Specialty Managed Care Plans
Some states have implemented specialized programs within their managed care contracts or created specialty managed care plans for CYSHCN. In most of these plans, special capitation rates are set, reflecting the higher costs involved in meeting the needs of CYSHCN.
In Florida, the Title V program operates a Medicaid and CHIP managed care program for CYSHCN, known as the Children’s Medical Services Network (CMS). The eligibility requirements for participation are based on a standard screening instrument that measures the functional capacity of a child. For both the Medicaid and CHIP populations, the program offers all Medicaid state plan services, including behavioral health care and care coordination. In addition, it covers certain services not offered through Medicaid, including parent support, therapeutic camps, early intervention, genetic and nutritional counseling, and pediatric palliative care services. Most of these services, excluding palliative care, are financed by the state General Revenue Fund. The Medicaid-eligible CYSHCN are enrolled in a primary care case management (PCCM) program; however, the CYSHCN in CHIP are enrolled in the Children’s Medical Services Network, which may elect to use either capitation or a PCCM model.
Arizona’s Medicaid managed care system includes several specialty programs for CYSHCN. These include a capitated plan for children with developmental disabilities, which is operated by the Division of Developmental Disability, and a Prepaid Inpatient Health Plan operated by Children’s Rehabilitative Services and based in multi-specialty clinics.
New Jersey Medicaid also operates an integrated medical and behavioral health managed care program for children with developmental disabilities through a program that is run by developmental disability specialists.
The District of Columbia operates a specialty managed care plan called Health Services for Children with Special Needs (HSCSN) for children who receive Medicaid and SSI benefits. Medically complex foster children and children with CHIP coverage may also enroll in the plan. HSCSN has no carved-out services; physical health, behavioral health, care coordination, residential treatment, and wrap-around services are all included in the managed care benefit package. The plan is capitated, but shares risk with the District of Columbia. A voluntary program, it currently enrolls more than 3,300 children in the District.
In Texas, a managed care health care program called STAR Health is designed to improve services, establish medical homes, and better coordinate care for children in foster care. Features of the new program include Health Passports and expedited enrollment.
Wisconsin’s Children Come First program is a managed care model in three counties for children with serious emotional disturbance. In addition to those services traditionally funded by Medicaid, Children Come First provides clinical case management, crisis services, intensive day treatment, and school-based mental health services. The program receives a capitation payment for mental health and drug treatment services, but physical health services are provided on a fee-for-service basis.
Massachusetts also operates a specialty managed care program for CYSHCN, which is described in the section on integrated delivery models for CYSHCN with specific diagnoses.
