IV. Priority Recommendations (continued)
5 Partnering with Medicaid to improve Part C EI
Overall, nearly half (46 percent) of all Pennsylvania children are covered by Medicaid or the Children’s Health Insurance Program (CHIP). Approximately 1.3 million children under age 21 were covered by Medicaid in Pennsylvania in 2019, including more than 200,000 infants and toddlers. High levels of Medicaid enrollment are common across the country, primarily because low-income families are more likely to have young children and Medicaid income eligibility levels for children are now set above extreme poverty levels. In Pennsylvania, the Medicaid income eligibility level is 220 percent of the federal poverty level for infants under one and 162 percent of the poverty level for children ages 1 through 5. Nationally, nearly half of all children with special health care needs are covered by Medicaid, many of whom are also enrolled in IDEA Part C or IDEA special education programs. Unlike federal IDEA Part C funds, which are capped, the federal government pays approximately half of the cost of qualifying services provided to every Medicaid-enrolled child, as defined by state law/ DHS Office of Medical Assistance Programs. This offers an opportunity to ensure federal matching dollars are maximized so that limited Part C dollars may be best targeted to ensure funding for services not covered by Medicaid reimbursement, services for children who do not qualify for Medicaid, or state infrastructure investments in quality and access. In Pennsylvania and many other states, Medicaid financing is braided with federal Part C EI funds and other dollars to finance the EI services. Pennsylvania has a unique Infant, Toddler, and Family Medicaid waiver program which provides financing for select EI services to more than 2,000 Medicaid beneficiary infants and toddlers with intellectual disabilities and developmental disabilities who would otherwise require care in an institutional setting. In addition,
Medicaid is the primary source of coverage for home and community-based services (HCBS) for people— including children—with disabilities, often under waiver programs. In a majority of states, health care for most Medicaid- enrolled children occurs through managed care arrangements. Managed care means that the state Medicaid agency pays private insurers, called managed care organizations (MCOs), to manage the health care needs of Medicaid beneficiaries who elect their MCO. MCOs negotiate with and reimburse health providers as detailed in a contract with the state. Some services or programs may fall outside of managed care arrangements, with reimbursements to providers administered directly from the state on a fee-for-service basis. In Pennsylvania, most Medicaid health services for children are financed under MCOs, but EI services are reimbursed separately by Medicaid on a fee-for-service basis. In effect, this means that MCOs are responsible for ensuring children are screened for delays during well-child visits and referred to EI as those screenings identify a potential need. If enrolled in EI, qualifying IFSP services are reimbursed directly to providers on a fee-for-service basis. The care experience and outcomes of children in Medicaid vary by state. In Pennsylvania, the percentage of children in Medicaid who had at least
June 2022
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