Fostering Social and Emotional Health through Pediatric Primary Care:

Strategy 2: Leverage quality and performance improvement initiatives to spur changes in pediatric practice.

States continue to look for ways to improve the quality of care provided in Medicaid, reflecting both strong federal requirements to improve quality and their own interest in ensuring that they are buying high-quality care for their substantial investments in Medicaid. Historically, however, little has been done to develop quality measures that address children’s social and emotional development. This is beginning to change, in part due to the growing recognition that these issues are critical to the long-term health and well-being of children and because of stronger federal requirements related to child health quality measures.

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) required the U.S. Department of Health and Human Services (HHS) to identify and publish a core set of children’s health quality measures for use by state Medicaid and CHIP programs. This “Child Core Set” provides an important tool for states to track and improve the quality of care provided to children with Medicaid and CHIP coverage. Although reporting has been voluntary, beginning in 2024, all states will be required to report on the full set of measures.³⁷

The 2021 Maternal & Perinatal Health Measures for Medicaid & CHIP³⁷ comprises 26 measures that span categories such as access to primary and preventive care, maternal and perinatal health, care of acute and chronic conditions, behavioral health, dental and oral health services, and beneficiaries’ experience of care.³⁸ One of the current measures considers the percentage of children with Medicaid and CHIP coverage who received a developmental screening in the first three years of life, including screening related to social and emotional health. In 2017, 27 states reported a median of 40 percent of children were screened for developmental, behavioral, and social delays using a standardized tool preceding or on their first, second, or third birthday.³⁹ Given that less than half the states are currently reporting on this measure, understanding of the national picture is incomplete at best. The requirement to report on the full set of Child Core Set measures beginning in 2024 is expected to increase states’ focus on gathering data and reporting on child health measures. It also could result in the adoption of additional measures related to the social and emotional development of children.

Ensuring that Metrics Evolve to Align with New Vision of Pediatric Care

The National Quality Forum (NQF) convenes the multi-stakeholder Measure Applications Partnership (MAP)—specifically a Medicaid Child Workgroup within MAP—that makes recommendations annually for strengthening the Child Core Set.⁴⁰ States and other stakeholders could encourage the federal government to incorporate specific measures related to social and emotional development into future versions. States also could develop their own measures that help assess progress on improving social and emotional development. For example, measures related to family experiences and changes in parenting behaviors and social circumstances as a consequence of health care received could be tracked.

Implementation Strategies

Tools For Implementation: Strategy 2

All citations are available here.

Strategy 3: Establish payment models that incentivize a focus on the social and emotional development of children, ideally as part of a high-performing pediatric medical home.

To reward quality outcomes and cost-efficiency in their Medicaid programs, states have been designing and implementing value-based payment (VBP) initiatives. With VBP, states are seeking to move away from reimbursing providers based on the volume of care they provide and move toward reimbursing them for improving outcomes and reducing costs. Generally, states and Medicaid managed care plans have focused their Medicaid value-based payment initiatives on adults with high-cost or chronic conditions. These efforts have not been aimed at children since, in the absence of special health care needs, most children are relatively healthy, making it unlikely that payment initiatives will generate near-term cost-savings. Moreover, many of the longer-term savings generated by upfront investments in children’s care are likely to accrue to the social service and educational sectors, a challenge known as the “wrong pocket” issue. States will need to take these challenges into account when they consider changing their current payment strategies to incentivize activities and outcomes related to children’s social and emotional development. Most importantly, they may need to place a greater priority on improved outcomes, rather than cost savings, when evaluating alternative payment strategies.⁴⁶

Implementation Strategies

Tools For Implementation: Strategy 3

All citations are available here.

Strategy 4: Facilitate investment in team-based care and training on children’s social and emotional development.

States can help pediatric providers overcome some of the constraints they face in adopting practices aimed at fostering children’s social and emotional health. These include having insufficient time to spend with each patient and family, as well as needing greater knowledge and resources to identify and address families’ health-related social needs. Integrating individuals such as social workers, community health workers, or promotoras into the health care team can extend the reach of pediatric care providers and deepen trust with families. States also have the flexibility under Medicaid to allow care to be provided in home or community-based early childhood settings, as well as help finance training and pediatric practice transformation.

Implementation Strategies

Tools For Implementation: Strategy 4

All citations are available here.

Strategy 5: Leverage a CHIP Health Services Initiative to finance interventions aimed at supporting children’s social and emotional development.

A CHIP Health Services Initiative (HSI) is an activity designed to improve the health of children with low income and targets children under age 19 who are eligible for Medicaid or CHIP, although a state’s HSI may benefit all children within a state regardless of income. States can use HSIs to cover the costs of direct services or to support public health priorities, such as the operation of poison control centers or intensive lead screening promotion and lead abatement.

