support mothers together with their infants as Streamlining processes with clear cross-sector part of treatment.96 responsibilities and feedback loops can aid understanding of whether children receive necessary 12 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT zz Clarify allowable payments for two-generation Medicaid provides care coordination activities through services or referrals to other systems. Thirty-three case management—a required service under EPSDT— states use Medicaid to finance home visiting for but its application is uneven.102 States should assess the pregnant women or young children, through a variety of extent and quality of care coordination currently available, mechanisms.97 Thirty-seven states allow, encourage, or starting with a review of existing policies (e.g. guidance, require maternal depression screenings during well- contract requirements, etc.) and practices with the goal child visits.98 Twenty-five states reimburse maternal of identifying opportunities to strengthen linkages and or caregiver depression screenings under a child’s handoffs among primary care practices and other systems Medicaid enrollment.99 States may also use a parent serving children and their families (e.g. early intervention, diagnosis to trigger eligibility for other supports or allow public health, maternal and child health, home visiting and for reimbursement for parent-child treatment to aid other social services and supports).103 States may also use child development. New York is providing additional payment policies to improve, enhance and incentivize care guidance to clarify reimbursement for parent-child coordination, with payment rates based on the intensity of therapy under a child’s Medicaid ID when a parent families’ needs.104 or caregiver is diagnosed with a mood, anxiety, or Extend Medicaid benefits to CHIP. States can substance abuse disorder. Michigan and Minnesota extend Medicaid’s EPSDT benefit to separate CHIP take a similar approach.100 programs to ensure all young children can access the full Strengthen linkages between health care and range of preventive care and treatment they need and other community services through improved create uniformity across both programs. Eleven states care coordination. Care coordination aims to link extend Medicaid EPSDT benefits to children in separate families with services within and outside the traditional CHIP programs. Twelve states with separate CHIP health care system and break down barriers to care.101 programs do not extend Medicaid benefits to CHIP. 105 Invest in prevention and pediatric care innovation as a key component of health reforms. Even as there is more to be done to ensure children and their become costlier down the road. This should include testing families get services and supports in the existing systems, new approaches to address social determinants of health the broader evolution of the health system must do more to through improved linkages between the healthcare and ensure that the needs of children—and specifically preventive social service systems.107 care for young children and their families—are adequately addressed. Prioritizing young children in system reform offers Use payment and delivery system reforms to a comprehensive approach to encapsulate many of the advance high-performing pediatric medical recommendations included throughout this paper. homes. States, directly or through managed care contracts, determine payments for providers. Health care delivery and payment reform efforts are Reimbursement rates for pediatric care are relatively low happening at the local, state and national levels. As reform compared to care for other populations, and typically efforts seek to save money in the short term, the needs of don’t allow for extended time and resources necessary to children are often overshadowed by adult-focused models, provide comprehensive screenings or guidance.108 More despite their real potential for long-term savings.106 Medicaid than 30 states have implemented some type of pediatric can play a role in helping to spread and sustain practice medical home initiative in Medicaid or CHIP.109 Figure changes that both elevate the preventive and developmental 5 offers key elements in any progression toward high- needs of young children and address conditions before they performing pediatric medical homes.110 13 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT zz The Department of Health and Human Services zz State payment policies should seek to improve should further invest in pediatric payment innovations pediatric primary care as a central care hub for focused on improved outcomes for young children. young children in Medicaid. Increased primary care Evaluations of new approaches should include a expenditures for young children will be required to comprehensive analysis of the long-term costs and provide and coordinate proven care interventions, savings both within and outside the health system of such as behavioral health integration, and tailored Medicaid & CHIP specific budget line item(s).111 A new care coordination using a broader, family-focused CMS funding opportunity for states