Medicaid Health Home Benefit Covers Children with Complex Conditions

CMS has issued guidance for state Medicaid programs about how to use the Medicaid health home benefit to support children with complex medical conditions.

“This new state plan option is about ensuring that children and families can get coordinated, high-quality care—particularly children with complex medical conditions. CMS is committed to working with states interested in pursuing this option to ensure they can quickly and efficiently get kids the care they need,” CMS Administrator Chiquita Brooks-LaSure said in the press release.

Under section 1945A of the Social Security Act, states can cover health home state plan benefits for Medicaid-eligible children with complex conditions starting October 1, 2022. The total amount of federal funding set aside for the health home benefit is $5,000,000.

A medically complex condition is one or more chronic conditions related to three or more organ systems. The condition impairs cognitive or physical functions and demands treatments including but not limited to medication, therapy, or surgery. Rare pediatric conditions and life-limiting illnesses also fall under the umbrella of complex conditions.

Health home services that Medicaid programs can cover include comprehensive care management, care coordination, transitional care, referrals, technology services, and more. Medicaid programs can also cover care for out-of-state providers.

These services are considered medical assistance, which means that states can get matched federal funding. Moreover, states can receive higher federal matching during the first two fiscal quarters that the states implement the benefit.

States are allowed some flexibility in their payment methodologies for the benefit. For example, they have the option to use a tiered payment methodology based on the condition’s severity or the provider’s capacities. States can also introduce alternative payment models that are not pay-for-performance.

The proposal for the benefit must outline rate-setting policies. States can cover a designated provider, a team of health care professionals including translators and community health workers, and interdisciplinary health teams. 

Providers must be dedicated to whole-person, patient-centered care. They must demonstrate promptness, personalization, culturally and linguistically sensitive care, care coordination, and proper information collection.

CMS outlined certain provider reporting and state monitoring and reporting guidelines.

“Every child deserves the care and support they need to stay healthy and thrive. This new Medicaid health home benefit will give states new options and financial incentive to improve care for children with complex medical conditions. At HHS, we are committed to providing families with access to appropriate pediatric specialty and subspecialty medical services, including when those services are needed across state lines,” Health and Human Services Secretary Xavier Becerra added.

Private payers have also taken steps to try to improve care for children with special needs and complex conditions. 

UnitedHealth Group has an initiative called the Special Needs Initiative that supports over 110,000 families in the US with children who have special medical needs. The initiative combines healthcare coverage, payer-provider partnership, social determinants of health efforts, and timely diagnostic processes to improve care and access to care for this population.

Additionally, Centene Corporation acquired Magellan Health to help address population health management needs for patients with complex behavioral and physical care plans.

While addressing complex clinical needs, states have also been trying to provide support for complex mental health and behavioral healthcare needs among children and adolescents.