Under CHIP, states can use up to 10 percent of the amount they spend on health coverage for program administration and other non-coverage activities. States must prioritize administrative funding for necessary programmatic expenditures, including eligibility determinations and renewals, contract negotiations, performance measurement, and other activities to meet regulatory requirements. However, they also can use a portion of administrative funds for outreach activities to identify and enroll eligible children in the program, and for the implementation of an approved HSI. Most states have significant “room” under the 10 percent administrative cap, meaning they have spent only a small portion of the available amount. In FY 2017, for example, state expenditures on non-coverage activities averaged only 4.2 percent (see Appendix C).⁶⁸

HSIs provide states flexibility and a chance to experiment. Since states are not required to execute HSIs on a statewide basis, they can identify communities or populations that might reap particular benefits from the HSI, or they can pilot new ideas and approaches to delivering quality health care. The federal matching rates for CHIP-funded activities are also advantageous to states. On average, the federal matching rates for state CHIP programs are 15 percentage points higher than the rates for Medicaid and range from 76.5 to 95.39 percent in FY 2020.^69,70

In addition, federal matching rates for CHIP have been temporarily enhanced even further: through September 2019, each state’s reimbursement rate receives a boost of an additional 23 percentage points, up to a maximum of 100 percent. For this limited period, with an average enhanced federal reimbursement rate of 94 percent, the non-federal share of the cost of an HSI averages just six percent and can be as low as zero. (In 2019, 13 states receive a CHIP matching rate of 100 percent.) After September 30, 2019, the enhanced match ratchets down to an 11.5 percentage point boost through September 30, 2020, and matching rates return to the customary CHIP enhanced levels thereafter.⁷¹

A critical first step in determining the opportunity for an HSI in a state (also the first step in CMS’s review in approving HSIs) is to assess the state’s CHIP administrative funds and current spending relative to the 10 percent limit.⁷² Appendix B presents an analysis of states’ current CHIP allotments and spending relative to the 10 percent limit. Assuming a state has available funding, it could pursue an HSI to finance an intervention that addresses children’s social and emotional development.

Implementation Strategies

Tools For Implementation: Strategy 5

All citations are available here.

PSP Medicaid/ CHIP State Implementation Workgroup

From August 2019 to December 2020, nine states—California, Kansas, Maine, Massachusetts, New York, Nevada, North Carolina, Virginia, and Wisconsin— participated in the Pediatrics Supporting Parents Initiative State Medicaid and CHIP Implementation Workgroup. Each state formed a team that included senior Medicaid agency leadership and staff as well as the key stakeholders in their state, such as local American Academy of Pediatrics Chapter representatives, early childhood advocates, family-led organizations, Title V Directors, and local funders. The states received customized technical assistance and participated in a peer learning community aimed at helping them implement strategies identified in the Blueprint to leverage the well-child visit to improve social and emotional development of the youngest children. Over 18 months, states in the Workgroup achieved concrete state policy changes and laid the groundwork for future action and transformation. The blogs and resources below describe some of the Workgroup’s successes and lessons learned.

Blogs

• A Check-In on Leveraging the Power of Children’s Check-Ups
• Once Upon a Time in North Carolina: CHIP Health Services Initiative Funds Early Literacy Promotion as Part of Well-Child Care
• Transforming Pediatric Primary Care: Moving From Theory To Practice In Massachusetts And Beyond
• California’s Medicaid Breakthrough: An Opportunity to Advance Children’s Social and Emotional Health
• Finding Opportunity in Adversity: How One State is Identifying Ways to Strengthen Services to Young Children and Families During COVID-19

Webinars

• How Can Medicaid and CHIP Support Children’s Emotional Health? 
  This webinar introduced the Blueprint to a national audience, covering the basics of social-emotional development and why Medicaid and CHIP present the greatest potential for boosting the standard of pediatric primary care for the youngest children. A summary of the five implementation strategies illustrated how existing Medicaid/CHIP policies and financing mechanisms can support transformation.
• Next-Generation Strategies to Transform Pediatric Primary Care 
  The webinar shared the key recommendations, strategies and lessons learned from the Massachusetts Child and Adolescent Health Initiative (CAHI) report Moving to the Vanguard on Pediatric Care: Child and Adolescent Health Initiative Recommendations for the MassHealth Section 1115 Waiver Renewal. The report identified Medicaid options and opportunities that can spur transformation in the Commonwealth of Massachusetts, as well as implications for state and federal action.
• A series of webinars conducted in in partnership with California’s First 5 Center for Children’s Policy focused on how Medi-Cal and the managed care delivery system can improve the health and well-being of young children and their caregivers.
  • Demystifying Medi-Cal to Support Young Children and Families reviews state and federal laws that govern Medi-Cal, the Medi-Cal manage care delivery system and best ways to partner with health plans to support young children and families.
  • Dyadic Care & Medi-Cal Family Therapy Benefit discusses the importance of preventing, identifying, and treating pediatric mental health needs, and opportunities to do so through Medi-Cal.
  • Early Identification and Intervention in Medi-Cal discusses opportunities within Medi-Cal to strengthen and expand services for young children, and highlights Help Me Grow (HMG) partnerships with health plans in several counties.