to test pediatric approach.113 Models should also consider innovative care models in response to the opioid crisis provides or promising approaches to address social an important first step and may also yield important determinants of health that play an important role in lessons on the integration of physical and behavioral children and families’ long-term well-being.114 health more broadly.112 Figure 5. Design for High Performing Pediatric Medical Homes in Medicaid Well-Child Visits zz Comprehensive well child visits as Care Coordination/Care Management required under EPSDT. zz Adherence to AAP Bright Futures Other Services scope and schedule. zz Individualized, with intensity commensurate with need. zz Screening for physical, developmental, social-emotional zz Routine care coordination for all zz Child/family support programs, behavioral health, maternal as part of medical home. including those designed to be depression and other social zz Intensive care coordination/ collocated in primary care (e.g., determinantsof health. care management for those with Healthy Steps, Project DULCE). Anticipatory guidance and parent higher needs dentified. zz zz Integrated behavioral health in education, as required in EPSDT zz Structured, family-focused primary care setting. and Bright Futures. approach to assess and respond zz Referrals to and integration with Family engagement, focused on to medical and non-medical zz other services such as home two-generation approaches to health-related needs. visisting, family support, early ensuring child health. zz Linkages to community intervention, early childhood zz Other primary care paractice resources, wth active mental health, and other augmentations (e.g. Reach Out and identification and engagement of programs. Read). those resources. Source: K. Johnson and C. Bruner (2018, forthcoming), A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health, Child and Family Policy Center. (Adapted with author permission.) Conclusion State and federal lawmakers can use Medicaid as a children, such as school readiness or long-term economic catalyst for improved care and support to young children success, also requires a broader focus on the child as part and their families, reaching them before they require more of a family and their needs as a whole. This wider lens involved, complex interventions within and outside the demands authentic collaboration and shared accountability healthcare system later in life. While necessary for change, between Medicaid and other public systems (e.g. public Medicaid and the health care system cannot successfully health, education, child welfare and others), as well as the serve young children in isolation. Improving outcomes for private sector, to get the job done. 14 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Policy Options to Promote Young Children’s Healthy Development in Medicaid CONGRESS zz Require 12-month continuous eligibility for all children in Medicaid and CHIP. p. 8 zz Allow states to extend the continuous eligibility period up to five years for young children under age 6. p. 8 FEDERAL AGENCY zz Require additional detail and transparency in state data reporting, with goal of disaggregating by child demographics (e.g. race/ p. 9 ethnicity), service delivery type (e.g. managed care versus fee-for-service), and service location (e.g. region, plan, provider) zz Support development of Child Core Set measures that move beyond screenings to capture follow-up referrals and treatment p. 9 received by young children. zz Support interventions that recognize the role of parents or caregivers in a child’s healthy development (e.g. behavioral health p. 11 care, home visiting) through new guidance. zz Invest in pediatric payment innovations that both focus on improved outcomes for young children and allow for a comprehensive p. 13 analysis of the long-term costs and savings both within and outside the health system. STATE (by program administrative functions) Eligibility and Enrollment zz Expand Medicaid to all adults up to 138% FPL through ACA Medicaid expansion. p. 6 zz Ensure all eligible parents are enrolled in Medicaid. p. 6 zz Ensure no newborn leaves the hospital without health coverage by improving technology and processes to immediately p. 7 enroll them in available Medicaid or CHIP coverage. zz Make a newborn’s CHIP coverage effective on their birth date, regardless of when they are enrolled in their first 90 days.* p. 7 zz Adopt presumptive eligibility for children and pregnant women, or all adults. p. 7 zz Adopt Express Lane Eligibility (ELE) for children. p. 8 zz Require 12-month continuous eligibility for all children in Medicaid and CHIP. p. 8 zz Extend the continuous eligibility period for up to five years for young children under age 6.