By Rebecca Mayo, J.D.
HHS is requesting public comments regarding the coordination of care from out-of-state providers for Medicaid-eligible children with medically complex conditions.
Before HHS issues required guidance to state Medicaid directors later this year, HHS has requested public comment on some of the major issues surrounding coordination of care from out-of-state providers. HHS is asking for information on barriers that prevent children with medically complex conditions from accessing care from out-of-state providers, whether barriers faced by states and agencies, by providers, or by caregivers and children. Input is requested on ways to reduce those barriers as well as how to streamline the process for screening, contracting with, and paying out-of-state providers who provide those services (Notice, 85 FR 3330, January 21, 2020).
Medicaid Health Homes. The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) authorized Medicaid health homes, which allows states to elect a Medicaid state plan option to provide a comprehensive system of care coordination for Medicaid beneficiaries with chronic conditions. The goal was to integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person. The Medicaid Services Investment and Accountability Act of 2019 expanded on this and allowed states to have the option to cover health home services for Medicaid-eligible children with medically complex conditions who choose to enroll in a health home. States that choose to exercise this option may receive a 15 percent increase in the federal match for their expenditures on health home services during the first 2 fiscal year quarters that the approved health home State Plan Amendment is in effect.
Health home services must be provided by a health home, which is a designated provider or health team that is qualified to serve as a health home and is selected by a Medicaid-eligible child with medically complex conditions, or by his or her family. However, if the state Medicaid agency determines that needed medical services or necessary supplementary resources for a beneficiary are more readily available in another state, Federal regulations require the state to pay for those services furnished in the other state just as it would pay for services within the state. Regulations also require state Medicaid agencies and Medicaid managed care plans to cover needed emergency services in-state and out-of-state.
Guidance. HHS must issue guidance to state Medicaid directors by October 1, 2020 on: (1) best practices for using out-of-state providers to provide care to children with medically complex conditions; (2) Coordinating care provided by out-of-state providers to children with medically complex conditions, including when provided in emergency and non-emergency situations; (3) reducing barriers that prevent children with medically complex conditions from receiving care from out-of-state providers in a timely fashion; and (4) Processes for screening and enrolling out-of-state providers, including efforts to streamline these processes or reduce the burden of these processes on out-of-state providers.
Request for information. HHS is soliciting general comments on the coordination of care provided by out-of-state providers who may provide care for Medicaid-eligible children with medically complex conditions. Specifically, HHS is seeking public comment on best practices for using out-of-state providers and coordinating care from out-of-state providers for children with medically complex conditions. HHS would like to learn about any state initiatives that have promoted and/or improved the coordination of services and supports provided by out-of-state providers to children with medically complex conditions. Also important is information on any administrative, fiscal, and regulatory barriers that states, providers, beneficiaries and their families experience, as well as any barriers that prevent caregivers from accessing or navigating care from out-of-state providers or financial barriers that prevent children from receiving care from out-of-state providers. HHS is asking for comment on successful methods to inform caregivers about ways to access care, and any measure that have been or could be employed to reduce barriers to coordinating care. Finally, HHS is seeking comment on how to screen and enroll out-of-state providers, challenges with referrals to these providers, and best practices for developing terms of contracts and payment rates for these providers.
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