Additional Reports

• Strengthening the Social and Emotional Health of California’s Young Children: Medi-Cal Strategies and Options for Creating an Advanced Child Health Delivery System 
  This report identifies three major sets of strategies that could be adopted to 1) establish greater accountability for child health among California’s Medi-Cal managed care plans; 2) realize the full potential of Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for California’s children; and 3) elevate a focus on children among the managed care plans and the State Medicaid agency.
• Guide to Leveraging Opportunities Between Title V and Medicaid for Promoting Social-Emotional Development
  The Center for the Study of Social Policy (CSSP) and Johnson Group Consulting, Inc. were asked by the Pediatrics Supporting Parents (PSP) initiative to develop this guide, which was designed to support state-level planning, action, and innovation aligned with the goals of the PSP initiative, using a framework that stretches from promotion to screening to prevention to early intervention and treatment. It describes opportunities for state Title V MCH programs, state Medicaid agencies, and for the two in partnership.

California     |     Colorado     |     Kansas     |     Louisiana     |     Maine     |     Massachusetts     |     Michigan     |     Minnesota     |     Missouri     |     New Mexico     |     New York     |     North Carolina     |     Oklahoma     |     Oregon     |     South Carolina     |     Virginia     |     Washington

California

Strategy 1

California. The California Department of Health Care Services (DHCS) issued new guidance in Summer 2020 clarifying that family therapy is a Medi-Cal (California’s Medicaid) covered service, providing the benefit to children under age 21. To be eligible for the family therapy benefit, the child must meet one of two criteria, both of which recognize the importance of covering pediatric preventive behavioral health services: (1) up to five sessions of family therapy are covered before a mental health diagnosis is required or (2) a risk factor for mental health disorders is identified. The guidance lists possible risk factors, that include experience of discrimination, separation from a parent/ guardian due to incarceration or immigration, death of a parent/ guardian, food insecurity, housing instability, and exposure to violence or trauma. This crosswalk helps identify how the family therapy benefit can support dyadic integrated care models active in California, including HealthySteps and DULCE. The family therapy guidance was highlighted by Georgetown University’s Center for Children and Families and the First 5 Center for Children’s Policy in California. Notably, MassHealth (Massachusetts’ Medicaid) adopted a similar policy in September 2021 to permit preventive behavioral health services for children regardless if they meet criteria for behavioral health diagnosis, given the preventive nature of the benefit.

Colorado

Strategy 1

Colorado reimburses pediatric and family medicine providers for screening new mothers for depression at well-child visits under either the mother’s or child’s Medicaid. The state also covers up to six visits of short-term behavioral health services—which includes diagnostic evaluation and family psychotherapy—delivered by behavioral health clinicians such as family therapists, social workers, and psychologists in a primary care setting. This allows for integration of primary and behavioral health care, as well as the opportunity to provide family-centered care.

Strategy 3

Colorado, a fee-for-service state, provides primary care medical providers additional payments for meeting a set of clinical and structural standards, including behavioral health integration, behavioral health screening, and development of patient-centered care plans.

Kanas

Strategy 1

Kansas. Effective January 1, 2021, the Kansas Department of Health and Environment (KDHE) implemented a new policy and billing guidance permitting pediatric primary care providers to screen for maternal depression as part of the EPSDT risk assessment conducted during the well-child visit. The Kansas policy provides up to three screenings during the prenatal period under the mother’s Medicaid ID and up to five screenings conducted during a pediatric well-child visit during the 12-month postpartum period under the child’s Medicaid ID. The State published a Perinatal Mental Health Toolkit as a resource for pediatric primary care providers. The value of the new screening policy was the subject of an opinion piece in the Kansas Reflector, which also highlighted the importance of extending postpartum coverage under Medicaid to ensure more mothers have access to the treatment they may need. 

Louisiana

Strategy 1

Louisiana is using its Medicaid managed care procurement process to encourage plans to offer adult dental coverage, medical respite care, and a number of other value-added services. Bidders that agree to do so receive additional points in the procurement processes. Similarly, a state could award extra points for plans willing to provide parenting programs or home visiting services (to the extent not otherwise covered) to families of children at high risk for social and emotional challenges.

Maine

Strategy 5

Maine’s Family Home Visiting Program provides funding for community agencies to deliver home visits to first-time families and pregnant and parenting adolescents.

Massachusetts

Strategy 5

Massachusetts’ initiative to prevent youth violence through after-school programs is aimed at mitigating the consequences of trauma and promoting healthy development.

