InCK and MOM Support Improved Care Delivery for Children

Manatt on Health: Medicaid Edition

On February 8, 2019, the Center for Medicare and Medicaid Innovation (CMMI) at the Centers for Medicare and Medicaid Services (CMS) released the funding announcements for the Integrated Care for Kids Model (InCK Model) and the Maternal Opioid Misuse Model (MOM Model). The new models are an important indication that CMMI is increasingly interested in children, a shift from its emphasis to date on high-cost adults and Medicare beneficiaries. The models focus on coordinating and integrating care, both across physical and behavioral health and outside of the healthcare system, in conjunction with other social support needs such as housing, food, transportation and education.

The InCK Model

The InCK Model offers up to eight state Medicaid agencies and lead organizations funding of approximately $14.5 million to $16 million per state over a seven-year period to test whether alternative payment models aimed at supporting stronger integration of care for children across the domains of physical health, behavioral health, and social and educational services can improve children’s outcomes and reduce expenditures.1 The model aims to improve care for children with significant behavioral health challenges—including due to the opioid epidemic and its impact on their lives or those of their caretakers—potentially keeping them out of hospitals, residential treatment centers and foster care homes.

InCK establishes a well-defined package of activities with clear requirements and parameters. The high level of prescriptiveness for the InCK Model reduces the flexibility of states to design their models—which should make it easier for CMMI to evaluate the initiative, but could also result in reducing the number of applications that CMMI receives.

Parameters and requirements of the InCK Model include:

  • Community and family engagement. State Medicaid agencies and local partners are expected to work together to facilitate coordination of care for children across health, educational and social service settings. Moreover, the state and local partners must establish a “Partnership Council” that includes representatives from physical health systems; behavioral health agencies; schools; child welfare agencies; food, housing and other social service agencies; families; and others to support the initiative. The Council is charged with helping to design and implement the model.
  • Assessment and risk stratification. States and their local partners must agree to deploy a standardized screening tool to be used by providers to assess children’s needs and to assign them to a risk level. CMMI already has defined three levels of stratification—Level 1 for children with mild or no issues who should be monitored; Level 2 for children with more significant needs that cross domains (e.g., a physical health issue and a housing need) with implications for their functioning; and Level 3 for children who already are in or at risk for out-of-home placement.
  • Service integration, team-based care and a crisis response strategy. To help families navigate the many systems that touch children’s lives, states and their local partners are expected to provide moderate-risk children (i.e., Level 2) with a single point of coordination (anticipated to be achieved by expanding the role of existing care coordinators or case managers) for all of the services they might require. These services include non-medical services such as housing, food and educational assistance. Kids who are already in or on the brink of out-of-home placement (Level 3) are expected to receive intensive team-based care that serves the same function, but is even more robust and includes family members, educational contacts, social service representatives and others. Along with coordination of care, states and their local partners must provide access to a 24/7/365 mobile response system and crisis hotline.
  • Social, emotional and behavioral health of children. The model requires states and their local partners to directly consider social, emotional and behavioral health when evaluating and serving children. Complex medical needs alone are not enough to warrant participation in the model. Indeed, states and their local partners must screen for socioeconomic challenges such as food insecurity and housing instability. A child’s ability to function in school and to engage in social relationships—not just medical factors—are included in the criteria used to assign children to a risk stratification level.
  • Alternative payment model (APM). States participating in the InCK Model are expected to develop an alternative payment model that supports the integration of health, social service and educational needs for children. CMMI notes that the APM(s) might be based on episode-based, shared savings, or population-based payment arrangements that include meaningful quality measures. Unlike with some other aspects of the InCK Model, CMMI appears to give states and their local partners significant discretion to design the details of the APM.
  • Evaluation. Applicants must gather and share data needed for evaluation. CMMI already has identified measures that will be used to evaluate the model’s impact on clinical care, care coordination, education (including kindergarten readiness), food insecurity and housing instability. Notably, CMMI also is linking about a third of each successful applicant’s funding—approximately $500,000 out of $1.5 million for Year 5—to performance beginning in the fifth year of the model.

CMMI offers a detailed description of what it is looking for in the InCK application, but several knotty issues still remain for applicants: whether they will be able to meet CMMI’s requirement to screen 80% or more of the children in a service area; whether it will be tenable to offer InCK services only to children who reside in a specific region of a state rather than all children (as required by CMMI to support evaluation efforts); and, most fundamentally, how they will pull together the many disparate organizations that share a commitment to children, but that long have operated in their own siloes.

The MOM Model

The MOM Model aims to address fragmentation in the care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) and to improve quality of care for their infants. The model offers up to 12 states and their local partners funding, with a maximum of $64.6 million across the awardees over a five-year period. The model requires that pregnant and postpartum women with OUD receive a comprehensive set of services, including physical healthcare, behavioral healthcare and wrap-around services, delivered in a coordinated and integrated approach. At the start of the model, medical services will be billed as usual to Medicaid, while coordination, engagement and referral services will be paid by model funding. From Year 3 on, all services in the model are expected to be covered by Medicaid. A goal of the model is also to leverage existing Medicaid flexibility to institute sustainable long-term funding mechanisms to provide care to mothers with opioid use disorders. Unlike the InCK Model, states can choose to implement the model statewide or in a specific region.

Parameters of the MOM Model include:

  • Clinical expertise. States must partner with one or more “care-delivery partners,” defined as a health system or payer, such as a Medicaid managed care plan, that is associated with a clinical delivery site. These partners will work with the state on all aspects of designing and implementing the model, from identifying, engaging and retaining beneficiaries to designing the intervention that ensures coordinated Medicaid and model services are delivered.
  • Evidence-based OUD treatment. Awardees must ensure access for the model population to evidence-based care consistent with current clinical guidelines. This includes requiring access to medication-assisted treatment (MAT), which has an extensive body of evidence supporting its effectiveness.
  • Integrated care and connection to other social supports. Under MOM, better coordinating and integrating existing Medicaid services is a key goal of the model. States are encouraged to partner with non-clinical entities, such as homeless shelters, early intervention services and child welfare agencies, to comprehensively address the needs of beneficiaries. Additionally, states and their partners must work to identify and address enrollees’ social service needs. These include housing, food, transportation, utilities, interpersonal safety, and family and community support.
  • Postpartum access to services. Under federal rules, all states must cover women eligible for Medicaid on the basis of pregnancy for 60 days after delivery. The model’s funding announcement encourages states to consider extending Medicaid eligibility to the model population beyond this period. States must also make efforts to ensure that model participants have continued access to necessary physical and behavioral healthcare services once their eligibility for Medicaid or the model ends.

Moving Forward

Applications for the MOM Model were due May 6, and award notice is expected by early November. For InCK, applications are due on June 10, with award notice expected in early December. While the InCK and MOM models present important opportunities for states to obtain design and implementation funds, some states may not apply, and not all of those that do will receive grants. Fortunately, many of the aims of the models can be achieved using existing Medicaid and CHIP funding mechanisms. For example, CMS in its November 13, 2018, State Medicaid Director (SMD) letter permitting Section 1115 demonstrations that waive the IMD exclusion for coverage of mental health treatment, offers a number of options available to states to promote innovative service delivery for adults with serious mental illness and children with serious emotional disturbance. These strategies can be used to achieve many of the goals of the InCK and MOM models, giving states the opportunity to enact meaningful changes to services for vulnerable women and children regardless of whether they receive CMMI awards.

1 Lead organizations must be a HIPAA-covered business entity, such as a hospital system, managed care plan or local health department.