Transparency in Medicaid Managed Care for Children and Youth in Foster Care by Andy Schneider, Allie Corcoran, and Emma Hurler Contents Key Findings Executive Summary zz In 2018, six states—Arizona, Florida, Georgia, Tennessee, Texas, and Washington—contracted Health Needs of Children and Youth in with Medicaid managed care organizations to Foster Care furnish services on a statewide basis exclusively to children and youth in foster care and other Medicaid for Children and Youth in vulnerable populations (MCO/FCs).  Foster Care zz None of the Medicaid agency websites in these Health Equity for Children and Youth in states posted all of the minimum data elements Foster Care required by federal regulations, and none of them posted information sufficient to enable The States and MCO/FCs We Scanned stakeholders to assess the performance of the What Performance Information We MCO/FCs for enrolled foster care children and Looked For youth. zz Although information on the race and ethnicity of The Performance Information We Found children and youth in foster care is collected by Discussion state child welfare agencies, the state Medicaid agency websites did not present data on the Conclusion provision or quality of services disaggregated by race and ethnicity. This lack of transparency Methodology makes it extremely challenging to identify and Appendices address heath inequities. October 2021 CCF.GEORGETOWN.EDU Transparency in medicaid managed care: children in Foster care 1 Executive Summary Children and youth in foster care are among the most year, we searched the websites of the Medicaid agencies, vulnerable populations covered by Medicaid. When children child welfare agencies, and MCO/FCs in each of these and youth enter the child welfare system, they are often not states. We conducted our scan between December 2020 up to date on routine care, and many have unrecognized and May 2021; this paper presents the results. A companion and untreated medical needs. In addition, the experience paper presents the results of a scan of the websites of 56 of removal from a child’s biological family, even when MCOs in 13 states for information on their performance for necessary for their safety, creates trauma which in turn enrolled children and pregnant women during calendar year generates additional health needs. Adverse events in early 2018.1 childhood including neglect, abuse, and toxic stress, can In this scan, we were able to locate enrollment data for each have long-lasting effects on children’s physical and mental of the MCO/FCs, but those data were not disaggregated health, especially if they go unaddressed. Given their by race or ethnicity. We were unable to find any measures circumstances, children and youth in foster care require of performance with respect to Medicaid’s comprehensive access to a broad range of health and behavioral health pediatric health benefit—Early and Periodic Screening, services and extensive care coordination. As the nation’s Diagnostic, and Treatment (EPSDT) services—which is of health insurer for children and youth whose foster care particular importance to a high-need population like those in families receive assistance under Title IV-E of the Social the child welfare system. Finally, we searched for evidence Security Act, Medicaid has a particularly important role of performance on quality measures during 2018 and found to play in protecting the health of individual children and substantial results for only four of the six MCO/FCs that youth as well as improving the well-being of the foster care were operational that year. None of the quality measures we population generally. were able to find were disaggregated by race or ethnicity. In 40 states and the District of Columbia, state Medicaid In short, much of the information one would need to assess programs contract with managed care organizations (MCOs) how well each of the six MCO/FCs performed for foster to furnish covered services to Medicaid beneficiaries. In care youth in FY 2018 was not publicly available. We are some of these states, children and youth in foster care not able to draw any conclusions about the performance are not enrolled in MCOs but continue to receive services of these MCO/FCs, and we cannot make any meaningful through fee-for-service (FFS) Medicaid. In other states, comparisons between their performance and that of their children and youth in foster care are enrolled in MCOs along MCO/FC peers in other states. with other Medicaid-eligible children and adults. And in some states, the Medicaid agencies currently contract with a single MCO to furnish services to all foster care children in the state. Because these MCOs focus on the foster care Medicaid has a particularly important population, rather than enrolling a range of beneficiary role to play in protecting the health of groups, we refer to them as MCO/FCs. individual children and youth as well as Six states—Arizona, Florida, Georgia, Tennessee, Texas, and improving the well-being of the foster Washington—contracted with MCO/FCs to furnish services care population generally. to children and youth in foster care in calendar year 2018. To assess how MCO/FCs performed for their enrollees in that CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 2 One premise of the MCO/FC model is that enrolling foster care children and youth in MCOs that specialize in the management of health and related services for this population will produce better outcomes than leaving them in uncoordinated fee-for-service (FFS) arrangements. Another is that enrolling them in MCO/FCs will produce better outcomes than enrolling them in MCOs that manage services for all Medicaid beneficiaries. The pervasive lack of transparency about the performance of individual MCOs/FCs and MCOs generally makes it impossible for the public and policymakers to evaluate either premise. It also increases the risk that MCO/FCs, and the state agencies with which they contract, will not be held accountable in the event of poor performance. Children and youth in foster care are a critically vulnerable group. More data are needed to hold Medicaid MCOs accountable for ensuring their access to needed physical and behavioral health services. In particular: 1. State Medicaid agencies that contract with an MCO/FC should maintain a child health dashboard that contains enrollment and performance information specific to that MCO/FC. At a minimum, the performance data should include EPSDT screenings and treatment, Child Core Set metrics, and all other information required to be posted by federal regulations. All enrollment and performance data should be disaggregated by race and ethnicity. 2. The Centers for Medicare & Medicaid Services (CMS) should add a child health dashboard as a measure to the State Administrative Accountability pillar of its Medicaid & CHIP Scorecard. The dashboard should present performance information on EPSDT services and Child Core Set metrics disaggregated by race and ethnicity for individual MCO/FCs as well as individual MCOs to enable comparison of performance from state to state. