Identifying and Assessing CSHCN: Lessons for States Transitioning to Medicaid Managed Care

Purpose

To describe the federal requirements of states and managed care organization to identify and service individuals with additional health care needs.

Outcome

When state Medicaid programs enroll children with special health care needs (CSHCN) into managed care they are obligated under federal regulation to ensure that there are mechanisms for identifying, assessing and producing treatment plans for the children. All three of these activities can be challenging, but the degree to which they are successful directly affects the quality of care these children will receive. This project reviewed the approaches taken by three states, California, Michigan and Massachusetts, to meet their obligations. All three states placed some of the responsibility for identification of CSHCN on the managed care organizations, some of whom further delegated responsibility to primary care providers. Mechanisms for assessment of the health status and needs of these children were not consistently regulated across states, though some stipulated an approach.  California and Michigan rely on diagnosis or condition-based definitions of CSHCN, while Massachusetts uses a broader, more functional definition. States differ in how they monitor the extent to which managed care organizations meet their contractual requirements for identification, assessment, planning and ensuring ongoing quality of care.