In November 2017, an “Intra-Agency Agreement between the NH Title V sections and the NH Office of Medicaid Services, Relative to Joint Planning, Coordination and Improvement of Health Programs under Title V and Title XIX” was signed jointly by MCH, BFCS and Medicaid. Three years in development, it had been 24 years since a previous intra-agency agreement had been signed.
Title V has worked judiciously with Medicaid in the past year. One easily implemented component of the agreement was the assignment of a seat for MCH on the Medicaid Medical Care Advisory Committee (MCAC), which advises the Medicaid Director on policy and planning. Members of the MCAC must be familiar with the comprehensive needs of low-income population groups and with the resources required for their care, which is consistent with the professional responsibilities of Title V staff. Duties comprise of reviewing and recommending proposals for rules, regulations, legislation, waivers, operation and other Medicaid policies. These include the annual report on managed care, marketing materials submitted by managed care entities, the managed care quality strategy and rating system and the development and update of the Medicaid access monitoring review plan.
A revised Medicaid rule coming to the MCAC in the next few months is the result of legislation establishing RSA 167:68, which states that “Home visiting programs for children and their families established pursuant to this subdivision shall be made available to all Medicaid eligible children and pregnant women without restriction…. The commissioner (of DHHS) shall adopt rules…relative to administering this section.”[1] Previously, the rules stated that agencies providing home visiting would receive Medicaid reimbursement for covered mothers 21 and under either with a first pregnancy and/or an infant up to the age of one. Agencies also had to be under contract with either MCH, BFCS and/or the Division Children, Youth or Families (DCYF; the State’s child protection agency). This rule dated back to the early days of voluntary home visiting provided by DHHS contract agencies, prior to MIECHV and the implementation of Healthy Families America as an evidenced based model. MCH currently has oversight over the MIECHV program and provides Title V funding for home visiting services under Comprehensive Family Support Services, a family support contract jointly run with DCYF and the DHHS Division of Economic and Housing Security. MCH and BFCS staff initially provided information to home visiting advocates securing a change in legislation in the 2019 session as well as the provision of additional funding to Medicaid starting in State Fiscal Year 21 (starting July 1st, 2020), solely for coverage under a new rule.
When RSA 167:68 was signed into law, MCH and BFCS staff started work with their Medicaid colleagues to revise the current Administrative rule, He-W 549. Regular meetings took place, including a coordinated stakeholder meeting, seeking input from provider agencies on how best to support rewriting the Medicaid rule to loosen restrictions and expand access for home visiting services.
In March 2019, the Governor and Executive Council approved three insurance plans to serve recipients of Medicaid Care Management beginning September 2019. Two, NH Healthy Families and Well Sense were already MCOs. One, AmeriHealth Caritas was a new provider. The BFCS was included as a reviewer of all required MCO readiness documentation related to care management activities as a component of the earlier re-procurement.
On September 19, 2019, NH Family Voices (NHFV) coordinated and facilitated a training for MCO’s and their staff, new and seasoned, to understand waiver services, family supports, laws/rules, and rehabilitative services required by individuals supported by the DLTSS. The morning training consisted of an overview, a DHHS Program and Services Panel and a presentation of community resources. The second half of the day consisted of information on client rights, adult protective services, guardianship and how to work with guardians.
The BFCS Clinical Coordinator and the CYSHCN Director began regularly attending individual case rounds with each of the MCO plans, in November 2019. Three back-to-back, hour long sessions are held monthly to focus on a particular topic such as substance use disorder, pediatrics, or mental health. The MCOs provide their most complex cases for discussion.
Medicaid has recently relaxed its Administrative Rules due to the COVID 19 pandemic, increasing the types of providers able to provide current services and enlarging its waivers, allowing for telehealth and enabling the origin of services to be wherever the patient is. All three of the MCOs are providing cell phones to those insured who do not have one, in order to increase their ability to receive needed care.
Title V staff are working with Medicaid on its Local Care Management Entity Project, which seeks to define and understand the myriad care/case management functions (both internal and contracted) within all of DHHS’s programs. Many Title V affiliated CHCs use their funding to provide client management otherwise not provided by insurance. Medicaid has contracted with the University of NH’s Institute on Health Policy and Practice to facilitate initial gathering specifics from each DHHS program (governing policy, funding, criteria, etc.).
