Reports:

A 50-State Analysis of Medicaid Benefit Coverage for Children without EPSDT.  Memorandum to the March of Dimes and National Association of Children's Hospitals, September 2005.

This memorandum provides an analysis of the Medicaid coverage that would be available to children in each state if the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit requirement was eliminated and states applied the coverage policies in effect for categorically needy adults. It examines 12 benefits of particular importance to children with chronic physical and developmental conditions, including physician services, inpatient hospital services, outpatient hospital services, prescription drugs, physical therapy, occupational therapy, speech therapy, home health services, private duty nursing, personal care services, durable medical equipment, and medical supplies.  Detailed state tables are included.  Information is based on state plans and state plan amendments, current as of April 2005.  Findings show that absent EPSDT, all children with chronic or disabling conditions, but especially those residing in Southern states, could face exclusions or restrictions in coverage for specialized therapeutic services.

Download a free pdf of this report.

States' Use of Medicaid Options for Expanding Children's Eligibility

by Harriette B. Fox and Stephanie J. Limb, Fact Sheet No. 6, 11 pages, May 2005.

This fact sheet reports on states' options for expanding Medicaid eligibility to children who do not quality for mandatory coverage.   It examines 13 major options provided to states for expanding children's Medicaid eligibility and presents current information on states' use of these options, including SCHIP coverage, 1115 research and demonstration waivers, home- and community-based waivers, and coverage of legal immigrants, the medically needy, and older adolescents, and is based on information from the Centers for Medicare and Medicaid Services, reports from private organizations, state plan documents, and telephone and e-mail interviews with state Medicaid agency staff.   It shows that all states use at least one of the major options, and most use at least 7, with the most common being coverage of children in state-subsidized adoptions and children in home- and community-based waiver programs.

Download a free pdf of this report.

An Analysis of States' Capitation Methods and Pediatric Rates, 1997-2003

by Harriette B. Fox, Stephanie Limb, Margaret A. McManus, and Ruti G. Levtov.  Issue Brief No.6, February 2005.

This issue brief provides an analysis of the methods states used to set their pediatric capitation rates and the amounts they paid to managed care organizations for TANF-related and SSI-related children at the end of 2003 as well as the extent to which these methods and amounts changed over the 6-year period from 1997 to 2003.  This brief looks at states' rate setting processes and risk adjustment methods.  It also examines state variation in TANF and SSI rates and rate differences based on service carve-out policies.  Increases in average payment accounts are compared to changes in both the Medicaid Care Consumer Price Index and children's total per capita national health care expenditures. The report includes detailed state tables on capitation methods and rates for children. Information was obtained through interviews with state Medicaid officials and an examination of state managed care contracts.

Download a free pdf of this report

Children Not the Target of Major Medicaid Cuts but Still Affected by States' Fiscal Decisions.

by Harriette B. Fox, Stephanie J. Limb, Ruti G. Levtov, and Margaret A. McManus, Fact Sheet No. 5, 8 pages, June 2004.

This fact sheet reports on Medicaid program affecting children in  states '  fiscal years 2003 and 2004.   It examines policy changes in eligibility, managed care enrollment, benefits, cost sharing, authorization, fee-for-service  provider payments, and home- and community-based waivers and is based on extensive interviews with Medicaid staff and analyses of state plan amendments, managed care contracts, and provider bulletins.   It shows that a few states have made reductions in children's income or categorical eligibility, a few have pursued new cost-sharing requirements for children, and a handful have tightened their home- and community-based waivers serving children with disabilities. States have been more likely to lower or freeze pediatric provider payments and to impose greater controls on service authorization.

Download a free pdf of this report.

An Analysis of Safeguards for Children with Special Needs in States´ Medicaid Managed Care Contracts, 1999
by Harriette B. Fox, Margaret A. McManus, and Jonathan S. Austrian. Issue Brief No. 4, 24 pages, December 2000, $30.00.

This issue brief provides an analysis of the extent to which the 34 states that mandatorily enrolled BBA special-needs child groups into managed care organizations at the end of 1999 used contract requirements consistent with HCFA´s interim review criteria. The brief includes background on the 34 states´ mandatory enrollment policies for each of the five BBA groups as well as an examination of their definitions for and methods of identifying these children; contract requirements concerning treatment plans, case management, and coordination; contract requirements concerning provider network capacity and access; and state policies governing quality assurance and payment protections. The analysis was based on telephone interviews with state Medicaid officials and an examination of state managed care contract documents.

