During 2018, the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) announced two new opportunities for state governments and their partners to improve their delivery systems for children and mothers, respectively, under the Integrated Care for Kids (InCK) and Maternal Opioid Misuse (MOM) models. Both models are designed to address the nation’s opioid crisis through a combination of payment and delivery system reform in Medicaid, with InCK also addressing more than the opioid crisis by offering opportunities to strengthen care for children with complex needs in general. Up to $128 million in funding is available for InCK and up to $64.5 million for MOM. Notices of Funding Opportunity for both models—which will contain full details for applicants and terms of participation—are expected early in 2019, after which interested states and partners will have about four months to apply to CMS.
Like CMMI’s previous Healthcare Innovation Awards (HCIA), approaches under these models will be built “bottom up,” with each applicant being expected to develop a proposal tailored to the specific needs of the state. The two models are separate, and nothing precludes a state from securing funding under both models.
Integrated Care for Kids (InCK) Model
InCK is the first pediatric-only model launched by CMMI, which describes it as “a child centered local service delivery and state payment model that aims to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and CHIP through prevention, early identification, and treatment of behavioral and physical health needs.” InCK participants will be expected to:
- Improve early identification and treatment of children with complex needs;
- Improve integration and care coordination across settings; and
- Develop alternative payment models in Medicaid (CHIP is optional) to support improved accountability for services to children with complex needs.
InCK models will be approved in up to eight states. Participants in InCK will be state Medicaid agencies working with designated local “Lead Organizations”—HIPAA-covered entities that will lead the implementation of the population health approaches. Different configurations will be accepted at the application phase, with either the Medicaid agency or another Lead Organization leading the application, but under either scenario the Medicaid agency will need to be involved in the provision of data and development of the alternative payment model.
Importantly, the applicant must choose a specific region of the state in which to test the model to allow for a control group within the same state. InCK will run for seven years. CMMI has indicated that it will be looking for applications that include specific strategies to tackle the impact of the opioid crisis on children, although the scope of the funding is broader than opioids, and applicants will likely be judged in part based on whether their proposals could lead to reductions in costly hospitalizations and out-of-home placements.
Maternal Opioid Misuse (MOM) Model
MOM is more narrowly focused than InCK and is centered on improving—through addressing fragmentation—services for Medicaid-enrolled pregnant and postpartum women with an opioid use disorder. MOM participants will be expected to define a “coordinated and integrated care delivery system approach” for the target population that spans physical and behavioral health and satisfies five components:
- Comprehensive care management;
- Care coordination;
- Health promotion;
- Individual and family support; and
- Referral to family and social services.
MOM models will be funded in up to 12 states, and unlike InCK, participants in MOM must be the state Medicaid agencies themselves. State Medicaid agencies must name an external “Care Delivery Partner” such as a health system or health plan that will lead implementation of the care delivery intervention.
Considerations for States and Their Delivery System Partners
States already have been spurred into action on opioids by the severity of the crisis and have begun employing diverse strategies (both inside and outside Medicaid), including expansion of medication-assisted treatment, enforcement of parity laws and comprehensive naloxone access. However, states can expect to fight this crisis on multiple fronts for years to come. In this context, InCK and MOM represent helpful funding opportunities for states and regional partners to test new or expanded interventions for children and mothers that complement one another and other strategies in play in the state. As states and delivery system partners gear up to apply, they may want to consider the following issues in particular:
- Combinations of the two models: CMS will allow states to apply for both models but has indicated that restrictions will apply. In particular, if an entity other than the state Medicaid agency proposes to act as the InCK applicant, that entity cannot also act as the MOM Care Delivery Partner. States intending to apply for both models should expect CMS scrutiny regarding how the interventions fit together and how a relatively “clean” comparison (control) group will be maintained such that CMS’s independent evaluators can draw conclusions about the efficacy of the interventions.
- Avoidance of duplication of services: Both InCK and MOM are entering what can be already crowded marketplaces for care management and care coordination, with multiple entities (including—depending on the state—managed care plans, behavioral health-specific plans, patient-centered medical homes, accountable care organizations and community health centers) already playing care management roles in Medicaid and other parts of the healthcare system. Moreover, child welfare, schools, early care, food, housing, mobile crisis and juvenile justice systems likely are working on care coordination and related issues for many of the children with the most complex needs in a state or region. CMS may well want to see applicants develop a proactive plan for engaging and coordinating with these other partners in their efforts, in order to avoid paying for the same services, ease the burden on families of working with multiple care managers from different initiatives, and bolster the success of care management interventions.
- Intersection with 1115 waivers: CMMI has not yet given guidance on how the models may interact with Medicaid 1115 waivers. There is no requirement that a waiver is needed to pursue either of these models; however, a proposal that envisions expanding Medicaid’s role in financing services not otherwise coverable with Medicaid funds will likely require a Medicaid 1115 waiver, especially because the InCK model, in particular, must be tested in only part of a state. Without an 1115 waiver, it may be difficult to provide benefits that are not statewide.
- Intersection with payment systems beyond healthcare: InCK appears poised to establish new opportunities for states to test creative approaches to combining funding across healthcare and social services. In particular, CMMI has been clear that it is very interested in proposals that potentially reduce out-of-home placements for children, raising the question of whether savings generated by such initiatives could be folded into a Medicaid-driven alternative payment model.
- Coverage of women after the postpartum period: States that have not expanded Medicaid under the Affordable Care Act (ACA) will need to determine whether they can put together a viable proposal for assisting mothers with opioid use disorders after their pregnancy-related Medicaid coverage ends at 60 days postpartum. CMMI has not limited eligibility for the MOM program to expansion states, but those states that have not yet expanded should be prepared to describe how they will address the coverage cliff that postpartum women with substance use disorders otherwise face.
States and delivery system partners interested in applying for InCK or MOM should subscribe to CMMI alerts to stay informed of developments and the release of the Notices of Funding Opportunities, which is expected imminently.