Michigan

Strategy 2

Michigan incorporates performance on quality metrics into its auto-assignment algorithms, with the Michigan Department of Health and Human Services setting quality metrics every year based on clinical performance, administrative performance, and network capacity. To date, these measures have included childhood immunization rates, well-child visits in the first 15 months of life and from three to six years, timeliness of prenatal care, and postpartum care. In future years, Michigan could elect to use measures even more directly related to the social and emotional development of children.

Minnesota

Strategy 1

Minnesota has a robust initiative to screen children routinely in accordance with Bright Futures guidelines, including screenings for social and emotional development and social determinants of health. The state has developed expansive training materials on how to conduct screenings and report results to families, and also provides resources on identifying appropriate screening tools. To help ensure that pediatric care providers focus attention on social and emotional development, the state allows them to bill separately for screenings that address social and emotional concerns.

Missouri

Strategy 4

Missouri requires Medicaid managed care plans to participate in the Local Community Care Coordination Program (LCCP), an evidence-based patient-centered concept that ensures every beneficiary has a primary care physician that leads an integrated team focused on care coordination and social needs and support referrals.

New York

Strategy 2

As part of the New York State First 1,000 Days on Medicaid initiative, the state is implementing a “Kids’ Quality Agenda” which requires the participation and collaboration of all Medicaid managed care plans on a two-year common PIP to improve performance on children’s and perinatal health care quality measures.42 The initial PIPs will address lead testing and follow-up, newborn hearing screening and follow-up, and developmental screening. Data collection and analysis will be underway from March 2019 through December 2020, with final reporting in July 2021.

New Mexico

Strategy 4

New Mexico’s Medicaid managed care contract requires plans to engage community health workers, and has established a goal to ensure that they serve at least three percent of enrolled members. The community health workers are expected to provide interpretation and translation services, offer informal counseling and guidance on health behaviors, and assist people in accessing social services.

North Carolina

Strategy 1

North Carolina requires Medicaid managed care plans to screen all beneficiaries (not only children) to identify whether they face interpersonal violence, are subject to toxic stress or have unmet housing, food, or transportation needs. Beneficiaries identified as “high risk” must be provided with enhanced care management services, including help addressing social and economic issues. The assistance is expected to be provided by local care managers in most instances because they have the ability to meet with families in person and have greater first-hand knowledge of community resources.

Strategy 3

North Carolina will be deploying an Advanced Medical Home (AMH) model in its forthcoming Medicaid managed care program. The AMH is designed to improve primary care for children and adults alike and, as such, it includes numerous features important to the social and emotional health of children. For example, AMHs are expected to adopt a team-based approach that addresses the whole person, including food, housing, interpersonal violence/toxic stress and transportation. In its Medicaid managed care contract, North Carolina requires its plans to contract with a large majority of AMH practices in each of the regions that they serve.

North Carolina requires its Medicaid managed care plans to conduct a “care needs screening” that includes questions on housing, food insecurity, domestic violence, and gaps in transportation within 90 days of a beneficiary signing up with a plan. To incentivize plans to focus on these issues, North Carolina intends to link a share of the money it withholds to reward plans that have high rates of screening and referral of beneficiaries to social services.

Strategy 5

North Carolina. The North Carolina Department of Health and Human Services (NC DHHS) led the design and implementation, with stakeholders and partners, of a CHIP Health Services Initiative (HSI) State Plan Amendment (SPA) to embed early literacy promotion into the routine well-child visit for children up to age five, using the evidence-backed, American Academy of Pediatrics-endorsed Reach Out and Read model. CMS approved the SPA  in October 2020, with the State securing enhanced federal matching funds of nearly 90 percent, retroactive to July 2020; federal funding over three years will be $2,400,432 with State’s share of $643,056, totaling $3,013,000. The HSI will enable Reach Out and Read to reach every county, expand the number of clinics, and begin the intervention at birth (rather than at the six-month well-child visit) bringing North Carolina’s program in line with best scientific practice on nurturing early brain development. The SPA has been featured by Georgetown University’s Center for Children and Families and in a Reach Out and Read podcast with Secretary Dr. Mandy Cohen of NC DHHS. 

Oklahoma

Strategy 5

Oklahoma’s HSI provides funds to train pediatric primary care providers to promote early literacy during well-child visits in accordance with the AAP practice recommendations. The HSI is also intended to help increase the percentage of young children attending well-child visits and improve the percentage of children receiving standardized developmental screening.

Oregon 

Strategy 2

Oregon is in the midst of a process to develop metrics that focus on the health sector’s role in achieving kindergarten readiness. The resulting metric or metrics are intended to be incorporated into the Oregon Medicaid’s Coordinated Care Organizations (CCOs) Incentive Measure Set, a powerful tool for encouraging CCOs to focus on the state’s child health and development priorities.

