Title V MCH-Title XIX Medicaid Inter-Agency Agreement:

Program Outreach and Enrollment

Title V has continued to collaborate with the Medicaid Program to improve access to health care services for women and children.  As a Medicaid Expansion state, Maryland has decreased the numbers of uninsured individuals over the past 6 years. Maryland’s uninsured rate declined from 10.1% in 2012 to 6.0% in 2018 and is lower than the national rate of 8.9%. Since 2015, the uninsured rate in Maryland decreased for all races and ethnicities but remained highest for Hispanic individuals (22.3% in 2018, a slight increase from 22.0% percent in 2017). The uninsured rate decreased for most age groups since 2015 but increased slightly for those ages 45 to 54 years of age (6.1% in 2015 to 7.2% in 2018). The uninsured rate remains highest among those aged 25 to 34 years. In 2021, birthing people’s coverage will increase from two months to 12 months postpartum.

As more eligible residents have received Medicaid coverage to enable them to access health care, Title V has shifted its structure from a direct and gap filling model to more of a population and infrastructure based model.  Direct, gap filling services are largely provided by the Children’s Medical Services (CMS) Program to children with special health care needs who are ineligible for Medicaid services. Over the past several years, the demand for direct, gap filling services for the CMS Program have increased.

Health Care Financing

Maryland Managed Care Organizations (MCOs) provide services to Medicaid recipients by contracting with a network of licensed/certified healthcare providers. All MCOs are responsible to provide or arrange for a wide array of healthcare services.  There are nine managed care organizations in Maryland: Aetna Better Health, Amerigroup Community Care, Carefirst Blue Cross Blue Shield Community Health Plan, Jai Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice, Priority Partners, and United HealthCare. As of June 2021, nearly 87% of Medicaid participants were enrolled in managed care.

Maryland Medicaid does not participate in a Primary Care Case Management (PCCM) program as PCCM is considered an alternative to manage care.

Through the Total Cost of Care All-Payer Model contract the State of Maryland has entered with the Federal Government, the Maryland Primary Care Program (MDPCP) has been developed. A separate office within MDH’s Public Health Services works with interested primary care offices to coordinate care for patients across both hospital and non-hospital settings, improve health outcomes, and constrain the growth of health care costs in Maryland. MDPCP is a voluntary program open to all qualifying Maryland primary care providers that provides funding and support for the delivery of advanced primary care throughout the state.

Waivers or State Plan Amendments

There are two main examples that influence healthcare delivery for the MCH population: the Home Visiting Services Pilot and the Asthma Home Visiting Program.

Medicaid has operated a Home Visiting Services (HVS) pilot since 2017 through its §1115 waiver, which has enabled an expansion of evidence-based home visiting services to Medicaid eligible high-risk pregnant individuals and children up to age two. The HVS pilot program is aligned with two evidence-based models focused on the health of pregnant individuals. The Nurse Family Partnership (NFP) model is designed to reinforce maternal behaviors that encourage positive parent-child relationships and maternal, child and family accomplishments. The Healthy Families America (HFA) model targets parents facing issues such as single parenthood, low income, childhood history of abuse, substance use disorder, mental health issues or domestic violence. The current financing structure of the HVS pilot, which requires local lead government entities to provide a local match through an intergovernmental transfer, has garnered limited participation from additional lead entities because of the requirement to produce the required match from non-federal 10 funding sources.

In 2017, the Maryland Department of Health submitted a successful application to the Centers for Medicare and Medicaid Services (CMS) for a Health Services Initiative (HSI) under the Children’s Health Insurance Program (CHIP). The new program, approved as a State Plan Amendment (SPA), allowed MDH to create a $3 million home visiting program for children who are enrolled in or eligible for Medicaid (including CHIP), based on diagnosis of either moderate to severe asthma or lead poisoning. The program operates in nine jurisdictions: Baltimore City and Baltimore, Charles, Dorchester, Frederick, Harford, Prince George’s, St. Mary’s, and Wicomico Counties. These are sites with some of the highest burden of asthma ED visits. Once they are deemed eligible and enrolled in the program, the children’s families are eligible for up to six home visits to receive education and training around home environmental factors that trigger asthma, durable goods that can reduce or eliminate home triggers, and improved care coordination with providers through asthma action plans. The program similarly provides home visiting for eligible children who have been lead poisoned and is one of the first such programs in the country. The home visiting program is built on evidence-based models that emphasize remediation of environmental factors, including the provision of education and training for parents, and provision of durable cleaning supplies and other equipment to assist families in reducing environmental factors including dust mites, insect and pet allergens, and other common allergens.

For SFY 2022, Medicaid staff will be working on reimbursement for birth workers/doulas, Centering Pregnancy, Healthy Steps, and the Maternal Opioid Misuse Model as part of the Statewide Integrated Health Improvement Strategy.  Doulas acts as advocates during and after pregnancy, including labor and delivery. These services will help increase access to care and lead to fewer low birth weight babies, birth complications, and C-sections. Centering Pregnancy is a program that offers group prenatal care for low-risk pregnancies, including screenings for sexually transmitted infections and HIV. Healthy Steps promotes positive parenting and healthy development for babies and toddlers. The program aims to decrease postpartum depression and emergency department usage for care, as well as to increase child vaccination rates and well-child visits. The MOM model provides extra support for pregnant and postpartum individuals with opioid use disorder, including screenings for needs related to social determinants of health and maternal anxiety and depression.

Joint Policy Level Decision Making

The current IAA with Maryland Medicaid outlines agreements and guidelines on administration and policy, systems coordination, outreach and referral activities and data sharing.

Title V staff at the local health departments work with and coordinate with the Administration Care Coordination Unit (ACCU) to identify and enroll eligible pregnant people and children in the Medicaid program.  ACCU serves as the central link between the beneficiary, managed care organization (MCO), healthcare provider and the Department of Health.

Title V is partnering  with Medicaid to improve referrals through the Prenatal Risk Assessment and the Postpartum Infant Maternal Referral Form to the local health departments. These referral forms assist in identifying social, economic, and medical needs for birthing people.

In addition, Title V staff is working with Medicaid to achieve the goals for the Statewide Integrated Health Improvement Strategy (SIHIS). Specifically, Title V staff is collaborating with Medicaid and Environmental Health to expand asthma home visiting and maternal, infant, and early childhood home visiting.