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 3 Health Needs of Children and Youth in Foster Care Approximately 673,000 children are served by the foster care system over the course of a year, and there are Any use of antipsychotics in children 424,000 children in care at any point in time.2 The American should be a last resort. Once Academy of Pediatrics (AAP) classifies these children prescribed, the regimen requires categorically as children with special health care needs.3 careful monitoring for side effects and Many have unaddressed health needs when entering the continual coordination between providers and child welfare system as a result of previous neglect, abuse, caregivers.12 Unfortunately, the fragmented or trauma. More than one-quarter of children in foster care nature of foster children’s interaction with have a mental health diagnosis and they are more likely to experience developmental delays and speech/language the system means that psychotropics are disorders than their peers.4 Fetal alcohol syndrome, a often inappropriately substituted for intensive condition in which early diagnosis and therapeutic services trauma-informed counseling and not well- are critical, is common among foster care children, but often monitored.13 not recognized or misdiagnosed.5 Children with a history of foster care are 1.5 times more likely to report oral health problems as compared to their counterparts.6 AAP recommends that, at minimum, all children and youth entering foster care are given a comprehensive screening within 72 hours of placement. Young children, children who are victims of abuse, and children with chronic conditions should be seen within 24 hours.7 AAP advises that pediatricians screen carefully for undiagnosed prenatal alcohol syndrome, signs of abuse or sex trafficking, and mental health conditions including suicide risk.8 In addition, children and youth in foster care should have more frequent visits than other children (monthly for the first six months of life, every three months between six months and 24 months, and every six months after that) and may require longer visits.9 When vaccination records are incomplete or missing, children should also be brought up-to-date with the AAP recommended immunization schedule.10 Children and youth in foster care face enormous challenges in accessing appropriate care. Chief among them is being moved in and out of the home and from foster care placement to foster care placement, which can result in needed medical or behavioral care being interrupted, uncoordinated, or not accessed at all. This makes effective care management, including a unified electronic health record for each child in foster care, particularly important.11 CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 4 Medicaid for Children and Youth in Foster Care Medicaid is the nation’s health insurer for children and Within limits, MCOs and MCO/FCs can retain revenues and, youth in foster care. Those whose families are receiving in some cases, earn profits from monthly capitation payments payments under Title IV-E of the Social Security Act that are not paid out to network providers for furnishing are automatically eligible for Medicaid in every state. covered services. This creates a financial incentive to withhold Medicaid coverage entitles these children to Early and approval for needed services. Periodic Screening, Diagnostic, and Treatment (EPSDT) One check on this incentive is that the MCO or MCO/FC is services, which are particularly important for a population required to report information on its performance to the state with significant medical and behavioral health needs.14 Medicaid agency. Two types of performance information are State Medicaid programs vary in how they deliver particularly important to children and youth in foster care: the EPSDT and other services to children and youth in foster provision of EPSDT services and quality measures from the care. Some use the fee-for-service delivery system; CMS Child Core Set. In each case, both the MCO/FC and the others enroll them in MCOs along with other Medicaid state Medicaid agency have this information for the enrolled populations; and some enroll them in MCO/FCs, which foster care population (see boxes on page 8 and 9). This enroll only foster care and other highly vulnerable child performance information enables the state Medicaid agency populations. In 2018, the Medicaid and CHIP Payment to assess and, where indicated, improve the performance of and Access Commission (MACPAC) estimated that 44 the MCO or MCO/FC for foster care children and youth. The percent of Title IV-E children were enrolled in managed collection, reporting, and validation of the data are paid for care plans; however, that share has likely grown as entirely with state and federal Medicaid funds. more states opt to move the population from FFS Additionally, state child welfare agencies are required to track to managed care.15 Currently, nine states enroll their metrics such as placement permanency and reunification foster care children and youth in MCO/FCs (Arizona, for children in care and report the outcomes to the national Florida, Georgia, Illinois, Kentucky, Tennessee, Texas, Adoption and Foster Care Analysis and Reporting System Washington, and West Virginia). (AFCARS).16 MCO/FCs can either facilitate or complicate State Medicaid agencies contract with MCOs and MCO/ access to health-based interventions such as trauma-informed FCs to organize networks of providers that are capable mental health care that promote stability and reunification.17 of furnishing covered services to enrollees and to ensure Consequently, although not the only drive of placement that those services are available and accessible to stability and reunification, the performance of MCO/FCs could enrollees when needed. The agencies pay MCOs and well have an impact on these important metrics. MCO/FCs under these contracts on a risk basis—i.e., a fixed amount per member per month for each enrollee, whether the enrollee uses services or not. These fixed amounts, or capitation payments, vary with the likelihood Currently, nine states enroll their foster care that a group of enrollees, such as infants under age one children and youth in MCO/FCs: Arizona, or children between ages one and five, will use services; Florida, Georgia, Illinois, Kentucky, in the case of a high-needs population like children and Tennessee, Texas, Washington, and youth in foster care, these monthly capitation payments West Virginia. will likely be higher than those for children and youth who are not in the child welfare system. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 5 Health Equity for Children and Youth in Foster Care Black and American Indian/Alaska Native children are rejection, neglect, and/or abuse from their origin family. overrepresented in the foster care population.18 This LGBTQ+ children may fear backlash from disclosing their overrepresentation makes all MCOs, and especially MCO/ sexual orientation or gender identity to foster placements or FCs, a critical point for achieving equity: they can either caseworkers, underscoring the need for providers who affirm furnish the children with the services that they need or their identity. they can be yet another point of systemic failure. Plan selection of certain providers, limited networks, and prior authorization practices may restrict children’s access to their Plan selection of certain providers, limited established care team and to providers they trust, which can networks, and prior authorization practices be especially harmful for children of color.19 It is estimated may restrict children’s access to their that children who identify as LGBTQ+ are disproportionately established care team and to providers represented in the foster care population, with around 30 percent of foster care youth (roughly between ages 10 and they trust, which can be especially harmful 20) identifying as LGBTQ+.20 These children may enter the for children of color. foster care system for reasons unrelated to their identity, but they may also enter the system because they face The States and MCO/FCs We Scanned Our scan focused on the six MCO/FCs that were operating and Washington—the majority of the foster care population in calendar year (CY) 2018: Comprehensive Medical and in 2018 were children of color (see figure 1). As a result, Dental Plan (Arizona); Sunshine State Health Plan (Florida); the MCO/FCs that enroll only this population have an Amerigroup Georgia Families 360° (Georgia); TennCare opportunity to manage the care of these children and youth Select (Tennessee); Superior Health