Strategy 3

Since 2011, Oregon has implemented an incentive program that allows its managed care plans (referred to as “Coordinated Care Organizations”) to earn as much as 4.25 percent above their capitation payments. Each year the state assesses how well the CCOs performed on specific measures and awards incentive funds based on their performance. In recent years, child development screening has been one of the measures, and CCOs have made impressive improvements, tripling screening rates statewide from 2011 to 2017. HealthShare of Oregon, one of the State’s largest CCOs, received about $69 million in incentive payments for over 315,000 members. It reinvested these funds into parent coaching strategies, efforts to reduce disparities in developmental screening rates across cultural groups, and other child health initiatives.

Strategy 4

In Oregon’s procurement for Coordinated Care Organizations (CCO 2.0), the State includes a provision requiring CCOs to ensure providers are trained in trauma-informed care, implementing trauma-informed practices, and screening for adverse childhood experiences (ACEs).

South Carolina

Strategy 4

South Carolina works in collaboration with the South Carolina Chapter of the American Academy of Pediatrics to operate the Quality Through Technology and Innovation in Pediatric Practice (QTIP). The initiative provides technical assistance and peer-learning opportunities in support of practice transformation, quality improvement, and integration of mental health services into pediatric practice.

Virginia

Strategy 3

Virginia requires its Medicaid managed care plans to maintain and implement a VBP strategy that follows the alternate payment model (APM) framework developed by the Health Care Payment Learning and Action Network (HCP LAN). In addition, Virginia’s Medicaid managed care contract stipulates that plans must implement special medical home initiatives—currently called Medallion System Innovation Partnerships (MSIP)—that feature value-based payment arrangements with providers, performance-based incentives, and/or other incentive reforms tied to state-approved quality metrics and financial performance. Virginia’s 2017-2018 contract required that the MSIP focus on pediatric services and target pediatric populations, and that services provided through the MSIP be designed to individually coordinate Medicaid primary and acute care and mental health services.

Washington

Strategy 4

Washington State’s Medicaid agency and Early Learning Department are working together to explore the use of preventive and developmental screenings covered by Medicaid at Head Start centers, as well as strategies for sharing results with pediatric practices.

Appendix A: Pediatrics Supporting Parents Background Information
Appendix B: Statutory And Regulatory Authorities
Appendix C: Table C1 And C2
Appendix D: Methodology

Introduction

¹ Harvard University, Center on the Developing Child. Brain Architecture. (2019). Retrieved from https://developingchild.harvard.edu/science/key-concepts/brain-architecture/.
² National Research Council (US), Institute of Medicine (US) Committee on Integrating the Science of Early Childhood Development, Shonkoff, J., Phillips, D. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK225557/.
³ Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics, et al. (January, 2012). Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health. Pediatrics, 129(1). Retrieved from https://pediatrics.aappublications.org/content/129/1/e224.
⁴ American Academy of Pediatrics. (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Retrieved from https://www.aap.org/en-us/Documents/periodicity_schedule.pdf.
⁵ Haley, J., Wang, R., Buettgens, M., Kenney, G. (2017). Health Insurance Coverage among Children Ages 3 and Younger and Their Parents: National and State Estimates. The Urban Institute. Retrieved from https://www.urban.org/research/publication/health-insurance-coverage-among-children-ages-3-and-youngerand-their-parents-national-and-state-estimates/view/full_report.
⁶ Centers for Medicare & Medicaid Services Medicaid/CHIP Health Care Quality Measures (2018, December). Quality of Care for Children in Medicaid and CHIP: Findings from the 2017 Child Core Set. Retrieved from https://www.medicaid.gov/medicaid/quality-of-care/downloads/performancemeasurement/2018-child-chart-pack.pdf.
⁷ Kaiser Family Foundation. (January, 2019). Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level. Retrieved from https://www.kff.org/health-reform/state-indicator/medicaidincome-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
⁸ Khullar, D., Chokshi, D. (2018, October). Health, Income, & Poverty: Where We Are & What Could Help. Health Affairs. Retrieved from https://www.healthaffairs.org/do/10.1377/hpb20180817.901935/full/.
⁹ Pittard WB III, Hulsey TC, Laditka JN, Laditka SB. School Readiness Among Children Insured by Medicaid, South Carolina. Prev Chronic Dis 2012;9:110333. Retrieved from: http://dx.doi.org/10.5888/pcd9.110333.
¹⁰ Center for Excellence for Infant and Early Childhood Mental Health Consultation. (2019). What is IECMHC. Retrieved from https://www.samhsa.gov/iecmhc/about.
¹¹ Committee on Psychosocial Aspects of Child and Family Health. (2001, November). The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care. Pediatrics, 108(5). Retrieved from https://pediatrics.aappublications.org/content/108/5/1227.long.
¹² American Academy of Pedatrics. (n.d.). AAP Agenda for Children: Medical Home. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAPAgenda-for-Children-Strategic-Plan-Medical-Home.aspx.
¹³ Sulaski Wyckoff, A. (2017, February). Bright Futures: 4th Edition Includes Focus on Social Determinants of Health. American Academy of Pediatrics. Retrieved from https://www.aappublications.org/news/2017/02/17/BrightFutures021717.
¹⁴ American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. (2007, March). Joint Principles of the Patient-Centered Medical Home. Retrieved from https://www.acponline.org/system/files/documents/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf. Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change June 2019 Page 54