** p. 8 Quality Improvement zz Implement a comprehensive children’s quality improvement focus in Medicaid. Engage other child-serving systems to p. 9 identify shared goals and outcomes to address through cross-system action (e.g. goal of school readiness). zz Publicly report all Child Core Set quality measures, disaggregating by child demographics (e.g. race/ethnicity), service p. 9 delivery type (e.g. managed care versus fee-for-service), and service location (e.g. region, plan, provider). zz Move toward standardized tracking of service referrals and follow-up. p. 11 zz Ensure EPSDT data reporting, outreach/education, service requirements are explicit in state agency agreements with p. 10 Medicaid managed care organizations (MCOs). Benefits zz Adopt Bright Futures preventive care schedule and guidance in Medicaid and CHIP policy and practice. p. 10 zz Review state pediatric medical necessity definition and application to ensure it accounts for preventive care and p. 11 comprehensive child development services. zz Extend EPSDT benefits to CHIP.* p. 12 Payment and/or Delivery System** zz Review and update policies or procedures for new and/or underutilized services (e.g. developmental screenings, infant-early p. 11 childhood mental health). zz Support interventions that recognize the role of parents or caregivers in a child’s healthy development (e.g. behavioral health p. 11 care, home visiting). zz Strengthen linkages between health care and other community services through improved care coordination. p. 12 zz Advance high-performing pediatric medical homes that serve as a care “hub” for young children and their families. p. 13 * Only applies to states with separate CHIP programs. ** May require demonstration waiver depending on Medicaid beneficiary served (child or parent) service, service location, geographic area, and/or individual providing the service. 15 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Acknowledgements This brief was written by Elisabeth Wright Burak of Georgetown Center for Children and Families. The author would like to thank the following individuals for their reviews and contributions to this report at many stages along the way: Joan Alker, Tricia Brooks, Charles Bruner, Maggie Clark, Donna Cohen Ross, Kay Johnson, Phyllis Jordan, Adriana Kohler, Mike Odeh, Mary Nelle Trefz, and Karina Wagnerman. The author also thanks Allie Gardner and Kyrstin Racine for analysis support and edits. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. About this Series This issue brief is fourth in a series of papers from Georgetown University Center for Children and Families on the future of children’s health coverage. Other briefs in the series include: The Future of Children’s Coverage: Children in the Marketplace. Focuses on ways to improve marketplace coverage and the associated financial assistance for children. Fulfilling the Promise of Children’s Dental Coverage. Focuses on pediatric dental coverage and ways to improve children’s oral health. How Medicaid and CHIP Shield Children from the Rising Costs of Prescription Drugs. Focuses on how Medicaid and CHIP protect most children from the rising costs of prescription drugs. 16 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT Endnotes Georgetown University Center for Children and Families tabulations 14 of the 2017 U.S. Census ACS data from IPUMS. Also see J. Haley et 1 “Medicaid’s Role for Young Children” (Washington: Georgetown al., “Health Insurance Coverage among Children Ages 3 and Younger University Center for Children and Families, December 2016). and Their Parents in 2016” (Washington: Urban Institute, January 2018). Also note: Since the majority of uninsured children are eligible but not 2 P. Dworkin, “Leveraging Medicaid to Promote Children’s Optimal enrolled in Medicaid and CHIP, there are likely more children that could Health” (Hartford, CT: Connecticut Children’s Office for Community be covered. Child Health, August 2018); J. Heckman, “There’s more to gain by taking a comprehensive approach to early childhood development,” 15 A. Cardwell et al., “Benefits and Cost Sharing in Separate CHIP (The Heckman Equation, December 2016). Note: Throughout the paper, Programs” (Washington: National Academy for State Health Policy, unless specifically referring to separate CHIP programs or EPSDT, Georgetown University Center for Children and Families, May 2014). “Medicaid” refers to Medicaid and CHIP together. More than half of 16 K. Whitener, “EPSDT: A Primer on Medicaid’s Pediatric Benefit” children funded by CHIP dollars are served in Medicaid. (Washington: Georgetown University Center for Children and Families, 3 Center on the Developing Child at Harvard University “From Best March 2017). Practices to Breakthrough Impacts: A Science-based Approach to 17 Ibid. Building a More Promising Future for Young Children and Families,” (working paper, Cambridge, MA, 2016). 18 J. Haley et al., “Health Insurance Coverage among Children Ages 3 and Younger and Their Parents in 2016” (Washington: Urban Institute, 4 Center on the Developing Child at Harvard University “Supportive January 2018). Relationships and Active Skill-Building Strengthen the Foundations of Resilience: Working Paper No. 13,” (working paper, Cambridge, MA, 19 Ibid. 2015). 