Plan (Texas); and Apple in a way that addresses unmet needs, reduces racial and Health Core Connections (Washington). We selected this ethnic disparities, promotes health equity, and improves performance year because it was the most recent for which outcomes such as family reunification. On the other hand, data was available at the time of the scan.21 limiting enrollment to foster care children and youth runs the risk of exacerbating racial disparities for children of color, In line with the national trend, Black non-Latino children separating them from trusted providers, and denying them were overrepresented as a share of the foster care access to the services they need. population in all six states in 2018 (see Appendix B). And, in five of the six states—Arizona, Florida, Georgia, Texas, CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 6 Figure 1. Composition of State Foster Care Programs by Race/Ethnicity, 2018 Arizona 11% 38% 5% 5% 34% Florida 30% 16% 7% 47% Georgia 39% 6% 6% 47% Tennessee 23% 6% 6% 65% Texas 22% 41% 5% 30% Washington 8% 20% 5% 16% 49% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BlackHispanic/AmericanAsian/NativeMultiple race Race White (non-Hispanic)LatinoIndianHawaiians groups Unknown (non-Hispanic) (non-Hispanic)(non-Hispanic) (non-Hispanic) Note: Numbers may not sum due to rounding. Source: Annie E. Casey Foundation Child Trends analysis of 2018 Adoption and Foster Care Analysis and Reporting System (AFCARs) data (March 2020), available at https://datacenter.kidscount.org/data/tables/6246-children-in-foster-care-by-race-and-hispanic-origin?loc=1&loct =1#detailed/2/4,11-12,15,19,44-45,49-50/false/37/2638,2601,2600,2598,2603,2597,2602,1353/12992,12993. In some states, enrollment in the MCO/FC is mandatory The parent company with the largest footprint among the six for foster care and adoption assistance children; in others, MCO/FCs is Centene, which operates subsidiaries in Florida, voluntary. As of 2018, enrollment was mandatory in four of Texas, and Washington that collectively enroll approximately the states we scanned and optional in two.22 98,000 children.24 Centene is a publicly traded company (#24 among the Fortune 500 in 2021) that operated 38 As of 2021, in five of the states, the MCO/FC contract with MCOs in 28 states as of July 2021. It is the nation’s largest the state Medicaid agency was held by a subsidiary of a Medicaid managed care company, whether measured by national insurer: Anthem, Centene, or CVS/Aetna. In each enrollment (14 million Medicaid beneficiaries in July 2021) or case, that insurer also operates an MCO that enrolls both Medicaid revenues ($74.8 billion in 2020).25 The company’s child and adult Medicaid beneficiaries in the state. With Texas subsidiary, Superior Health Plan, was a subject of the exception of Tennessee, the state Medicaid agencies the award-winning Dallas Morning News investigative contract with the MCO/FC on a risk basis.23 In four of the series “Pain & Profit,” which documented the withholding of states, the contract is separate from the main MCO risk needed services from children with disabilities by MCOs in contract with the insurer; in the remaining two states the Texas.26 arrangement is an amendment to the main risk contract. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 7 What Performance Information We Looked For We are not aware of any generally accepted set of measures for answering the question: How well is an MCO/FC Collected and Cleaned: performing for foster care children and youth? Our search EPSDT Services and CMS focused on data elements that we believe are the minimum Form-416 necessary to answer that question. Some of these data elements are required to be posted by federal regulation; Children enrolled in Medicaid are entitled to the others are not. These elements fall into four broad comprehensive Early and Periodic Screening, categories. Diagnostic, and Treatment (EPSDT) benefit package. In order to monitor access to EPSDT services, First, what is each MCO/FC’s role for foster care children states are required to report to CMS: and youth (and the other child populations that may also zz The number of children provided child health be enrolled)? How many are enrolled? What is the age screening services distribution (e.g., <1, 1-5, etc.)? What is their demographic profile? zz The number of children referred for corrective treatment as a result of the screenings Second, we tried to gather information about the structure of zz The number of children receiving dental services each MCO/FC that is required to be posted on the website of either the state Medicaid agency or individual MCO/FC. CMS collects this information from states on CMS- This information includes MCO/FC management, the MCO/ 416, the Annual EPSDT Participation Report. In FC’s accreditation status, and the risk contract between order to complete the form, Medicaid agencies the MCO/FC and the state Medicaid agency. These data in managed care states have to obtain encounter elements are among those that federal Medicaid managed data on the number of children receiving these care regulations require.27 screenings and services from each MCO. In other words, MCOs are already required to collect this Third, we wanted to know whether foster care children and data, and state agencies are already cleaning the youth enrolled in the MCO/FC are receiving the Early and data by removing duplicative entries, incomplete Periodic Screening, Diagnostic, and Treatment (EPSDT) information, and correcting formatting errors. All services to which they are entitled. We looked for the same that remains is for the state Medicaid agencies to data elements that the state Medicaid agencies report post the data.29 annually to CMS on Form-416 (see Box).28 We also sought to determine whether there were any differences in access to these services based on race or ethnicity. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 8 Finally, we wanted to know what results each MCO produced There are data elements relevant to MCO/FC for foster care children as measured by the metrics in the CMS performance that we did not examine. These include Child Core Set (see Box).30 We examined a subset of measures information on the adequacy of the MCO/FC’s provider from the Core Set that, in our judgment, reflect the health care network for pediatric and behavioral health services; needs of foster care children and youth. Seven of these relate to denials of services; the disposition of grievances, primary and preventive care; six to behavioral health; and one to appeals, and state fair hearings involving children and maternal health (see Appendix D). Again, we looked for whether foster care families; and sanctions or administrative these metrics varied by race and ethnicity. penalties or corrective action plans imposed on MCO/ FCs for violations of contract requirements. We also did not search for information relating to the MCO/FC’s Collected and Cleaned: financial performance, such as the annual medical loss Child Core Set ratio report to the state Medicaid agency or the annual The Child Core Set are metrics chosen by CMS in financial filing with the state insurance department. consultation with input from a national committee of experts to evaluate access to and quality of care for Medicaid and CHIP beneficiaries. The measures cover a variety of domains including preventative care, oral health, and behavioral health. The standard metrics in the Set allow for comparisons both over time and between states, though there are limitations.31 Currently, it is optional for state agencies to report the metrics on an aggregate, statewide basis to CMS, but reporting on all measures will become mandatory starting in fiscal year 2024.32 As with the EPSDT metrics, this means that managed care states are already collecting the records from their MCOs and are cleaning the data to ensure accuracy and consistency across MCO and FFS records before they combine the datasets to find the statewide rate. Some measures included in the Set, such as use of first- line psychosocial care for children and adolescents on antipsychotics, are particularly pertinent to monitoring access and treatment of foster care youth. However, the overall Set is designed with the entire child population in mind and does not address measures specific to foster youth such as comprehensive risk-screening, reducing outplacement, and reducing placement turnover. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 9 The Performance Information We Found Our scan of the websites of the six state Medicaid agencies and their individual MCO/FCs did not yield enough information to enable us to assess how well each MCO/FC performed for its enrollees in CY 2018. Here’s what we were able to find. Enrollment available for Tennessee (and, even then, the information was only posted on the Department of Insurance website We found enrollment data for each MCO/FC, although as opposed to the Medicaid agency website). Georgia and the years for which those data were available varied (see Washington posted partial information.37 Arizona, Florida, Appendix A). In the case of those MCO/FCs that enrolled and Texas made no information on plan ownership and populations other than foster care youth, such as youth management available, although the Florida Agency for in the juvenile justice system, we were unable to find Health Care Administration does post a detailed list of MCO enrollment breakouts by subpopulation. None of the state subcontractors.38 agency or MCO/FC websites disaggregated the enrollment data by race or ethnicity. Early and Periodic Screening, Racial and Ethnic Disparities Diagnostic, and Treatment (EPSDT) In an effort to measure and address racial and ethnic Services for Children disparities in the child welfare system, federal regulations We could not find any EPSDT performance information for require that child welfare agencies record the race and any of the six MCO/FCs during CY 2018. We were unable to ethnicity of children in the Adoption and Foster Care determine how many screenings each MCO/FC’s network Analysis and Reporting System.33 These data, analyzed by providers conducted, how many of the children screened the Annie E. Casey Foundation and presented in Figure 1, were referred for corrective treatment, or whether they show that all six states with MCO/FCs we scanned have received that treatment. high shares of Black and/or Latino children. Even though these data are already collected by the state’s child welfare Child Health Quality Metrics agency, none of the state Medicaid agency websites we In all of the states we scanned other than Washington, looked at posted MCO/FC enrollment disaggregated by race MCO/FC-specific performance data for CY 2018 were and ethnicity. available in the Annual Technical Report (ATR) prepared by the Medicaid agency’s External Quality Review Organization Federal Transparency Requirements (EQRO) and posted on the agency’s website.39 Appendix D Federal regulations require that state Medicaid agencies provides detail about MCO/FC performance on Child Core post their contracts with MCOs.34 As shown in Appendix Set quality measures in relation to state and U.S. median C, only two of the six states we scanned—Tennessee and rates in CY 2018. Washington—post the actual contracts with their MCO/FCs The limited data available show mixed results; consider the on the Medicaid agency website. Three states—Florida, data on the Tennessee MCO/FC and the Texas MCO/FC. In Georgia, and Texas—post what appear to be template Tennessee, the MCO/FC performed the worst on well-child contracts. In every state, the contract is between MCO/FC visits in the first 15 months (52.6 percent) when compared and the state Medicaid agency, not the state child welfare to the state average (68.4 percent), the U.S. median (64.0 agency.35 percent), and each of the other MCO/FCs (see Figure 2). Federal regulations also require that state Medicaid agencies In Texas, on the other hand, the MCO/FC significantly post information about the ownership and management outperformed the state rate and the national median on use of each MCO/FC (and its subcontractors).36 However, full of first-line psychosocial care for children and adolescents information on plan ownership and management was only on antipsychotics (see Figure 3). CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 10 Figure 2. Well Child Visits in the First 15 Months of Life 80% U.S. Median 70% 69.6% 67.6% 68.4% 68.2% 64.0% 67.0% 64.1% 61.6% 61.7% 62.0% 60% 52.6% 50% 40% MCO/FC 30% State rate 20% 10% 0% Arizona Florida Georgia Tennessee Texas Washington Note: Higher rates are better for this measure. Data reflects performance year 2018. Source: Georgetown Center for Children and Families analysis of 2019 Child Core Set Report and state 2020 External Quality Review Annual Technical Reports. Figure 3. Use of First-Line Psychosocial Care for Children and 100% Adolescents on Antipsychotics 90% 89.5% 80% 78.0% U.S. 71.3% Median 70% 70.1% 62.8% 60% 60.4% 54.5% 52.7% 50% 46.3% 40% MCO/FC State rate 30% 20% 10% 0% Arizona Florida Georgia Tennessee Texas Washington Note: Higher rates are better for this measure. Data reflects performance year 2018. Source: Georgetown Center for Children and Families analysis of 2019 Child Core Set Report and state 2020 External Quality Review Annual Technical Reports. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 11 Despite the availability of some Child Core Set metrics in all the performance of the MCO/FCs in which foster care states, significant data gaps remain. Only Florida breaks out children and youth are enrolled (see Appendix E). The enrollment by age; in all the other states, it is impossible to Arizona agency’s dashboard presents the percentage of gauge the performance of the MCO/FC for younger children children and youth in foster care receiving services, but or older youth in foster care. Georgia reported its MCO/FC’s does not describe the services or present quality metrics.40 performance on depression screening and follow-up, while The Texas agency makes demographics of the children the other states did not. None of the states reported quality and youth it serves available monthly by region and service data disaggregated by race, ethnicity, sexual orientation, or level, but does not present any information on the MCO/ gender identity, even though children of color and LGBTQ+ FC’s performance.41 The Georgia agency’s dashboard youth are disproportionately represented in the foster care presents child demographics (age, race, and sex) for all population. children served by the agency, as well as for children in foster care; once again, no quality information on the MCO/ Child Welfare Dashboards FC is included.42 Florida’s data dashboard was the only The findings above reflect our examination of state Medicaid one to present data on the provision of medical and dental agency and MCO websites. We also looked at the websites services, highlighting the metrics “Children Receiving of the child welfare agencies in these states. In four Dental Services” and “Children Receiving Medical states (Arizona, Georgia, Florida, and Texas), the agencies Services.”43 These metrics are presented as the percentage maintain data dashboards all of which contain substantive of children in out-of-home care who received a medical or information about the agency’s own performance in dental service, and are disaggregated by age, sex, race, managing their programs. However, with the exception of and placement. Florida, the dashboards did not contain information about Discussion Given the limited amount of information available on state agency or MCO/FC websites, we are unable to draw any conclusions about how well the six MCO/FCs performed for children and youth in foster care in 2018. The Child Core Set quality measures available on each MCO/FC are limited and not consistent from state to state, and no state provides any plan-specific data on whether children and youth in foster care are receiving the EPSDT services to which they are entitled. The absence of any performance data disaggregated by race or ethnicity prevents us from assessing how effectively MCO/FCs are addressing racial and ethnic disparities in access or health outcomes. These findings are consistent with the lack of transparency we observed in our companion paper looking more broadly at Medicaid managed care services for children.44 This lack of transparency is especially unfortunate given the increasing interest on the part of state Medicaid agencies in enrolling vulnerable foster care children and youth in managed care. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 12 Conclusion The delivery system through which foster care children State Medicaid agencies that contract with an and youth receive their Medicaid coverage matters. 1 MCO/FC should maintain a child health dashboard The choices among delivery systems—FFS, MCO, that contains enrollment and performance MCO/FC—are state-specific.45 State policymakers information specific to that MCO/FC. At a and stakeholders evaluating these choices would minimum, the performance data should include EPSDT benefit greatly from data on the performance of both screenings and treatment, Child Core Set metrics, and all MCOs and MCO/FCs for foster care children and information required to be posted by federal regulations. All youth. Unfortunately, in the states we reviewed, the enrollment and performance data should be disaggregated publicly available data are inadequate to that task. The by race and ethnicity. state and MCO/FC websites did not enable us to The Centers for Medicare & Medicaid Services understand how the MCO/FCs are performing and how their performance compares to that of MCOs or the FFS 2 (CMS) should add a child health dashboard as a measure to the State Administrative Accountability delivery system.  pillar of its Medicaid & CHIP Scorecard. The This is an avoidable error. State Medicaid agencies dashboard should present performance information on and MCO/FCs have the data necessary to assess EPSDT services and Child Core Set metrics disaggregated performance; they simply need to make those data by race and ethnicity for individual MCO/FCs and as well available to the public. We have two recommendations as individual MCOs to enable comparison of performance to promote transparency of this information: from state to state. This brief was written by Andy Schneider, Allie Corcoran, and Emma Hurler. The authors would like to thank Joan Alker, Julia Buschmann and Ema Bargeron of the Center for Children and Families for their contributions. 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. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 13 Methodology Data Sources care; performance improvement projects; sanctions and We searched the websites of state Medicaid agency administrative penalties imposed; and financial performance websites, state insurance departments, state child welfare (e.g., Medical Loss Ratios). agencies, and individual MCO/FCs for data about the We limited our search to publicly accessible websites. We performance of the MCO/FCs for children and youth in did not review the minutes of meetings of state Medical Care foster care and other high-risk populations. In some cases, Advisory Committees. While we validated the availability of state agency websites referred us to external websites, such information, we did not attempt to validate the accuracy of as that of the National Committee for Quality Assurance the information that we found. We did not file Public Records (NCQA). We cross-checked our findings relating to MCO/FC Act requests with state Medicaid agencies, child welfare contractors, parent companies, and overall MCO/FC quality agencies, or insurance departments for the performance rankings with the information presented on the Kaiser Family data we were seeking. We also did not file Freedom of Foundation’s Medicaid Managed Care Market Tracker. Information Act requests for this information with CMS. The quality measures presented in this paper reflect MCO/ FC performance during calendar year (CY) 2018 (Healthcare Limitations Effectiveness Data and Information Set 2019). These rates This scan was limited to six MCO/FCs operating in six states were the most recent data available at the beginning of our in CY 2018. These findings, therefore, do not necessarily scan in December 2020. In order to permit comparison of apply to MCO/FCs that operate in other Medicaid managed MCO/FC performance with the performance of other MCOs care states or the District of Columbia. We excluded states we scanned, we present (CY) 2018 performance data for all that contract with MCO/FCs below the state-level (for six MCO/FCs. CY 2019 (HEDIS) results may have become example, Wisconsin). available during the course of our scan. We limited the collected data elements to those we Data Collection consider most relevant to the performance of individual MCOs for children in foster care. It is possible that, had we The six states included in this scan (Arizona, Florida, searched for all potential performance data, we would have Georgia, Tennessee, Texas, and Washington) are states uncovered more information to assess the performance of where foster care children and youth were enrolled in individual MCOs, thereby affecting our judgments regarding MCOs that primarily or exclusively managed health care transparency in the six states that we did scan. services for them on a statewide basis in 2018. Four of these (Arizona, Georgia, Tennessee, and Texas) are states where We looked for EPSDT and Child Core Set data only for one CCF provides ongoing technical assistance to child health year (CY 2018). Therefore, we are not able to present trends advocates. in MCO/FC performance on EPSDT and Child Core Set quality measures from year to year. The list of data elements for which we searched can be found on this report’s page on CCF’s website. In our view, Finally, as noted above, caution should be exercised in these elements are the minimum necessary for advocates comparing MCO/FC performance across states, even for the and the public to make an informed assessment about the one year for which we found measure data. The demographic performance of an individual MCO/FC for children. There are profile and health status of the children in foster care enrolled additional data elements that could inform this assessment in these MCOs, as well as the provider networks that MCOs for which we did not search. These include additional are able to assemble to furnish services to these populations, MCO/FC-specific information: the resolution of grievances, may vary significantly from state to state. appeals, and state fair hearings relating to denials of CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 14 Appendix A. Populations Served and Enrollment Information Mandatory Enrollment Foster State Parent Enrollment in Enrollment by Race/ Enrollment Enrollment Children Plan Firm Population MCO/FCa (date)b Ethnicity Breakouts Available (FFY 2020)c Arizona Department Children and youth Yes 13,600 – – Monthly 13,300 Mercy Care DCS of Child placed in out-of-home (9/2020) Comprehensive Safety and care; youth in juvenile Health Plan Aetna/CVS justice system Florida Centene Foster care youth Yes 37,800 – By age (<1, Monthly 24,600 Sunshine State under the age of 21; (9/2020) 1-13; 14+); by Health Plan Medicaid agency has region (11) the discretion to extend eligibility to young adults in extended foster care under age 26 Georgia Anthem Foster care youth; Yes 28,700 – By region (6) Monthlyd 12,900 Amerigroup adoption assistance (6/2020) 360° youth; youth in juvenile justice system Tennessee BlueCross Foster care children, No 52,400 – –e Monthly 9,300 TennCare Select BlueShield children receiving SSI, (9/2020) of children receiving Tennessee services in a nursing facility or intermediate care facility for individuals with intellectual disabilities, other beneficiaries if other plans do not have capacity Texas Centene Foster care children Yes 36,400 – By region (14) Quarterly 31,400 Superior Health under the age of 22; (8/2020) Plan adoption assistance youth; former foster care children under 21 Washington Centene Foster care children; No 24,000 – – Yearly 10,900 Apple adoption assistance; (2018) Health Core former foster care youth Connections under age 26 (if enrolled on 18th birthday) a Reflects information presented in Center for Medicaid and Medicare Services, “Managed Care: Profiles & Program Features,” (Baltimore: Center for Medicaid and Medicare Services, 2018), available at https://www.medicaid.gov/medicaid/managed-care/profiles-program-features/index.html. b Figures rounded to the nearest hundred. Enrollment for Washington sourced from the latest document available at the time of the scan, the 2019 External Quality Review Annual Technical Report. c This column shows the number of foster care children in the state on September 30, 2019 rounded to the nearest hundred. This is a point-in-time statistic, meant to give a general ballpark for the number of children in foster care at the start of FFY 2020. d There is a significant data lag for the enrollment statistics in Georgia. As of 1/18/2021, the latest report available was from June 2020. e Tennessee’s monthly enrollment report divides TennCare Select beneficiaries into “High” and “Low” categories, but offers no explanation as to what this division means. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 15 Appendix B. Race and Ethnicity of All Children and Foster Care Children All Children Foster Care Children Arizona American Indian/Alaskan Native (non-Hispanic) 5% 5% Asian/Native Hawaiian/Pacific Islander (non-Hispanic) 3% <0.5% Black (non-Hispanic) 5% 11% Other/Two or More Races (non-Hispanic) 4% 5% White (non-Hispanic) 39% 34% Hispanic/Latino 45% 38% Florida American Indian/Alaskan Native (non-Hispanic) <0.5% <0.5% Asian/Native Hawaiian/Pacific Islander (non-Hispanic) 3% <0.5% Black (non-Hispanic) 20% 30% Other/Two or More Races (non-Hispanic) 5% 7% White (non-Hispanic) 41% 47% Hispanic/Latino 32% 16% Georgia American Indian/Alaskan Native (non-Hispanic) <0.5% <0.5% Asian/Native Hawaiian/Pacific Islander (non-Hispanic) 4% <0.5% Black (non-Hispanic) 33% 39% Other/Two or More Races (non-Hispanic) 5% 6% White (non-Hispanic) 43% 47% Hispanic/Latino 15% 6% Tennessee American Indian/Alaskan Native (non-Hispanic) <0.5% <0.5% Asian/Native Hawaiian/Pacific Islander (non-Hispanic) 2% <0.5% Black (non-Hispanic) 19% 23% Other/Two or More Races (non-Hispanic) 5% 6% White (non-Hispanic) 65% 65% Hispanic/Latino 10% 6% Texas American Indian/Alaskan Native (non-Hispanic) <0.5% <0.5% Asian/Native Hawaiian/Pacific Islander (non-Hispanic) 4% <0.5% Black (non-Hispanic) 12% 22% Other/Two or More Races (non-Hispanic) 3% 5% White (non-Hispanic) 31% 30% Hispanic/Latino 49% 41% Washington American Indian/Alaskan Native (non-Hispanic) 1% 5% Asian/Native Hawaiian/Pacific Islander (non-Hispanic) 8% 2% Black (non-Hispanic) 4% 8% Other/Two or More Races (non-Hispanic) 10% 16% White (non-Hispanic) 56% 49% Hispanic/Latino 21% 20% Note: Shares of population should be read as an approximation. Given that the two estimates come from different data sources, it is not possible to calculate statistical significance between the shares. Share of foster care children whose race is unknown is 6 percent or below and is not included in presentation. Sources: For all children: Georgetown Center for Children and Families analysis of 2018 U.S. Census Bureau American Community Survey Public Use Mircodata (PUMS). For foster care children: Annie E. Casey Foundation Child Trends analysis of 2018 Adoption and Foster Care Analysis and Reporting System (AFCARs) data (March 2020), available at https://datacenter.kidscount.org/data/tables/6246-children-in-foster-care-by-race-and-hispanic-origin?loc=1&loct=1#detail ed/2/4,11-12,15,19,44-45,49-50/false/37/2638,2601,2600,2598,2603,2597,2602,1353/12992,12993. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 16 Appendix C. Company and Contracting Structure State Parent Firm Operates Risk Contract Ownership and Parent Firm MCO/FC Non-Foster Care Posted Management of MCO in State MCO/FC Available Arizona Department of Child P No* No Mercy Care DCS Comprehensive Safety (and Aetna/CVS)* (amendment) Health Plan Florida Centene P Template  No Sunshine State Health Plan (amendment) Georgia Anthem P Template P** Amerigroup 360 ° (stand-alone) Tennessee BlueCross BlueShield of P P P TennCare Select Tennessee (stand-alone) Texas Centene P Template  No Superior Health Plan (stand-alone) Washington Centene P P P** Apple Health Core Connections (stand-alone) * During the performance year assessed, the MCO/FC was operated by the Department of Child Safety. The Aetna/CVS arrangement is as of 2021. Arizona’s contract between the MCO/FC and the state was not available from the state; however, an outdated contract is available from the Commonwealth Fund’s Medicaid Managed Care Database at https://www.commonwealthfund.org/medicaid-managed-care-database#/states/AZ. ** Indicates that partial information is available. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 17 Appendix D. Foster Care-Specific MCO Quality Metrics Compared to National and State Median, CY 2018 a Sunshine Apple Health US Mercy Care Amerigroup TennCare Superior Quality Measure AZ State FL GA TN TX Core WA Median DCS CHPb 360° Select Health Plan Health Plan Connections Primary and Preventive Care Childhood Immunization Status: 68.8% – – 79.1% 73.3% 77.9% 72.2% 67.2% 72.3% 58.6% 68.8% – 70.0% Combination 3 Adolescent Immunization Status: 78.6% – – 65.7% 74.1% 86.6% 86.9% 67.9% 75.1% 82.8% 77.2% – 76.0% Combination 1 Well-Child Visits in the First 15 Months 64.0% – 61.6% 61.7% 69.6% 67.6% 62.0% 52.6% 68.4% 64.1% 68.2% – 67.0% of Life (6 or More) Well-Child Visits in 3rd, 4th, 5th, and 69.0% 72.6% 61.8% 84.0% 77.9% 80.4% 68.3% 76.8% 73.6% 89.4% 77.7% – 67.7% 6th Years Adolescent Well Care 50.6% 72.4% 41.5% 64.0% 60.2% 60.5% 52.8% 49.6% 57.3% 73.1% 67.5% – 46.6% Weight Assessment for Children 69.7% – – 89.9% 87.8% 83.5% – 83.1% 80.0% 17.8% 73.8% – 72.2% and Adolescents: BMI Percentile Documentation Depression Screening and Follow-up – – – – – 19.0% – – – – – – – Behavioral Health Follow-Up Care for Children 48.6% – 58.8% 50.8% 40.6% 44.4% – 42.0% 45.0% 51.0% 37.4% – 42.8% Prescribed ADHD Medication Initiation Phase Follow-Up Care for Children 58.6% – 66.0% 61.5% 54.3% 49.5% – 59.7% 58.3% 56.5% 51.8% – 50.8% Prescribed ADHD Medication Continuation and Maintenance Phase Follow-Up within 7 days after 41.9% – 69.5% – 41.3% 45.2% – 39.2% 48.7% 55.6% 35.4% – 72.6% Hospitalization for Mental Illness: Ages 6-17 Follow-Up within 30 days after 66.3% – 85.8% – 61.1% 70.3% – 58.6% 70.0% 80.4% 58.5% – 88.1% Hospitalization for Mental Illness: Ages 6-17 Use of First-Line Psychosocial Care 62.8% – 71.3% 70.1% 60.4% 78.0% – 52.7% 54.5% N/A for 1-17 46.3% – – for Children and Adolescents on Antipsychotics: Ages 1-17 Use of Multiple Concurrent 2.6% – 1.0% 1.3% 2.1% 3.4% – 3.5% 2.6% 2.3% 2.0% -- 2.4% Antipsychotics in Children and Adolescents c Maternal Health Timeliness of Prenatal Care 80.7% – – 64.9% 83.2% 62.1% 67.2% 76.6% 83.0% 58.9% 88.1% – 80.6% a Measures were selected from the Child Core Set to represent three critical areas of care for foster care youth. Currently, it is optional for states to report Child Core Set metrics (on an aggregate state level) to CMS; reporting will become mandatory in 2024. We looked for plan-level performance data on these measures in each state’s EQRO Annual Technical Report (ATR). The performance results in this table come from the 2020 ATRs, which reflect HEDIS 2019 measures, which in turn reflect data collected for calendar year 2018. National median and state-level performance data are as reported by CMS in the 2020 Child Core Set, which reflects FFY 2019 reporting, which in turn reflects data collected during calendar year 2018. Some state-level measures may reflect performance for both Medicaid and CHIP populations. Though Apple Health Core Connections (Washington) was established by CY 2018, the EQRO ATR does not include any quality data for the plan for that year. b Effective April 1, 2021, Arizona’s MCO/FC merged with Mercy Care, an Aetna/CVS subsidiary. Data included in the chart reflects performance prior to merger when the Arizona Department of Child Safety was wholly responsible for the MCO/FC. c Lower percentages indicate better performance. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 18 Appendix E. Elements Contained in Data Dashboards on State Child Welfare Agency Websites Demographics of children Demographics of children HEDIS measure State EPSDT in foster care enrolled in MCO/FC rates Arizona –a – – – Georgia P – – – Florida – – – Pb Texas Pc – – – a Arizona makes the demographics of children in foster care available in a monthly report on the Department of Child Safety’s website. b The measures available were “Children Receiving Dental Services” and “Children Receiving Medical Services,” which are not EPSDT metrics but do measure the provision of services that are similar to EPSDT. c Texas presents child demographics for each region and authorized service level in its monthly enrollment reports on the Department of Family and Protective Services website. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 19 Endnotes 1 Corcoran, A., et al., “ Transparency in Medicaid Managed Care: CHIP Payment and Access Commission, March 2018), available at Findings from a 13-State Scan” (Washington, D.C.: Georgetown Center https://www.macpac.gov/wp-content/uploads/2018/03/Report-to- for Children and Families, September 2021), available at https://ccf. Congress-on-Medicaid-and-CHIP-March-2018.pdf. georgetown.edu/2021/09/09/transparency-in-medicaid-managed-care- 16 Information about the AFCARS reporting system can be found at findings-from-a-13-state-scan/. https://www.acf.hhs.gov/cb/data-research/adoption-fostercare. 2 Administration on Children, Youth and Families, Children’s Bureau, 17 Barnett, E. R., “Children’s Behavioral Health Needs and Satisfaction “Trends in Foster Care and Adoption: FY 2010 -FY 2019,” U.S. and Commitment of Foster and Adoptive Parents: Do Trauma-Informed Department of Health and Human Services, October 16, 2020, available Services Make a Difference?,” Psychological Trauma: Theory, Research, at https://www.acf.hhs.gov/sites/default/files/documents/cb/trends_ Practice, and Policy 11, no. 1 (2019): 73-81, available at https://doi. fostercare_adoption_10thru19.pdf. org/10.1037/tra0000357. 3 Council on Foster Care, Adoption, and Kinship Care; Committee on 18 Administration for Children and Families, Children’s Bureau, “Child Adolescence; Council on Early Childhood, “Health Care Issues for Welfare Practice to Address Racial Disproportionality and Disparity” Children and Adolescents in Foster Care and Kinship Care,” Pediatrics (Washington, D.C.: U.S. Department of Health and Human Services, 136, no. 4 (October 2015): e1131-e1140, available at https://pediatrics. April 2021), available at https://www.childwelfare.gov/pubPDFs/racial_ aappublications.org/content/136/4/e1131. disproportionality.pdf. In Arizona, a state with an MCO/FC included 4 Keefe, R., et al., “Mental Health Diagnoses of Children in Foster in this scan, data from the child welfare agency show that while Care: A Comparison Study between Foster and Non-Foster Children approximately 5.2 out of every 1,000 children are in foster care, the Covered by Medicaid,” Pediatrics 146, no. 1 (meeting abstract) (July numbers are vastly different for children of color: 12.5 out of every 1,000 2020), available at https://doi-org.ezproxy.library.wisc.edu/10.1542/ American Indian children and 16.9 out of every 1,000 African-American peds.146.1_MeetingAbstract.508-a; Bilaver, L., Havlicek, J., and Davis, children living in the state are in foster care. Preliminary data estimated M., “Prevalence of Special Health Care Needs Among Foster Youth for state fiscal year 2021. Arizona Department of Child Safety, “Monthly in a Nationally Representative Survey,” JAMA Pediatrics 174, no. 7 Operational Report,” State of Arizona (July 2021), available at https:// (May 2020): 727-729, available at https://jamanetwork.com/journals/ dcs.az.gov/reports. jamapediatrics/fullarticle/2765817. 19 Stevens, G. and Shi, L., “Effect of Managed Care on Children’s 5 Chasnoff, I., Wells, A., and King, L., “Misdiagnosis and Missed Relationships with their Primary Care Physicians,” Archives of Pediatric Diagnoses in Foster and Adopted Children with Prenatal Alcohol and Adolescent Medicine 156, no. 4 (2002), available at https:// Exposure,” Pediatrics 135, no. 2 (February 2015): 264-270, available at jamanetwork.com/journals/jamapediatrics/fullarticle/191765. https://pediatrics.aappublications.org/content/135/2/264?ijkey=9e3374 20 This estimate comes from a recent report from the Administration for 7ca31f3cd9815077c21ce950f14c006819&keytype2=tf_ipsecsha. Children and Families which in turn summarizes data from three studies 6 Sarvas, E., et al., “Oral Health Needs Among Youth with a History of of foster care youth spanning the following age brackets: 10-18, 12-21, Foster Care: A Population-Based Study,” The Journal of the American and 13-20. For more information, see Administration for Children and Dental Association 152, no. 8 (June 2021), available at https://www. Families, Children’s Bureau, “Supporting LGBTQ+ Youth: A Guide for sciencedirect.com/science/article/abs/pii/S0002817721001677. Foster Parents” (Washington, D.C.: U.S. Department of Health and 7 Council on Foster Care, Adoption, and Kinship Care; Committee on Human Services, June 2021), available at https://jamanetwork.com/ Adolescence; Council on Early Childhood, op cit. journals/jamapediatrics/fullarticle/191765. 8 Jones, V. et al., “Pediatrician Guidance in Supporting Families of 21 For accompanying examination of MCOs in 13 states that enroll a Children who are Adopted, Fostered, or in Kinship Care,” Pediatrics 146, broader population of children, see Corcoran, A., et al., “Transparency in no. 6 (December 2020), available at https://pediatrics.aappublications. Medicaid Managed Care: Findings from a 13-State Scan” (Washington, org/content/146/6/e2020034629; Council on Foster Care, Adoption, and D.C.: Georgetown Center for Children and Families, September 2021), Kinship Care; Committee on Adolescence; Council on Early Childhood, available at https://ccf.georgetown.edu/2021/09/09/transparency-in- op cit. medicaid-managed-care-findings-from-a-13-state-scan/. 