An Analysis of States´ Medicaid Managed Care Enrollment Policies Affecting Children, 1996-1999
by Harriette B. Fox, Jonathan S. Austrian, Wesley Hsu, and Stephanie J. Limb. Issue Brief No. 3, 19 pages, October 2000 $25.00.

This issue brief provides an analysis of states´ policies concerning the mandatory and voluntary enrollment of children into managed care entities at the end of 1999 and how these enrollment policies have changed over the four-year period between 1996 and 1999. It addresses both primary care case management systems (PCCMs) and managed care organizations (MCOs) and also describes the approach taken by states that have elected to use the option to mandatorily enroll most Medicaid-eligible children into managed care without a federally approved waiver. Included in the report are detailed tables on the populations of children enrolled into PCCMs and MCOs, the type of enrollment requirement, and the geographic scope of enrollment for each state. Information for this issue brief was obtained through an analysis of state managed care contracts and telephone interviews with state Medicaid officials.

An Analysis of States´ Medicaid Managed Care Plan Arrangements and Service Requirements Affecting Children 1995-1999
by Harriette B. Fox, Stephanie J. Limb, Christine Y. Chen, and Margaret S. Hayden. Issue Brief No. 2, 24 pages, April 2000, $35.00.

This issue brief provides an analysis of plan arrangements and coverage requirements in effect at the end of 1999 and the extent to which these requirements changed in the five-year period from 1995 to 1999. It looks at both general and specialized plan arrangements and also at the scope of capitated services and contractual requirements governing the EPSDT benefit. The report includes detailed state tables on the ownership and membership of participating plans, carve-out policies, and EPSDT contract language. Information was based on telephone interviews with state Medicaid officials and analysis of state managed care contracts.

An Analysis of Medical Necessity Standards in States´ Medicaid Managed Care Contracts, 1995-1999
by Harriette B. Fox, Margaret A. McManus, and Margaret S. Hayden. Issue Brief No. 1, 10 pages, January 2000, $25.00.

This issue brief provides an analysis of current state medical necessity standards affecting children and the extent to which these standards have changed in the five-year period from 1995 to 1999. The analysis addresses medical necessity criteria pertaining to the scope of health problems covered, evidence-of-effectiveness requirements, and cost requirements. Detailed state tables on each of these criteria are included. Information for the brief was obtained through an analysis of state managed care contracts.

A Summary of Interviews with State Medicaid Managed Care Directors Regarding Developmental Support Services for Families with Young Children
by Harriette B. Fox, Dominique G. Kim, and Margaret A. McManus. Report, 19 pages, January 1999, $20.00.

This report describes state Medicaid financing outside of capitated arrangements for developmental support services to young children enrolled in Medicaid managed care organizations. The analysis addresses the nature and extent of carve-out policies for six types of developmental support services: comprehensive risk assessments, telephone advice lines, parent education, parent counseling, home visiting, and case management. It includes information on service providers, billing categories, and the extent of coordination with managed care organizations. The analysis was based on telephone interviews conducted in the fall of 1998 with Medicaid managed care staff.

State Medicaid Managed Care Contract Provisions Regarding Developmental Support Services for Families with Young Children
by Harriette B. Fox, Margaret A. McManus, and Dominique G. Kim. Report, 20 pages, December 1998, $20.00.

This report presents a summary of Medicaid managed care contract provisions related to developmental support services for young children and their families based on an analysis of state managed care contracts in effect in April 1998. The analysis focuses on six types of developmental support services: comprehensive risk assessments, telephone advice lines, parent education, parent counseling, home visiting, and case management. It includes a description of the five states with the most expansive set of contractual requirements.

Current Policies and Future Directions in State Medicaid Managed Care Arrangements for Children
by Harriette B. Fox, Margaret A. McManus, and Ruth A. Almeida. Report, 93 pages, March 1997, $40.00.

This report presents information on states´ 1996 Medicaid managed care policies affecting children and on the ways in which these policies are expected to change in the future. The report describes states´ use of primary care case management and fully capitated arrangements to serve children. With respect to fully capitated plans, the report also examines the types of plans states use, the scope of capitated services, guidance given to plans about coverage, methods used for setting pediatric capitation rates, and monthly premium amounts paid for children. Information for the report was obtained through telephone interviews with state Medicaid agency staff and through an analysis of state managed care contracts.

The Effect of Managed Care on Medicaid Financing for Public Programs Serving Children with Special Needs
by Harriette B. Fox, Margaret A. McManus, Ruth A. Almeida, and Cara Lesser. Report, 21 pages, October 1996, $20.00.