20 Kaiser Family Foundation, “Current Status of State Medicaid 5 V. J. Felitti et al., “Relationship of Childhood Abuse and Household Expansion Decisions” (Washington: Kaiser Family Foundation, July Dysfunction to Many of the Leading Causes of Death in Adults: The 2018); Assistant Secretary for Planning and Evaluation, “U.S. Federal Adverse Childhood Experiences (ACE) Study,” American Journal of Poverty Guidelines Used to Determine Financial Eligibility for Certain Preventative Medicine 14, no. 4 (May 1998): 245-258. Federal Programs” (Washington: Assistant Secretary for Planning and Evaluation). 6 Georgetown University Center for Children and Families, “Healthy Parents and Caregivers are Essential to Children’s Healthy 21 J. Haley et al., “Health Insurance Coverage among Children Ages 3 Development” (Washington: Georgetown University Center for Children and Younger and Their Parents in 2016” (Washington: Urban Institute, and Families, December 2017). January 2018). 7 L. Murray and P. Cooper, “Effects of postnatal depression on infant 22 Medicaid and CHIP Payment and Access Commission, “Medicaid development,” Disease in Childhood 77, no. 2 (1997): 99-101. 101” (Washington: Medicaid and CHIP Payment and Access Commission, 2018). 8 L. Smith, “The Opioid Epidemic and its Effect on Young Children” (Washington: Bipartisan Policy Center, February 2018). J. Alker, O. Pham, “Nation’s Uninsured Rate for Children Drops to 23 Another Historic Low in 2016” (Washington: Georgetown University 9 K. Wagnerman, “Medicaid: How Does It Provide Economic Security Center for Children and Families, September 2017). for Families?” (Washington: Georgetown University Center for Children and Families, March 2017). 24 Georgetown University Center for Children and Families analysis of 2016 American Community Survey (ACS) Integrated Public Use 10 American Academy of Pediatrics and Bright Futures, Microdata Series (IPUMS). More than half of all uninsured children “Recommendations for Preventative Pediatric Health” (Elk Grove, IL: are eligible for Medicaid/CHIP but not enrolled, but Medicaid/CHIP American Academy of Pediatrics, February 2017).. participation rates are higher for children under age 6. The exact 11 K. Hoagwood et al., “The Interdependence of Families, Communities, proportion of eligible, not enrolled children under age 6 is not available. and Children’s Health: Public Investments That Strengthen Families For more information, see J. Haley et al., “Medicaid/CHIP Participation and Communities and Promote Children’s Healthy Development and Rates Rose among Children and Parents: Variation in 2016 and Recent Societal Prosperity” (Washington: National Academy of Medicine, April Trends” (Washington: Urban Institute, September 2018). 2018). 25 Georgetown University Center for Children and Families analysis 12 T. Brooks and K. Whitener, “Leveraging Medicaid to Address Social of 2016 American Community Survey (ACS) Integrated Public Use Determinants and Improve Child and Population Health” (Washington: Microdata Series (IPUMS). Georgetown University Center for Children and Families, February 26 Georgetown University Center for Children and Families analysis of 2018). Census ACS data, 2017. Updated analyses forthcoming upon release 13 Georgetown University Center for Children and Families analysis of of more detailed data. Census ACS data, 2017. Updated analyses forthcoming upon release 27 J. Haley et al., “Health Insurance Coverage among Children Ages 3 of more detailed data. and Younger and Their Parents in 2016” (Washington: Urban Institute, January 2018). 17 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT 28 Medicaid and CHIP Payment and Access Commission, “EPSDT 41 K. Wagnerman, “Medicaid: How Does It Provide Economic Security in Medicaid” (Washington: Medicaid and CHIP Payment and Access for Families?” (Washington: Georgetown University Center for Children Commission). and Families, March 2017); M. Karpman and G. Kenney, “QuickTake: Health Insurance Coverage for Children and Parents: Changes between Georgetown University Center for Children and Families analysis of 29 2013 and 2017” (Washington: Urban Institute Health Policy Center, EPSDT U.S. CMS-416 FFY2017, Participant ratio. September 2017). 30 For a variety of reasons highlighted elsewhere, some rates as 42 M. Venkataramani, C. E. Pollack, and E. T. Roberts, “Spillover reported may not reflect the full extent of screening, even as efforts Effects of Adult Medicaid Expansions on Children’s Use of Preventive to improve data collection continue. In 2014, Alaska established a Services,” Pediatrics 140, no. 6 (December 2017). CPT billing code modifier policy to identify the nine standardized developmental screening tools included in the Developmental 43 C. Bhatt and C. Beck-Sagué, “Medicaid Expansion and Infant Screening measure specifications. Claims filed without this modifier Mortality in the United States,” American Journal of Public Health 108, were excluded from measure calculations. Alaska attributes the low no. 4 (April 2018): 565-567. rate to the incomplete and inconsistent adoption of the modifier E. K. Adams et al., “Prepregnancy Insurance and Timely Prenatal 44 among the state’s providers. Additionally, Alaska believes the rate Care for Medicaid Births: Before and After the Affordable Care Act In is underestimated because some providers do not bill for CPT code Ohio,” Journal of Women’s Health (August 2018). 