Strategy 1

¹⁵ Venkataramani, M., Pollack, C., & Roberts, E. (2017). Spillover Effects of Adult Medicaid Expansions on Children’s Use of Preventive Services. Pediatrics, 140(6). doi: 10.1542/peds.2017-0953.
¹⁶ Kaiser Family Foundation. (2019). Status of State Action on the Medicaid Expansion Decision. Retrieved from https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaidunder-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
¹⁷ Haley, J., Wang, R., Buettgens, M., Kenney, G. (2017). Health Insurance Coverage among Children Ages 3 and Younger and Their Parents: National and State Estimates. The Urban Institute. Retrieved from https://www.urban.org/research/publication/health-insurance-coverage-among-children-ages-3-and-youngerand-their-parents-national-and-state-estimates/view/full_report.
¹⁸ American Academy of Pediatrics. (2017). Bright Futures, Recommendations for Preventive Pediatric Health Care. Retrieved from https://www.aap.org/en-us/Documents/periodicity_schedule.pdf.
¹⁹ Adopted in October of 2018, the law is the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. Public Law No: 115-271.
²⁰ American Academy of Pediatrics. (2017). Bright Futures, Recommendations for Preventive Pediatric Health Care. Retrieved from https://www.aap.org/en-us/Documents/periodicity_schedule.pdf.
²¹ Weitzman, C., & Wegner, L. (2015). Promoting Optimal Development: Screening for Behavioral and Emotional Problems. Pediatrics, 135(2). doi: 10.1542/peds.2014-3716.
²² Smith, S., Granja, M.R., Hguyen, U.S., Rajani K. (2018). How States Use Medicated to Cover Key Infant and Early Childhood Services. National Center for Children in Poverty. Retrieved from http://www.nccp.org/publications/pdf/text_1211.pdf.
²³ Weitzman, C., & Wegner, L. (2015). Promoting Optimal Development: Screening for Behavioral and Emotional Problems. Pediatrics, 135(2). doi: 10.1542/peds.2014-3716.
²⁴ Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. (2006, July). Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics, 118(1). Retrieved from https://pediatrics.aappublications.org/content/118/1/405.full.
²⁵ US Department of Health and Human Services (2014, March). Birth to 5: Watch Me Thrive! A Compendium of Screening Measures for Young Children. Retrieved from https://helpmegrownational.org/wp-content/uploads/2018/03/screening_compendium_march2014.pdf.
²⁶ Minnesota Department of Human Services (2019, January 15). Child and Teen Checkups.
Retrieved from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_150092#develop.
²⁷ Louisiana Department of Health. (2010). Request for Proposals for Louisiana Medicaid Managed Care Organizations. Retrieved from http://ldh.la.gov/assets/medicaid/RFP_Documents/RFP3/MCO_RFP.pdf.
²⁸ Thompson, R. (2018, April). Social-Emotional Development in the First Three Years. Robert Wood Johnson Foundaiton. Retrieved from https://www.rwjf.org/en/library/research/2018/04/social-emotionaldevelopment-in-the-first-three-years.html.
²⁹ Center for Children and Families. (2017, March). Health Coverage for Parents and Caregivers Helps Children. Georgetown University Health Policy Institute. Retrieved from https://ccf.georgetown.edu/wpcontent/uploads/2017/03/Covering-Parents-v2.pdf.
³⁰ Centers for Medicare & Medicaid Services. (2016, May 11). Informational Bulletin: Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf. Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change June 2019 Page 55
³¹ Centers for Medicare & Medicaid Services. (2016, May 11). Informational Bulletin: Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf.
³² Masho, S., Cha, S., Karjane, N., McGee, E., Charles, R., Hines, L., Kornstein, S. (2018, June). Correlates of
Postpartum Visits Among Medicaid Recipients: An Analysis Using Claims Data from a Managed Care Organization. J Womens Health, 27(6):836-43. doi: 10.1089/jwh.2016.6137.
³³ Smith, S., Granja, M.R., Hguyen, U.S., Rajani K. (2018). How States Use Medicated to Cover Key Infant and Early Childhood Services. National Center for Children in Poverty. Retrieved from http://www.nccp.org/publications/pdf/text_1211.pdf.
³⁴ Centers for Medicare & Medicaid Services. (2013, February). State Medicaid Director: Affordable Care Act Section 4106 (Preventative Services). Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/smd-13-002.pdf.
³⁵ US Preventive Services Task Force (2019, February). Interventions to Prevent Perinatal Depression: US Preventive Services Task Force Recommendation Statement. JAMA, 321(6):580-87. doi: 10.1001/jama.2019.0007.
³⁶ Colorado Department of Health Care Policy & Financing (2018, June). Short-term Behavioral Health Services in the Primary Care Setting. Retrieved from https://www.colorado.gov/pacific/sites/default/files/Short-term%20Behavioral%20Health%20Services%20in%20Primary%20Care%20Fact%20Sheet%20June%202018.pdf.