This briefing report, prepared for the National Health Policy Forum, assesses the effects that Medicaid managed care has had on five major public programs serving children with special health needs: the Title V Program for Children with Special Health Care Needs, the Special Education Program, the Early Intervention Program, the Children´s Mental Health Services Program, and the Title IV-E Child Welfare Services for children in foster care. Information for the report was obtained through a literature review, a telephone survey of state Medicaid agency staff, and a review of state managed care contracts.

Medicaid Managed Care for Children with Chronic or Disabling Conditions: Improved Strategies for States and Plans
by Harriette B. Fox and Margaret A. McManus. Report, 67 pages, July 1996, $40.00.

This report presents findings and recommendations from an extensive study of Medicaid managed care arrangements for children with developmental, emotional, behavioral, or complex physical conditions. The report describes the range of chronic conditions and disabilities among children, provides a snapshot of Medicaid managed care policies and plan practices affecting children, and presents a discussion of alternative structural arrangements that states might use in serving these children through managed care. It also identifies essential components of state managed care contracting policies and plan practices. Information for the report was obtained through an extensive literature review and interviews with plans, state Medicaid agency staff, pediatric providers, and families. Expert advice was also obtained through an advisory group and key informant interviews.

Impacts of State Medicaid Demonstration Waiver Programs on Children: Results From Hawaii, Oregon, Rhode Island, and Tennessee
by Harriette B. Fox and Margaret A. McManus, Report, 100 pages, March 1996, $40.00.

This report presents findings from an examination of four state Section 1115 Medicaid demonstration waiver programs to assess their impacts on children. The report addresses each program´s impact on uninsurance among children, the extent to which the enrollment process facilitated appropriate plan placement, the adequacy of plans´ pediatric provider networks and coordination mechanisms, the appropriateness of service coverage and authorization policies, the sensitivity of quality assurance measures for children, and the impact on publicly funded programs that traditionally serve children with special health needs. Information for the report was obtained primarily through on-site interviews with key officials, providers, families, and plan medical directors in the four states.

Using Medicaid to Finance Care Coordination Services for Children and Adolescents with Severe Emotional Disorders
by Harriette B. Fox and Lori B. Wicks, Technical Report, 80 pages, 1991, $25.00.

This report identifies the ways in which Medicaid can be used to finance care coordination services furnished to children and adolescents with severe emotional disorders. It presents information about basic Medicaid program requirements that pertain to coverage of care coordination services, describes six options for Medicaid financing of various care coordination activities, and assesses the pros and cons of each option with regard to youth having severe emotional disorders. The report also describes five model care coordination systems and indicates the extent to which Medicaid could be used to finance each one.

Medicaid Financing for Mental Health and Substance Abuse Treatment Services for Children and Adolescents
by Harriette B. Fox, Lori B. Wicks, Margaret A. McManus, and Rebecca W. Kelly, Technical Report, 69 pages, May 1990, $25.00.

This report provides an assessment of the ways in which the Medicaid program can be used to finance many components of treatment for children and adolescents with mental health or substance abuse problems. The report provides an overview of the state role in developing Medicaid eligibility and service benefit policies, provides detailed information on Medicaid coverage policies in each state, and discusses opportunities for covering mental health and substance abuse treatment services under the various Medicaid benefit categories.

The Role of Medicaid and EPSDT in Financing Early Intervention and Preschool Special Education Services
by Harriette B. Fox and Lori Neiswander Wicks, Technical Report, 147 pages, April 1990, $30.00.

This report provides an assessment of the ways in which the Medicaid program, and Medicaid´s EPSDT benefit in particular, can be used to finance many components of states´ early intervention and preschool special education programs. The report includes a discussion of important implementation issues that states need to address in developing a strategy for maximizing Medicaid financing of health-related services.

Articles:

A National Study of Commercial Health Insurance and Medicaid Definitions of Medical Necessity: What Do They Mean for Children?
by Harriette B. Fox and Margaret A. McManus. Ambulatory Pediatrics. Vol. 1, No.1, pp.16-22, January 2001.

This article analyzes the medical necessity criteria used by each state´s HMO and PPO enrolling the largest number of commercially insured individuals and by each state´s Medicaid agency that contracts with managed care organizations to serve Medicaid participants. Definitions were analyzed according to the scope of health problems covered, evidence of effectiveness required, and cost restrictions imposed. Information was obtained through analysis of commercial health insurance and Medicaid contract documents.

How Far Have State Medicaid Agencies Advanced in Performance Measures for Children?
by Margaret A. McManus, Regina R. Graham, Harriette B. Fox, CM Mercil, and Charles E. Irwin. Archives of Pediatric and Adolescent Medicine. Vol. 154, No. 7, pp. 665-71, July 2000.