96110. There is also some underreporting because encounter records for services provided by tribal health organizations and community 45 J. Haley et al., “Medicaid/CHIP Participation Rates Rose among health centers use an all-inclusive reimbursement and may not Children and Parents: Variation in 2016 and Recent Trends” delineate individual services. For more information see p. 5, E. Burak (Washington: Urban Institute, September 2018). and M. Odeh, “Developmental Screenings for Young Children in Medicaid and the Children’s Health Insurance Program” (Washington: 46 J. Haley et al., “Medicaid/CHIP Participation Reached 93.7 Percent Georgetown University Center for Children and Families, March 2018). Among Eligible Children in 2016,” Health Affairs 37, no. 8 (August 2018): Page 1194-1199, see Supplemental Appendix. Table DEV-CH available from Performance on the Child Core Set 31 Measures, FFY 2016 (ZIP 3.4 MB), “Children’s Health Care Quality 47 L. Ku and E. Steinmetz, “Bridging the Gap: Continuity and Quality of Measures,” Centers for Medicare and Medicaid Services. Coverage in Medicaid” (Washington: George Washington University, Association for Community Affiliated Health Plans, September 2013). 32 A. Schneider, “How Can We Tell Whether Medicaid MCOs are Doing a Good Job for Kids?” (Washington: Georgetown University Center for 48 Georgetown University Center for Children and Families tabulations Children and Families, February 2018). of 2016 U.S. Census American Community Survey data from IPUMS. 33 C. Bruner, K. Johnson, and M. Trefz, “Young Child Primary Pediatric 49 42 CFR § 435.117 (2007); Centers for Medicare & Medicaid Services, Practice Transformation – Medicaid Financing to Improve Child Health State Health Official Letter #09-009, (August 31, 2009). This policy Trajectories” (Learning Collaborative on Health Equity and Young was clarified in CHIP’s 2009 Reauthorization to assure immediate Children, August 2016). enrollment. Bailit Health, “Value-Based Payment Models for Medicaid Child 34 50 C. Cantrell, “Electronic Enrollment of Newborns into Medicaid: Health Services” (Albany, NY: Schuyler Center for Analysis and Insights from Oklahoma” (Portland, ME: National Academy for State Advocacy, July 2016). Health Policy, June 2010). 35 Center on the Developing Child at Harvard University, “3 Principles to 51 42 CFR 435.915 Improve Outcomes for Children and Families” (Cambridge, MA: Center 52 T. Brooks et al, “Medicaid and CHIP Eligibility, Enrollment, Renewal, on the Developing Child at Harvard University, October 2017). and Cost Sharing Policies as of January 2018: Findings from a 50-State 36 T. Brooks et al, “Medicaid and CHIP Eligibility, Enrollment, Renewal, Survey” (Washington: Kaiser Family Foundation, March 2018). and Cost Sharing Policies as of January 2018: Findings from a 50-State 53 While states set their own timeliness standards for Medicaid eligibility Survey” (Washington: Kaiser Family Foundation, March 2018). determinations, the ACA set a 45-day outer limit for timeliness of 37 R. Garfield, A. Damico, and K. Orgera, “The Coverage Gap: application decisions for income-based eligibility (42 CFR 435.912). Uninsured Poor Adults in States that Do Not Expand Medicaid” Medicaid and CHIP Payment and Access Commission, “Federal (Washington: Kaiser Family Foundation, June 2018). Requirements and State Options: Enrollment and Renewal Procedures” (Washington: Medicaid and CHIP Payment and Access Commission, 38 M. Whitebook et al., “Early Childhood Workforce Index 2018” July 2017). (Berkeley, CA: Center for the Study of Child Care Employment at University of California Berkeley, 2018). 54 Federal Medicaid policy allows qualified entities (for example, community health centers and schools) to assess a child or pregnant 39 Ibid. woman’s eligibility for Medicaid and receive Medicaid payments for their immediate care pending a full determination. The ACA allows 40 L. Antonisse et al., “The Effects of Medicaid Expansion under the states that have presumptive eligibility (PE) in place for children or ACA: Updated Findings from a Literature Review” (Washington: Kaiser pregnant women to extend it to parents and other adults. It also Family Foundation, March 2018). 18 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT allows Medicaid hospitals to conduct PE for low-oncome individuals threshold below the upper income limit. See C. Mann, “Improving regardless of whether the state otherwise adopted presumptive Enrollment and Retention in Medicaid and CHIP: Federal Options for a eligibility. Also see: K. Kronebusch and B. Elbel, “Simplifying Children’s Changing Landscape” (New York: United Hospital Fund, 2009). Medicaid and SCHIP,” Health Affairs 23, no. 3 (May 2004): 233-46; T. 66 A. Schneider, “How Can We Tell Whether Medicaid MCOs are Doing Brooks, “Hospital Policy Brief: Hospital Presumptive Eligibility,” Health a Good Job for Kids?” (Washington: Georgetown University Center for Affairs (January 2014). Children and Families, February 2018). 