9 Council on Foster Care, Adoption, and Kinship Care; Committee on 22 Center for Medicaid and Medicare Services, “Managed Care: Profiles Adolescence; Council on Early Childhood, op cit. & Program Features” (Baltimore: Center for Medicaid and Medicare Services, 2018), available at https://www.medicaid.gov/medicaid/ 10 Ibid. managed-care/profiles-program-features/index.html. 11 Jones, V. et al., op cit. 23 BlueCross BlueShield of Tennessee is reimbursed on a non-risk, non- 12 Ibid. capitated basis (or a partial risk basis for some services) and receives 13 Butler, J., Reck, J., and Hensley-Quinn, M., “Evidence-Based fees for its administrative costs. In Arizona, the Department of Child Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use Safety (DCS) is compensated on a capitated basis. among Children in the Foster Care System” (National Academy for State 24 Given that not all states report eligibility in the same way or with the Health Policy, February 2019), available at https://www.nashp.org/wp- same frequency, this number is an estimate based on the enrollment content/uploads/2019/02/Antipsychotic-Meds-Foster-Kids-Brief-1.pdf. from state reports from September 2020 (Florida), August 2020 (Texas) 14 Centers for Medicare and Medicaid Services, “EPSDT - A Guide for and the end of 2018 (Washington). Note that Centene makes a concerted States: Coverage in the Medicaid Benefit for Children and Adolescents” effort to present itself as a leader in care management for foster care (Baltimore: Centers for Medicare and Medicaid Services, June 2014), youth; there is a dedicated section on the Centene website listing available at https://www.medicaid.gov/sites/default/files/2019-12/ their plans that serve children in foster care across the United States epsdt_coverage_guide.pdf. (including plans that are not specifically tailored to meet the needs of foster children alone). Centene Corporation, “Centene Foster Care,” Medicaid and CHIP Payment and Access Commission, “Report to 15 September 2021, available at https://www.centenefostercare.com/. Congress on Medicaid and CHIP” (Washington, D.C.: Medicaid and CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 20 25 Corcoran, A., “Medicaid Managed Care: 2021 Results for the ‘Big 39 Comparing the performance of individual MCO/FCs to their state Five’ at Q2,” Say Ahh! Health Policy Blog (August 2021), available at medians helps show how the MCO/FC performs in relation to the MCOs https://ccf.georgetown.edu/2021/08/18/medicaid-managed-care- that enroll a broader population of children in the state. Additionally, 2021-results-for-the-big-five-at-q2/; and Schneider, A. and Corcoran, comparing the performance of the MCO/FC to the U.S. median offers A., “Medicaid Managed Care: 2020 Results for the ‘Big Five,’” SayAhh! context but should be done with care, given that particular state Health Policy Blog (February 2021), available at https://ccf.georgetown. characteristics can contribute to lower quality scores relative to those edu/2021/02/23/medicaid-managed-care-2020-results-for-the-big-five/. of other states and regions. For more information on the external quality 26 The series won an award for investigative reporting from the Nieman review process and interpreting quality metrics, see Machledt, D., Foundation at Harvard. Nieman Foundation, “‘Pain and Profit’ by The “Medicaid External Quality Review: An Updated Overview” (Washington, Dallas Morning News wins Worth Bingham Prize for Investigative D.C.: National Health Law Program, November 2020), available at Journalism” Harvard University (April 2019), available at https://nieman. https://healthlaw.org/resource/medicaid-external-quality-review-an- harvard.edu/news/2019/04/pain-and-profit-by-the-dallas-morning- updated-overview/; and, Machledt, D., “Finding and Analyzing Medicaid news-wins-worth-bingham-prize-for-investigative-journalism/. Quality Measures,” (Washington, D.C.: National Health Law Program, January 2021), available at https://healthlaw.org/resource/finding-and- 27 42 C.F.R. 438.332(c)(1); 438.364(c)(2)(i); 438.602(g). analyzing-medicaid-quality-measures/. 28 Centers for Medicare and Medicaid Services, “Instructions for 40 Arizona Health Care Cost Containment System, “Resources for Completing Form CMS-416: Annual Early and Periodic Screening, Foster/Kinship/Adoptive Families,” State of Arizona (September 2021), Diagnostic, and Treatment (EPSDT) Participation Report” (Baltimore: available at https://www.azahcccs.gov/Members/AlreadyCovered/ Centers for Medicare and Medicaid Services), available at https://www. MemberResources/Foster/. medicaid.gov/medicaid/benefits/downloads/cms-416-instructions.pdf. 41 Texas Department of Family and Protective Services, “Monthly Data,” 29 At least one state Medicaid agency posts MCO-specific EPSDT State of Texas (September 2021), available at https://www.dfps.state. performance data for all children. “MCO External Quality Review Annual tx.us/About_DFPS/Monthly_Data/default.asp#children-in-care. Technical Reports,” District of Columbia Department of Health Care Finance, available at https://dhcf.dc.gov/page/mco-external-quality- 42 Georgia Department of Human Services, “Child Welfare Data: Children review-annual-technical-reports. Served,” State of Georgia (September 2021), available at https://dhs. georgia.gov/division-family-children-services-child-welfare. 30 “Children’s Health Care Quality Measures,” Centers for Medicare and Medicaid Services, available at https://www.medicaid.gov/medicaid/ 43 Florida Department of Children and Families, “Florida Child Welfare quality-of-care/performance-measurement/adult-and-child-health-care- Statistics,” State of Florida (September 2021), available at https://www. quality-measures/childrens-health-care-quality-measures/index.html. myflfamilies.com/programs/childwelfare/dashboard/index.shtml. 31 Center for Medicaid and CHIP Services, “Criteria for Using the Child 44 Corcoran, A. et al., op cit. and Adult Core Set Measures to Assess Trends in State Performance 45 For example, in California, the policy choice was between a single in Medicaid and the Children’s Health Insurance Program” (Baltimore: statewide MCO/FC, with medical, behavioral health, and dental services Centers for Medicaid and Medicare Services, November 2019), available fully integrated; a regional MCO/FC; or an MCO that enrolls more at https://www.medicaid.gov/medicaid/quality-of-care/downloads/ beneficiary groups than foster youth and has a county-level service performance-measurement/methods-brief.pdf.  area. The view of some advocates was, “Overall, the accountability 32 “State Readiness to Report Mandatory Core Set Measures,” Medicaid of managed care organizations, along with the opportunities for and CHIP Payment and Access Commission, March 2020, available enforcement of access to care and consumer protections, make at https://www.macpac.gov/publication/state-readiness-to-report- managed care delivery preferable to FFS for foster children and youth.” mandatory-core-set-measures/; and, §1139A of the Social Security Act. Lewis, K. and Cohen, C., “Foster Care Model of Care Workgroup: Assessing Different Managed Care Options for Foster Youth in 33 45 C.F.R. 1355, Appendix A. California” (Los Angeles: National Health Law Program, December 34 42 C.F.R. 438.602(g)(1). 2020), available at https://www.dhcs.ca.gov/provgovpart/Documents/ 35 For the time period reviewed, the Arizona MCO/FC was operated by NHeLP-Foster-Care-Options.pdf. the Department of Child Safety. Currently, the state Medicaid Agency contracts with both the Department of Child Safety and the private insurer, Mercy Care (a subsidiary of CVS/Aetna), on a risk basis to operate the MCO/FC. In West Virginia, the MCO/FC launched after the time period included in this scan, is under contract with both the state Medicaid agency and Child Welfare agency. 36 42 C.F.R. 438.602(g)(3). 37 Information for Georgia available at Amerigroup Georgia Families 360 website, https://www.myamerigroup.com/ga/your-plan/georgia-families- 360-stakeholder-information.html. Information for Washington available at State Department of Insurance website, https://fortress.wa.gov/oic/ consumertoolkit/Company/CompanyFinancialStatements.aspx?WAOIC =Ttd7tAycAG5hjFu7z87hMg%253D%253D. 38 The “Administrative Subcontractors and Affiliates Report” can be accessed from the Agency for Healthcare Administration’s Statewide Medicaid Managed Care home page or at https://ahca.myflorida.com/ medicaid/statewide_mc/pdf/Adm_Subcontractor_Affilites_Report.pdf. CCF.GEORGETOWN.EDU transparency in medicaid managed care: children in foster Care 21