Health Care Delivery and Title XIX Medicaid IAA

VDH & the Department of Health Access (Medicaid) have a strong working relationship. As part of the same Agency of Human Services (AHS), VDH & Medicaid work jointly on policy issues impacting women & children, have data sharing agreements, & systematically address funding for the MCH population. DVHA convenes a monthly Medicaid Exchange & Advisory Board (MEAB); MCH convenes the EPSDT subgroup of the MEAB, which consists of consumer advocates around the state. The group reports to Medicaid leaders about necessary policy change to improve outcomes.

Outreach & Informing

Title V is closely linked with EPSDT-funded initiatives & efforts to promote the administration of Medicaid & improve health for children & adolescents. Key program elements of EPSDT in VT are administered within MCH & coordinate closely under interagency agreements with DCF & the state Medicaid agency. MCH manages grants to the VT chapter of the AAP & the AFP to improve population-based health outcomes & access to preventive services for Medicaid-eligible children & youth, & their families. Often the work done through these grant efforts benefit all children & youth in VT. MCH’s annual grant to the VT Child Health Improvement Program (VCHIP) is designed to improve health outcomes for Medicaid-eligible children & youth & their families through population-based health services, research, & quality improvement. A monthly Primary Care & Public Health Integration meeting convenes the leadership of MCH, VCHIP, AAPVT, VT AAFP, Planned Parenthood, ObGyn, & internal medicine to tackle key public health issues for pregnant individuals, children, adolescents, & young adults.

In 2018 MCH was selected to participate in a National MCH Workforce Development Center TA opportunity. MCH (in partnership with Medicaid) proposed the creation of a multi-year EPSDT outreach & informing plan. This work is ongoing. Following this, MCH successfully applied to the CDC/Harvard T.H. Chan School of Public Health’s MCH Program Evaluation Practicum in Jan 2019 to create an evaluation plan on current EPSDT outreach & informing efforts to provide an improvement framework including gathering input from individuals & families enrolled in Medicaid. Interns through the Title V MCH Internship Program implemented portions of that the plan. Their work primarily included hosting focus groups with families & call center surveys with our Medicaid office to help inform our work. We plan to continue to use information from this work to guide efforts moving forward (temporarily on hold due to COVID). 

Health Care Financing/Waivers

VT has a long history of leadership in creating health care reform policy designed to reach the goal of universal health insurance coverage and increasing access to quality and affordable health care. Ongoing federal and state healthcare reform activities and changes continue to impact pediatric care, including CSHCN.

In 2004, VT developed the prevention-focused Blueprint for Health to help primary care practices manage patients with one or more chronic conditions. The Blueprint has added an extensive program of self-management for patients, Community Health Teams to support patients and providers and has been rolling out intensive practice redesign across the state to achieve 100% coverage of Advanced Patient-Centered Medical Homes.

In fall 2005, VT secured approval for Section 1115 Medicaid Waiver, the "Global Commitment waiver” (GC). The waiver imposes a cap on the amount of federal Medicaid funding available to VT for nearly all Medicaid expenditures. It also includes all Medicaid administrative expenses. In exchange for taking on the risk of operating under a capped funding arrangement, the waiver allows VT to use federal Medicaid funds to refinance a broad array of its own, non-Medicaid health programs, and a greater level of program flexibility. In 2017 the GC waiver was extended to December 31, 2021. In 2018 it was amended to authorize VT to receive federal financial participation for the continuum of services to treat SUD. Vermont’s 1115 Waiver is currently under review with CMS—Vermont anticipates some potential changes that may improve health outcomes for children and families including care coordination and the financing of the DULCE model. Additionally, Vermont is working in close partnership with Medicaid to submit an amendment to provide additional funding for sustained home visiting and adoption of Parents-as-Teachers, as a second evidence-based home visiting model in Vermont.

In 2011, the Legislature passed Act 48, creating Green Mountain Care, a publicly financed health care program designed to contain costs and to provide comprehensive, affordable, high-quality health care coverage for all VT residents. The act sets out 14 principles as a framework for reforming health care in VT and expands the list ongoing health care reform efforts. The act creates an independent, 5-member board to oversee nearly all aspects of health care in the state.

Vermont’s All-Payer Model is changing the way health care is delivered and paid for, with the goal of keeping the state’s health care spending in check and improving the quality-of-care Vermonters receive. It gives health care providers the flexibility to provide services like telehealth, group visits, and coordination with fellow providers that were previously not billable. And it holds insurers and providers jointly accountable for the quality and cost of care they provide to Vermonters. The Model pays for care based on value not volume, driving improved outcomes and enhancing the quality of care. It encourages increased communication and coordination between health care providers, especially those who are caring for the sickest or highest-risk patients. It helps ensure Vermonters are connected to the right care, at the right place, at the right time. And by shifting the focus to preventive care, the Model helps patients catch and treat small health problems before they turn into big issues.

The All-Payer Accountable Care Organization Model Agreement (sometimes referred to as the All-Payer Model, APM, the “Model”, or the “Agreement”) is a five-year (2018-2022) agreement between Vermont and the federal government that allows Medicare to join Medicaid and commercial insurers to pay for health care in a different way. VT’s primary ACO, OneCare, has demonstrated significant successes & achieved considerable savings, as shown in a recent impact analysis. OneCare has an established pediatric subcommittee with the former MCH Director as a member. This group is currently looking for the right methodology to stratify risk for pediatric populations that previously used disease burden. Child health providers are eager to have a child’s SDOH contribute to the assigning of risk for increased resource allocation & care coordination.