55 T. Brooks et al, “Medicaid and CHIP Eligibility, Enrollment, Renewal, 67 K. Whitener, “Using Data to Document and Improve EPSDT and Cost Sharing Policies as of January 2017: Findings from a 50-State Participation” (Washington: Georgetown University Center for Children Survey” (Washington: Kaiser Family Foundation, January 2017). and Families, June 2016); and Ibid. 56 § 1902(e)(13) of the Social Security Act. Eligible public programs 68 T. Brooks, “Measuring and Improving Health Care Quality for Children include: Temporary Assistance to Needy Families, Medicaid, CHIP, in Medicaid and CHIP: A Primer for Child Health Stakeholders” Head Start, National School Lunch Program, WIC, Child Care and (Washington: Georgetown University Center for Children and Families, Development Block Grant, child support enforcement, some homeless March 2016). and housing assistance programs, and others. See § 1902(e)(13) 1902(e)(13)(F) for full list. 69 Centers for Medicare and Medicaid Services, “Quality of Care for Children in Medicaid and CHIP: Findings from the 2017 Child Core Set 57 Georgia used WIC for ELE before ending use of the option in 2016. Chart Pack” (Washington: Centers for Medicare and Medicaid Services, See p.13, T. Brooks et al, “Medicaid and CHIP Eligibility, Enrollment, September 2018). Renewal, and Cost Sharing Policies as of January 2017: Findings from a 50-State Survey” (Washington: Kaiser Family Foundation, January 70 See P.L. 115-123. The CHIP-related provisions are in “Division E – 2017). Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act.”; K. Whitener, “HEALTHY KIDS and ACCESS Acts: Summary 58 S. Murrin, “State Use of Express Lane Eligibility for Medicaid and of Key Provisions Impacting Children” (Washington: Georgetown CHIP Enrollment” (Washington: Department of Health and Human University Center for Children and Families, March 2018). Note that the Services, Office of the Inspector General, October 2016). Child Core Set is revised and updated annually. 59 See for example, E. Maag, “Income Volatility: New Research Results 71 New York State Department of Public Health, “First 1,000 Days with Implications for Income Tax Filing and Liabilities” (Washington: The on Medicaid: Require Managed Care Plans to have a Kids Quality Urban Institute, May 2017). Agenda,” New York State Department of Public Health (proposal, 60 L. Ku, E. Steinmetz, and B. Bruen, “Continuous-Eligibility Policies Albany, December 2017). Stabilize Medicaid Coverage For Children And Could Be Extended To 72 Seventy-fve percent threshold will be based on CMS-416 Adults With Similar Results,” Health Affairs 32, no. 9 (September 2013): participation ratio data NC RFP, p. 173, RFP 30-190029-DHB 1576-1582. Addendum 1: Scope of Services; “Requests for Proposals (RFPs) and 61 Montana and New York provide 12-month continuous coverage Requests for Information (RFIs),”NC Department of Health and Human for adults through a Section 1115 waiver. See p. 16, T. Brooks et Services. al., “Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost 73 C. Howard et al., “School Readiness: The Next Essential Quality Sharing Policies as of January 2018: Findings from a 50-State Survey” Metric For Children,” Health Affairs, July 2018, available at https://www. (Washington: Kaiser Family Foundation, March 2018); MACPAC healthaffairs.org/do/10.1377/hblog20180711.857544/full/. recommends this practice for all adults per Medicaid and CHIP Payment and Access Commission, “Promoting Continuity of Medicaid 74 See Table J, p. 86 for examples in shared early childhood measures Coverage among Adults under Age 65” (Washington: Medicaid and across national data sets. K. Johnson and C. Bruner (2018, CHIP Payment and Access Commission, March 2014). forthcoming), A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong 62 T. Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, Renewal, Health. Child and Family Policy Center; also see U.S. Department of and Cost Sharing Policies as of January 2018: Findings from a 50-State Health and Human Services and U.S. Department of Education, Policy Survey” (Washington: Kaiser Family Foundation, March 2018). Statement to Support the Alignment of Health and Early Learning “Pennsylvania State Plan Amendment: PA-18-0001,” Centers for 63 Systems, Statement. Medicare and Medicaid Services, April 2018. Centers for Medicare and Medicaid Services, “2018 Core Set of 75 64 J. Pac et al., “Young child poverty in the United States: Analyzing Children’s Health Care Quality Measures for Medicaid and CHIP (Child trends in poverty and the role of anti-poverty programs using the Core Set)” (Washington: Centers for Medicare and Medicaid Services, Supplemental Poverty Measure,” Child and Youth Services Review 74, December 2017). Note: Includes prenatal care for women. (March 2017): 35-49; C. Fitzgerald, “What to do to Improve Children’s 76 K. Whitener, “Using Data to Document and Improve EPSDT Public Health Coverage” (Washington: First Focus). Participation” (Washington: Georgetown University Center for Children 65 To address possible concerns about providing coverage for children and Families, June 2016); A. Schneider, “How Can We Tell Whether whose family incomes might have increased over the eligibility Medicaid MCOs are Doing a Good Job for Kids?” (Washington: threshold during the enrollment period, states could limit demonstration Georgetown University Center for Children and Families, February under a 1115 waiver to children in families with incomes at some 2018). 