Strategy 2

³⁷ 2021 Maternal & Perinatal Health Measures for Medicaid & CHIP https://www.medicaid.gov/medicaid/quality-of-care/downloads/2021-maternity-core-set.pdf.
³⁸ Centers for Medicare & Medicaid Services. (2018, December). Quality of Care for Children in Medicaid and CHIP: Findings from the 2017 Child Core Set. Retrieved from https://www.medicaid.gov/medicaid/qualityof-care/downloads/performance-measurement/2018-child-chart-pack.pdf.
³⁹ Centers for Medicare & Medicaid Services. (2018, December). Quality of Care for Children in Medicaid and CHIP: Findings from the 2017 Child Core Set. Retrieved from https://www.medicaid.gov/medicaid/qualityof-care/downloads/performance-measurement/2018-child-chart-pack.pdf.
⁴⁰ National Quality Forum, Measure Applications Partnership Medicaid Adult and Child Workgroups. (2018, August). Strengthening the Core Set of Healthcare Quality Measures for Children Enrolled in Medicaid and Chip, 2018. Retrieved from http://www.qualityforum.org/Publications/2018/08/Strengthening_the_Core_Set_of_Healthcare_Quality_Measures_for_Children_Enrolled_in_Medicaid_and_CHIP,_2018.aspx.
⁴¹ Oregon Health Authority, Office of Health Analytics. (n.d.). Health Aspects of Kindergarten Readiness Technical Workgroup. Retrieved from https://www.oregon.gov/oha/HPA/ANALYTICS/Pages/KR-Health.aspx.
⁴² Kaiser Family Foundation (2018). Medicaid Managed Care Quality Initiatives. Retrieved from https://www.kff.org/medicaid/state-indicator/medicaid-managed-care-quality-initiatives/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
⁴³ Kaiser Family Foundation. (2019). Status of State Action on the Medicaid Expansion Decision. Retrieved from https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaidunder-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

Strategy 3

⁴⁴ State of Michigan. (2018). Comprehensive Health Care Program for the Michigan Department of Health and Human Services. Retrieved from https://www.michigan.gov/documents/contract_7696_7.pdf.
⁴⁵ California Health Care Foundation. (2006). Putting Quality to Work: Rewarding Plan Performance in Medi-Cal Managed Care, Appendix B. Retrieved from https://www.chcf.org/wp-content/uploads/2017/12/PDFPuttingQualityToWorkAppendixB.pdf. Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change June 2019 Page 56
⁴⁶ Bailit Health. (July 2016). Value-Based Payment Models for Medicaid Child Health Services. United Hospital Fund. Retrieved from https://uhfnyc.org/publications/publication/value-based-payment-models-formedicaid-child-health-services/.
⁴⁷ Garner A.S., Shonkoff, J.P., et al. (2012). Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Development Science into Lifelong Health. Pediatrics, 129. doi: 10.1542/peds.2011-2662.
⁴⁸ Johnson, K. & Bruner, C. (2018, October). A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health. Child and Family Policy Center. Retrieved from https://www.cfpciowa.org/documents/filelibrary/medicaid_finance/section_pdfs/Introduction_8D6E8F3FB002C.pdf.
⁴⁹ Roby, D. H., & Jones, E. E. (2016). Limits on same-day billing in Medicaid hinders integration of behavioral health into the medical home model. Psychological Services, 13(1), 110-119. http://dx.doi.org/10.1037/ser0000044.
⁵⁰ Colorado Department of Health Care Policy & Financing. (2017, January). Enhanced Primary Care Medical Provider Program Fact Sheet. Retrieved from https://www.colorado.gov/pacific/sites/default/files/Enhanced%20Primary%20Care%20Medical%20Proivder%20Definitions.pdf.
⁵¹ North Carolina Department of Health and Human Services, Division of Health Benefits. (2018, December). Programmatic Guidance on PHP Contracting Requirements for Tier 3 AMH Practices. Retrieved from https://files.nc.gov/ncdma/documents/Providers/Programs_Services/amh/AMH_Programmatic_Guidance_Contracting_12.17.18.pdf.
⁵² North Carolina Department of Health and Human Services (2018, August). Request for Proposal for Medicaid Managed Care Prepaid Health Plan. Retrieved from https://www.ncdhhs.gov/requestinformation.
⁵³ North Carolina Department of Health and Human Services. (2018, March). North Carolina’s Medicaid Managed Care Quality Strategy. Retrieved from https://files.nc.gov/ncdhhs/documents/DRAFT_QualityStrategy_20180320.pdf.
⁵⁴ New York Department of Health. (February, 2019). Children’s Value Based Payment Quality Measure Set, Measurement Year 2019. Retrieved from https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/quality_measures/2019/docs/childrens_qms.pdf.
⁵⁵ Health Care Payment Learning & Action Network. (July, 2017). Alternative Payment Model Framework. Retrieved from https://hcp-lan.org/.

