Managed Care

Some states have implemented specifications within their managed care contracts or created specialty managed care plans for children and youth with special health care needs (CYSHCN). In most of these plans, special (risk adjusted) capitation rates are set, reflecting the higher costs associated with meeting the health care needs of CYSHCN.

The District of Columbia’s (DC) Health Services for Children with Special Needs Plan (HSCSN) is a Medicaid Managed Care Organization (MCO) for children who meet SSI-level or SSI-level-like criteria. The plan provides a higher level of care coordination and case management for the more complex children it serves. As of March 2017, about 5,000 children were enrolled with HSCSN. It is a not a full risk MCO. The Health Services for Children with Special Needs Plan receives a capitated amount for each beneficiary and DC Medicaid shares the financial risk with the plan. 

Kansas Medicaid covers orthodontia when it is necessary for treatment of cleft palate or other congenital conditions. To ensure children receive medically necessary orthodontic care, the Kansas Division of Health Care Finance (Medicaid) encourages the MCOs it contracts with to arrange single case agreements, or out-of-network payments if no orthodontists are in network, for orthodontic treatment for children with cleft palate needs. In addition, Medicaid asks the MCOs to identify a liaison within the MCO to work with the Division of Maternal and Child Health to synchronize cleft palate and orthodontic processes to ensure coordination between Title V and the MCO plans.

The Performance Goal Program in Rhode Island establishes a timeline for health screenings and care management services provided by its Medicaid MCOs to ensure they are meeting certain health care quality measures for children. This includes well visits, immunizations, and behavioral health follow-up appointments for treatment and medication management.

In an effort to more fully integrate care for Medicaid enrollees, MCOs in West Virginia now include behavioral health services, which were previously carved out.

 

Resources Related to Managed Care