19 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT 77 J. Hagan, J. Shaw, and P. Duncan, eds., Bright Futures Guidelines for and F. Heider, “The Nuts and Bolts of Medicaid Reimbursement for Health Supervision of Infants, Children, and Adolescents, 4th Ed. (Elk Developmental Screening: Insights from Georgia, Minnesota, and North Grove, IL: American Academy of Pediatrics, 2017). Periodicity schedule Carolina” (Portland, ME: National Academy for State Health Policy, available at American Academy of Pediatrics and Bright Futures, September 2016); C. Plaza, J. Rosenthal, and L. Hinkle, “The Enduring “Recommendations for Preventative Pediatric Health” (Elk Grove, IL: Influence of the Assuring Better Child Health and Development (ABCD) American Academy of Pediatrics, February 2017). Initiative” (Portland, ME: National Academy for State Health Policy, July 2013). 78 See for example: S. Murrin, “Recommendation Followup Memorandum Report: CMS Needs to do More to Improve Medicaid National Academy for State Health Policy, “Referral and Care 90 Children’s Utilization of Preventive Screening Services,” Department Coordination” (Portland, ME: National Academy for State Health Policy). of Health and Human Services, Office of the Inspector General (letter, 91 Colorado Department of Health Care Policy and Financing, “Short- Washington, November 12, 2014). term Behavioral Health Services in the Primary Care Setting” (Denver, 79 S. Rosenbaum et al., “Room to Grow: Promoting Child Development CO: Colorado Department of Health Policy and Financing, July 2018). Through Medicaid and CHIP” (Washington: The Commonwealth Fund, Zero to Three, “Zero to Three Infant and Early Childhood Mental 92 June 2001). Health Policy Convening” (Washington: Zero to Three, February 2017).. K. Johnson, “Managing the ‘T’ in EPSDT Services” (Portland, ME: 80 93 A. Mosle, N. Patel, and J. Stedron, “Top Ten for 2Gen” (Washington: National Academy for State Health Policy, June 2010). First Focus, 2015); Ascend at the Aspen Institute, “What is 2Gen?” 81 The most recent edition, updated in 2017, added universal maternal (Washington: Ascend at the Aspen Institute). depression screening and new guidance related to psychosocial/ 94 Health Resources and Services Administration and Centers for behavioral assessments, noting that they should be “should be Medicare & Medicaid Services, “Coverage of Maternal, Infant, and Early family-centered and may include may include an assessment of child Childhood Home Visiting Services,” Informational Bulletin (March 2, social-emotional health, caregiver depression, and social determinants 2016). of health.” See Footnote 13, American Academy of Pediatrics and Bright Futures, “Recommendations for Preventative Pediatric Health” 95 Center for Medicaid & CHIP Services, “Maternal Depression (Elk Grove, IL: American Academy of Pediatrics, February 2017). ; also Screening and Treatment: A Critical Role for Medicaid in the Care of see C. Weitzman and L. Wegner, “Promoting Optimal Development: Mothers and Children” Informational Bulletin, Washington (May 11, Screening for Behavioral and Emotional Problems,” Pediatrics 135, no. 2016). 2 (February 2015): 384-395; Council on Community Pediatrics, “Poverty 96 Center for Medicaid & CHIP Services, “Neonatal Abstinence and Child Health in the United States,” Pediatrics 137, no. 4 (April Syndrome: A Critical Role for Medicaid in the Care of Infants” 2016). Informational Bulletin (June 11, 2018). 82 Georgetown University Center for Children and Families analysis of 97 B. Normile, K. VanLandeghem, and A. King, “Medicaid Financing American Academy of Pediatrics, “Children’s Health Care Coverage of Home Visiting Services for Women, Children, and Their Families” Fact Sheets” (Elk Grove, IL: American Academy of Pediatrics). (Portland, ME: National Academy for State Health Policy, August 2017); 83 Ibid. and National Academy for State Health Policy, “Using Medicaid to Finance Home Visiting Services: a Checklist for State Decision Makers” American Academy of Pediatrics, “2015 Medicaid Reimbursement 84 (Portland, ME: National Academy for State Health Policy, December Reports,” (Elks Grove: American Academy of Pediatrics, 2015). 2016); K. Gifford et al., “Medicaid Coverage of Pregnancy and Perinatal 85 C. Bruner, K. Johnson, and M. Trefz, “Young Child Primary Pediatric Benefits: Results from a State Survey” (Washington: Kaiser Family Practice Transformation – Medicaid Financing to Improve Child Health Foundation, April 2017). Trajectories” (Learning Collaborative on Health Equity and Young 98 National Academy for State Health Policy, “Maternal Depression Children, August 2016). Screening” (Portland, ME: National Academy for State Health Policy). 