Medicaid Home Health Benefit Supports Children with Complex Medical Conditions
CMS anticipates that the new benefit will help these children receive the care they need
THE VBP Blog
September 13, 2022 – Children with complex medical conditions are finally going to receive the care they need and deserve. Section 1945A of the Social Security Act, enacted as part of the Medicaid Services Investment and Accountability Act of 2019, authorizes states to cover an optional health home state plan benefit for
Medicaid-eligible children with medically complex conditions.
Section 1945A goes into effect October 1, 2022. To incentivize participation, states can adopt this optional Medicaid benefit and will receive a 15 percent increase in the federal Medicaid eligibility rate (up to a maximum of 90%) during the first six months that the benefit is in effect.
In this blog, we will look at the optional health home state plan, the whole-person care it strives to provide, and how it can transformational for children with complex medical conditions and their families.
1945A Provides Health Home Benefit to Assist Families with Children Who Have Complex Health Conditions
Managing care for a child with complex medical conditions can be extremely tough for families. The care they need and deserve is extremely expensive and can put a financial hardship on even financially advanced individuals. Imagine being a parent deciding between paying for your child’s healthcare or paying rent that month. Or having to choose between purchasing more expensive healthy food for your other children, or paying medical bills for a child with complex medical needs. This financial hardship and the stress that comes with these decisions is a burden that families shouldn’t have to bear.
As we’ve noted in our earlier blog on OhioRISE, health care is also often difficult to find, especially in rural or lower-income areas. That’s not to mention the struggle that parents face trying to coordinate services and address non-medical needs that affect health like community and social support services.
That is what section 1945A aims to address. Those eligible are Medicaid-eligible children under age 21 with “medically complex conditions” as defined in the Eligibility Criteria. Beneficiaries that have one or more serious chronic diseases and/or a life-limiting illness or rare pediatric disease can receive services. Examples of chronic conditions included in section 1945A are cerebral palsy, spina bifida, blood diseases like anemia or sickle cell, epilepsy, or a serious mental health illness, among others.
Eligible participants can receive high-quality health home services that align with the whole-person care philosophy. That means states must provide services that according to a recent State Medicaid Director Letter, “considers all the medical, behavioral, and social supports and services needed by a child with medically complex conditions.”
Services provided through section 1945A include:
- Comprehensive care management;
- Care coordination, health promotion, and the provision of access to the full range of
- pediatric specialty and subspecialty medical services, including services from out-of-state
- providers, as medically necessary;
- Comprehensive transitional care, including appropriate follow-up, from inpatient to other
- Patient and family support (including authorized representatives);
- Referrals to community and social support services, if relevant; and
- Use of health information technology to link services, as feasible and appropriate
Similar to the OhioRISE concept that we wrote about in an earlier blog and the direction that CalAIM is taking by addressing social determinants of health, services are not just limited to medical care. This is important because family support might not seem like a service that directly correlates to a better health outcome, but consider that parents are often the ones providing care and support day in and day out. Without proper support, they face caregiver burnout, which can negatively affect the care received and the health outcome of the child. Parents often juggle care for other children in the home and work and without support, they can struggle to make ends meet.
Care coordination and referrals to community and social services are also included to ensure that all the medical and non-medical needs of the child are met. It is often not enough to address just the medical needs of children. Wrap-around care with non-medical services and supports are essential to improve health outcomes and keep children in the community where they belong.
Transitional care is also essential in cases of children with complex medical conditions. These children deserve to receive care where they want and to experience childhood as best as possible. If appropriate, receiving health care services at home can improve health outcomes and allows them to remain active members of the community.
New Provision Receiving Strong Support
The provision received strong support from the families of children that have complex medical needs as it ensures that they can receive the care they need while also keeping them at home.
Both CMS Administrator Chiquita Brooks-LaSure and Health and Human Services Secretary Xavier Becerra are unsurprisingly very supportive of the initiative.
“This new state plan option is about ensuring that children and families can get coordinated, high-quality care — particularly children with complex medical conditions,” said Brooks-LaSure.
Secretary Becerra added, “Every child deserves the care and support they need to stay healthy and thrive. This…will give states new options and financial incentive to improve care for children with complex medical conditions.”
CMS Ensuring Stakeholders are Heard
One promising thing about the opportunity is that CMS has been actively working with stakeholders for almost two years. While rolling out these services to children and families in need is important, it is also essential that it is done properly. Through a Request for Information in 2020, CMS obtained feedback from not just states interested in participating, but also familiars and advocates.
This is important because it means that the voices of the consumers and those utilizing services were heard. When designing programs and benefits such as these, it is crucial that they actually address the needs of the population they are geared towards. That is what will truly promote health equity and allow children with complex medical needs across the country to obtain the services that they need.
It is also promising to see the requirements around states that wish to participate. Any states interested in establishing a Medicaid health home program for children with medically complex conditions will need to submit a state plan amendment (SPA) to CMS for review and approval. This is good to see as it shows that CMS is ensuring that programs and benefits meet a certain standard.
There are several positive things about section 1945A. The first is the aspect of whole-person care for a underserved demographic. Medical needs are not the only thing being considered. From home and community-based services to family support and care coordination, the provision is designed to ensure that children do not slip through the cracks and get the care they deserve. There is also the angle of health equity by allowing beneficiaries to receive care across state lines. Often the specialized care these complex conditions require is difficult to find and now families aren’t limited by geographical boundaries. What is also nice to see is that eligible beneficiaries are given choices. They can elect to participate and can choose any available and qualified health home provider. The downside of the provision is that it is optional for states to participate. Though there are financial incentives for states to offer the health home benefits, we would like to see more states get involved to ensure that whole-person care is eligible for all, even children with complex medical conditions.
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About the Author
Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).
His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.
About the Co-Author
Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.