This article presents 1998 findings on the use of pediatric performance measures by state Medicaid agencies. The measures examined were effectiveness, utilization, and access measures. Information was obtained through telephone surveys of state Medicaid officials responsible for managed care quality oversight.

An Examination of State Medicaid Financing Arrangements for Early Childhood Development Services
by Harriette B. Fox, Margaret A. McManus, and Stephanie J. Limb. Maternal and Child Health Journal. Vol. 4, No. 1, pp. 19-27, March 2000.

This article examines the extent to which state Medicaid agencies finance early childhood development services either through their capitated contracts or on a fee-for-service basis. It also looks at states´ interest in funding these services in the future. The services examined were parent counseling, home visiting, comprehensive assessments, telephone advice lines, parent education classes, and case management. Information was obtained through telephone surveys with state Medicaid managed care directors and through an analysis of Medicaid managed care contracts.

Managed Care´s Impact on Medicaid Financing for Early Intervention Services
by Harriette B. Fox, Margaret A. McManus, and Ruth A. Almeida. Health Care Financing Review. Vol. 20, No. 1, pp. 59-72, Fall 1998.

The article presents an analysis of Medicaid financing for seven types of early intervention services in 39 states before and after the introduction of managed care. It includes an assessment of the association between the level of Medicaid financing for these services and program characteristics, provider arrangements, managed care carve-out policies, and managed care contract requirements. Information was obtained through telephone surveys with state early intervention and Medicaid program staff and through an analysis of Medicaid managed care contracts.

Improving State Medicaid Contracts and Plan Practices for Children with Special Needs
by Harriette B. Fox and Margaret A. McManus. The Future of Children. Vol.8, No.2, pp.105-118, Summer/Fall 1998.

This report provides a set of recommendations for structuring plan service and delivery requirements so that children with special health care needs are adequately addressed. These pertain to pediatric benefits, provider capacity, medical necessity criteria, quality of care measures, capitation rates, and incentives for quality improvement. Also included in the article is a discussion of the actions that plans should take in providing care to children with special needs. Among these are special primary and specialty care arrangements, flexible service authorization policies, and adapted profiling systems.

Medicaid Managed Care Policies Affecting Children with Disabilities: 1995 and 1996
by Harriette B. Fox, Margaret A. McManus, Ruth A. Almeida, and Cara Lesser. Health Care Financing Review. Vol. 18, pp. 23-36, Summer 1997.

This article presents findings from a study of state Medicaid managed care enrollment and benefit policies in 1995 and 1996 for children with disabilities. The results include trends with respect to categorical groups enrolled on a voluntary or mandatory basis, pediatric services excluded from contracts, and state guidance on EPSDT and medical necessity decisions.

Three Options for Providing Health Coverage to Children
by Paul Newacheck, Margaret A. McManus, and Harriette B. Fox. Providing Universal Health Insurance Coverage To Children: Four Perspectives. Princeton, NJ: The Robert Wood Johnson Foundation, 1996.

This report examines three policy options for expanding health insurance to all children. The first option is a state-run premium subsidy program for the uninsured. The second option is a Medicaid buy-in program for the uninsured and a new public wraparound health insurance plan for specialized services. The third option is a state and community formula grant program offering communities direct control over their children´s health care.

The Effect on Children of Curtailing Medicaid Spending
by Paul Newacheck, Dana Hughes, Abigail English, Harriette Fox, Neal Halfon, and James Perrin. Journal of the American Medical Association. Vol. 274, No. 18, pp. 1468-1471, 1995.

This commentary documents the importance of Medicaid as a safety net for all children and as a financial link to health care for poor children. The costs and effects of the program are discussed and recommendations are made concerning programmatic changes in Medicaid.

State Implementation of OBRA ´89 EPSDT Amendments withinMedicaid Managed Care Arrangements
by Harriette B. Fox and Lori B. Wicks. Child Health Supervision: Analytical Studies on the Financing, Delivery, and Cost-Effectiveness of Preventive and Health Care Services for Infants, Children, and Adolescents. Washington, DC: George Washington University, Center for Health Policy Research, 1995.

This book chapter presents findings from a national survey of state Medicaid agencies on state policies regarding implementation of OBRA ´89 EPSDT amendments within managed care arrangements. Information was elicited regarding state policies on EPSDT screening schedules and protocols, state efforts to inform providers and recipients of EPSDT changes, state coverage policies and financial arrangements related to the expanded service coverage mandate, and state EPSDT reporting requirements and monitoring efforts.