In 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.

MCH is an appointed representative on the Medicaid Medical Care Advisory Committee (MCAC), whose responsibility is to advise on policy, rules, waivers and other operational issues. Currently, the Long Term Supports & Services (DLTSS) Director attends MCAC meetings. However, due to staff turnover, BFCS has not had a representative to MCAC since late 2019. The CSHCN Director is working with Division Leadership to appoint the Clinical Program Manager. There are three Medicaid Care Management organizations (MCOs) in the State: NH Healthy Families, Well Sense and AmeriHealth Caritas.

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 severe maternal morbidity.

MCH staff also closely work with the Medicaid Quality Program (MQP), particularly in the last year determining the Medicaid Care Management Quality Improvement Priorities. All are HEDIS measures and seven of the eleven specifically focus on women and children and are of concern to MCH, including prenatal and postpartum care, immunizations for adolescents in combination with and without HPV, and weight assessment and follow-up counseling for children and adolescents. Each priority has a goal to be achieved by the end of December 2023 and represent the benchmark of the 75th percentile of national Medicaid health plans.

These will become the focus of MCO performance improvement projects of which MCH staff will participate as subject matter experts.

There are also eight lever measures (some the same, some different from the priority measures) and half are focused on women and children, including the HEDIS measure on adolescent well visits. The lever programs include withholding (of a specific percentage of funds until a measure is met) and incentives (the amount that is not recouped from withholding goes to those MCOs who do meet the measures). MCOs will be required to reach specific thresholds for the measure or risk losing a percentage of their capitation payments. High performing MCOs have the potential to receive incentives. MCH staff again will be utilized as subject matter experts.

In addition, MCH is working with the MQP on its 2023 Annual Forum, which will focus on prenatal and postpartum care.

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 for sustaining or even increasing capacity for any type of staff helping with client insurance needs. Dependent upon the CHC, approximately 1-29% of the clients coming in for the first time are uninsured.[1]

This is particularly important at this time as redeterminations are being made, post public health emergency (PHE) policies. Title V funded agencies are utilizing their insurance navigators to reach out to parents and caregivers of children receiving Medicaid coverage. Since many of these adults are on expanded Medicaid (Granite Advantage), the hope is that by talking to them about their children’s coverage, they will take action on their own coverage if necessary as well. For CSHCN who are especially vulnerable, BFCS’ health care and family support coordinators provide outreach to ensure redeterminations are completed regardless of the exemptions during the PHE. As part of the enrollment process, the Medicaid redetermination date is provided to the coordinator who works with families to complete applications on time. This has become especially important during the COVID unwinding as BFCS staff work to prevent families from being dropped. Working collaboratively with the three MCO’s or the Medicaid HIPP program, assures clients and families receive all the benefits for which they are entitled.

In addition, BFCS provides outreach to applicants for Home Care for Children with Severe Disabilities (HC-CSD aka Katie Beckett) and Social Security Disability (SSI) through a partnership with the Medicaid office.

MCH meets quarterly with Medicaid clinical and policy colleagues to discuss updates on efforts such as the unbundling of long acting reversible contraceptives after delivery, which took place almost three years ago.

MCH and BFCS staff started work almost three years ago with these same colleagues to revise the now expired Home Visiting Administrative rule He‑W‑549, which focused payment on young, first time mothers with children under one. A DHHS team was selected and has been working for two years in conjunction with the National Academy for State Health Policy, State Policy Institute on Public Insurance Financing of Home Visiting Services, which enable a facilitated space to learn of strategies, advantages and barriers that different states had faced in pursuing various paths to utilize public financing of home visiting. This was extremely valuable as the project to change the rule progressed and finalized.

In October 2021, HFA agencies were included in an updated rule and allowed to start billing Medicaid for home visiting, with restrictions capping the number of visits to three per year removed for prenatal families along with those with children under one. Restrictions previously limiting reimbursable visits to first time mothers under age 21 were also removed.

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 years of age who are not otherwise eligible and who have an income at or below 133% of the FPL. Individuals must 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 and treatment for sexually transmitted infections when performed routinely as part of an initial, regular, or follow-up family planning visit, as well as sterilization. As of March 31, 2022, 630 individuals had utilized this SPA in the past year.

Sterilization is extremely difficult to get covered by Medicaid and Title V staff have heard directly from clients about the challenges in getting this service covered. Medicaid requires it to be medically necessary and not an elective, voluntary method like other contraceptive methods. No Title V funded (or Title X) offer these services, so there are few programs in the State that can help cover the costs.

The strength of the relationship between NH Medicaid and BFCS is exemplified in a recent request from the Medicaid Director. Upon his announcement that the long-time Medicaid Fee for Service Administrator, Jane Hybsch, would retire, he requested that BFCS participate in the interim plan for coverage and transition. The Clinical Program Manager and a senior nurse health care coordinator have been trained as back-up staff to provide prior authorizations. In addition, they will conduct clinical review of policies submitted by the MCOs, when Medicaid approval is required. With this retirement, the Department will lose a significant amount of institutional knowledge and BFCS is committed to supporting the transition to ensure continuity of Ms. Hybsch’s long-time dedication as a champion for CSHCN and their families.

As a member of the Leadership team for DLTSS, the CSHCN Director participates in development and renewals of Medicaid Home and Community-Based Services waivers; particularly the In Home Supports Waiver for Children with Developmental Disabilities. The purpose of this 1915(c) waiver is to provide in-home residential habilitation, inclusive of personal care, and other related supports and services to promote greater independence and skill development for a child or youth who has a developmental disability and has significant medical or behavioral challenges. This is determined in accordance with state rules; allows eligible CSHCN to remain living at home with their family, and be actively engaged with their community. Health care coordinators frequently provide families with information about the Waiver and promote the benefits available to support families with CSHCN.

[1] UDS Tables (2020).