The BFCS and the MCOs have maintained a working partnership to address access and coverage. Additionally, the CYSHCN Director is a member of the MCO operations oversight group and reviews quarterly reports on “Appeals by Type of Resolution and Category of Service.” The objective is to determine if the report identifies any “performance issues” that should be escalated. A performance issue is defined as one that materially affects the quality/scope of the program; violates compliance with the contract or other regulations; or negatively impacts the budget or timeline and may require resources to address.
DHHS’s Bureau of Quality Assurance and Improvement (QAI), which primarily works with NH Medicaid, has continued its partnership with MCH by routinely sharing data, such as monthly birth linkages (linked births and Medicaid delivery claims), for routine querying and matching for programs such as newborn screening and newborn hearing screening. This linkage enables more in-depth analyses than are possible with either dataset alone and has been used to examine issues such as early elective deliveries and currently with maternal mortality and severe maternal morbidity.
One of the outcomes of the Title V/Medicaid Intra-Agency Agreement is the co-development of health standards as well as quality improvement activities, including the sharing of data and outcome measures. Policies are sometimes re-worked when there is evidence that a change might improve quality of care. Such was the case when Medicaid unbundled the cost of labor and delivery services in January 2018 allowing for a separate paid cost for IUD or implant insertion directly post-partum. MCH and the QAI are collaborating on an evaluation of this change in policy, running quarterly reports to see if postpartum LARC insertion has increased. Unfortunately, the first two years of data (1/1/18-1/1/20) has shown that this benefit is infrequently used. When utilized, the coding for reimbursement does not appear to be understood by health care providers. In contrast, in fall 2019 interviews with 30 postpartum women insured by Medicaid note that 26 out of 30 responded affirmatively about being given the choice of receiving a LARC prior to discharge after delivery; however, none took the offer.[2]
NH has been focusing on National Performance Measure #10, the percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year, which aligns with the CMS/HEDIS measure which increases the age to 21. MCH, the QAI and MCOs have worked together with their respective partners, to increase this through a variety of different mechanisms. In a paper published in January 2020 based on interviews with MCH and QAI staff, NH’s collaborative work was highlighted by the National Alliance to Advance Adolescent Health[3] because of placing fifth nationally on the HEDIS measure.
“Interviewees from New Hampshire rated four factors…influencing their positive ranking, including alignment of payment incentives with adolescent preventive care performance, use of standardized quality performance measures across payers, state public health performance goals on adolescent well-care and the use of HEDIS measures, which automatically incentivize Medicaid and commercial health plans to focus on the adolescent well-care measure”.[4]
Medicaid’s External Quality Review Organization will be facilitating interviews, with questions determined by the QAI and MCH, with caregivers of adolescents to discuss overall healthcare with an emphasis on the importance of annual visits.
The Title V/Medicaid Agreement also reaffirms the commitment to have Title V funded contractors identify, enroll and re-enroll Medicaid eligible clients and to refer those clients to appropriate services. Seven of the funded CHCs utilize Title V (mostly through braiding of funds) for sustaining or even increasing capacity for any type of staff helping with client insurance needs. Dependent upon the CHC, approximately 10% to 50% of the clients coming in for the first time are uninsured.[5] With the loss of job related insurance as part of the COVID pandemic, this number will certainly increase.
Medicaid and MCH’s Family Planning Program also work together on a special State Plan Amendment (SPA). This particular SPA allows presumptive eligibility for Medicaid to non-pregnant individuals 19-64 who are not otherwise eligible and who have an income at or below 133% of the FPL. Individuals have to be enrolled by a qualified entity, including all of the MCH (Title V and Title X) contractors, who can facilitate presumptive eligibility. The SPA allows clients to receive coverage for family planning medical visits, contraceptive devices or drugs, both prescription and some non-prescription, pregnancy tests and screening for sexually transmitted infections when performed routinely as part of an initial, regular, or follow-up family planning visit as well as sterilization. In State Fiscal Year 19, 836 people used this SPA.
[2] Horn Research (January 2020). New Hampshire Medicaid Care Management, MEMBER SEMI-STRUCTURED INTERVIEWS, SUMMARY REPORT FALL 2019. Internal communication from Medicaid colleague.
[3] McManus, P. and Schmidt, A. The National Alliance to Advance Adolescent Health (2020). Summary of Factors Influencing Adolescent Well-Care Performance in Top-Performing State Medicaid Programs. Retrieved from https://static1.squarespace.com/static/5871c0e9db29d687bc4726f2/t/5e60197d4823b81d7739ec74/1583356286612/Summary+of+Factors+Influencing+Adolescent+Well-Care+Performance.pdf on 04/13/20.
[4] Ibid.
[5] UDS Tables (2019).
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