86 Centers for Medicare and Medicaid Services, “EPSDT – A Guide for 99 National Center for Children in Poverty (2018), Early Childhood Two States: Coverage in the Medicaid Benefit for Children and Adolescents” Generation State Policy Profiles. Email Correspondence from Uyen (Washington: Centers for Medicare and Medicaid Services, June 2014). Nguyen (9/26/2018); S. Smith et al., “Using Medicaid to Help Young 87 Georgetown University Center for Children and Families analysis of Children and Parents Access Mental Health Services: Results of a American Academy of Pediatrics, “Children’s Health Care Coverage 50-State Survey” (New York: National Center for Children in Poverty, Fact Sheets” (Elk Grove, IL: American Academy of Pediatrics). Mailman School of Public Health, Columbia University, 2016). 88 A. Szekely et al., “Advancing Infant and Early Childhood Mental 100 Proposal 18: New York State Department of Public Health, “First Health: The Integration of DC: 0-5 Into State Policy and Systems” 1,000 Days on Medicaid: Parent/Caregiver Diagnosis as Eligibility (Washington: Zero to Three, July 2018).. Criteria for Dyadic Therapy,” New York State Department of Public Health (proposal, Albany, December 2017). E.W. Burak and M. Odeh “Improving Developmental Screenings in 89 Medicaid and CHIP: A Toolkit for State Stakeholders” (Georgetown University Center for Children and Families, forthcoming); N. Mention 20 CCF.GEORGETOWN.EDU PROMOTING YOUNG CHILDREN’S HEALTHY DEVELOPMENT K. Johnson, “Managing the ‘T’ in EPSDT Services” (Portland, ME: 101 T. Brooks, “Exciting News: CMS Announces First Innovation Model 112 National Academy for State Health Policy, June 2010). Grants Aimed at Children and Youth” (Washington: Georgetown University Center for Children and Families, August 2018). 102 Centers for Medicare and Medicaid Services, “Making Connections: Strengthening Care Coordination in the Medicaid Benefit for Children Bailit Health, “Value-Based Payment Models for Medicaid Child 113 and Adolescents” (Washington: Centers for Medicare and Medicaid Health Services” (Schuyler Center for Analysis and Advocacy, July Services, September 2014); S. Rosenbaum et al., “Medicaid and Case 2016); C. Bruner, K. Johnson, and M. Trefz, “Young Child Primary Management to Promote Healthy Child Development” (Washington: Pediatric Practice Transformation – Medicaid Financing to Improve The George Washington School of Public Health and Health Services); Child Health Trajectories” (Learning Collaborative on Health Equity and K. Johnson and J. Rosenthal, “Improving Care Coordination, Young Children, August 2016). Case Management, and Linkages to Service for Young Children: T. Brooks and K. Whitener, “Leveraging Medicaid to Address Social 114 Opportunities for States” (Portland, ME: National Academy for State Determinants and Improve Child and Population Health” (Washington: Health Policy, April 2009). Georgetown University Center for Children and Families, February K. Johnson and J. Rosenthal, “Improving Care Coordination, 103 2018). Case Management, and Linkages to Service for Young Children: Opportunities for States” (Portland, ME: National Academy for State Health Policy, April 2009). K. Johnson and C. Bruner (2018, forthcoming), A Sourcebook on 104 Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health, Child and Family Policy Center.   Anita Cardwell et al., “Benefits and Cost Sharing in Separate CHIP 105 Programs” (Washington: National Academy for State Health Policy and Georgetown University Center for Children and Families, May 2014). C. Wong, J. Perrin, and M. McClellan, “Making the Case for Value- 106 Based Payment Reform in Children’s Health Care,” JAMA Pediatrics 172, no. 6 (June 2018): 513-514. 107 See, for example: C. Bruner and N. Counts, “CMMI RFI Responses: Some Common Themes” (Child and Family Policy Center and Mental Health America, June 2017); C. Bruner, N. Counts, and P. Dworkin, “Alternative Payment Models for Pediatrics: Operationalizing Value- Based Care Over the Life Course” (Hartford, CT: Connecticut Children’s Georgetown University Center for Office for Community Child Health, August 2018). Children and Families K. Johnson and C. Bruner (2018, forthcoming), A Sourcebook on 108 McCourt School of Public Policy Medicaid’s Role in Early Childhood: Advancing High Performing Box 571444 Medical Homes and Improving Lifelong Health, Child and Family Policy Center.   3300 Whitehaven Street, NW, Suite 5000 Washington, DC 20057-1485 National Center for Medical Home Implementation, “States At-a- 109 Glance” (Elk Grove, IL: American Academy of Pediatrics, June 2018). Phone: (202) 687-0880 K. Johnson and C. Bruner (2018, forthcoming), A Sourcebook on 110 Email: childhealth@georgetown.edu Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health, Child and Family Policy Center.   www.ccf.georgetown.edu 111 C. Bruner and N. Counts, “CMMI RFI Responses: Some Common Themes” (Child and Family Policy Center and Mental Health America, facebook.com/georgetownccf June 2017); C. Bruner, N. Counts, and P. Dworkin, “Alternative Payment Models for Pediatrics: Operationalizing Value-Based Care Over the Life twitter.com/georgetownccf Course” (Hartford, CT: Connecticut Children’s Office for Community Child Health, August 2018). See Center for Medicare and Medicaid Innovation (CMMI), “Request for Information on Pediatric Alternative Payment Model Concepts” (Baltimore, MD: Center for Medicare and Medicaid Services).