Strategy 4

⁵⁶ Virginia Department of Medical Assistance Services. (2018, July). Medallion 4.0 Medicaid Managed Care Contract. Retrieved from http://www.dmas.virginia.gov/files/links/1566/Medallion%204.0%20Contract%20(07.26.2018).pdf.
⁵⁷ U.S. Department of Health & Human Services. (2017, July). State Advisory Councils on Early Childhood Education and Care. Retrieved from https://www.acf.hhs.gov/ecd/early-learning/state-advisory-councils.
⁵⁸ Centers for Medicare & Medicaid Services. (2013, November 27). Information Bulletin: Update on Preventive Services Initiatives. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib-11-27-2013-prevention.pdf.
⁵⁹ Snyder, J.E. (2016, January). Assistant Secretary for Planning and Evaluation Issue Brief: Community Health Workers: Roles and Opportunities in Health Care Delivery System Reform. United States Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/system/files/pdf/168956/CHWPolicy.pdf.
⁶⁰ Rosenbaum, S., Proser, M., et al. (2001). Room to Group: Promoting Child Development through Medicaid and CHIP. Commonwealth Fund. Retrieved from https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publiations_fund_report_2001_jun_room_to_grow__promoting_child_development_through_medicaid_and_chip_rosenbaum_room_451_pdf.pdf. Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change June 2019 Page 57
⁶¹ Delaware Health and Social Services Division of Public Health, Delaware Center for Health Innovation, Health Management Associates. (2017, June). Development and Deployment of Community Health Workers in Delaware: Establishing a Certification Program and Reimbursement Mechanism. Retrieved from https://www.dhss.delaware.gov/dph/hsm/files/dechwreport.pdf.
⁶² New Mexico Human Services Department. (n.d.). Medicaid Managed Care Services Agreement. Retrieved from http://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCO’s%20Centennial%20Care%202.0/BCBS%20Contract%20PSC%2018-630-8000-0033%20A1.pdf.
⁶³ Shuell, J., Steinberg, A., et al. (2018). Early Childhood and Medicaid: Opportunities for Partnering. Nemours Children’s Health System. Retrieved from http://www.movinghealthcareupstream.org/wp-content/uploads/2018/11/23421_Nem_EarlyChildhdMedcdRept_RevFINAL.pdf.
⁶⁴ Missouri Department of Social Services, MO HealthNet Division. (2017, May 1). Managed Care Contract Approved on July 19, 2018. Retrieved from https://dss.mo.gov/business-processes/managed-care/docs/Managed-Care-Contract-Approved.docx.
⁶⁵ Gifford, K., et al. (2018, October). States Focus on Quality and Outcomes Amid Waiver Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019. Kaiser Family Foundation. Retrieved from https://www.kff.org/report-section/states-focus-on-quality-and-outcomes-amid-waiverchanges-managed-care-initiatives/.
⁶⁶ South Carolina Department of Health and Human Services. (n.d.). South Carolina Healthy Connections Medicaid, Quality Through Technology and Innovation in Pediatrics (QTIP). Retrieved from https://msp.scdhhs.gov/qtip/.

Strategy 5

⁶⁷ Oregon Health Authority. (n.d.). Oregon Health Plan Health Plan Services Contract: Coordinate Care Organization, 2020. Retrieved from https://www.oregon.gov/oha/OHPB/CCODocuments/03-CCO-RFA-4690-0-Appendix-B-Sample-Contract-Final.pdf.
⁶⁸ MACPAC. (2017). Exhibit 33: CHIP Spending by State. Retrieved from https://www.macpac.gov/publication/chip-spending-by-state/.
⁶⁹ Centers for Medicare & Medicaid Services. (n.d.). CHIP Financing. Retrieved from https://www.medicaid.gov/chip/financing/index.html.
⁷⁰ Kaiser Family Foundation. (2018, November). Enhanced Federal Matching Assitance Percentage (FMAP) for CHIP. Retrieved from https://www.kff.org/other/state-indicator/enhanced-federal-matching-rate-chip/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
⁷¹ Centers for Medicare & Medicaid Services. (n.d.). CHIP Financing. Retrieved from https://www.medicaid.gov/chip/financing/index.html.
⁷² Centers for Medicare & Medicaid Services. (2017, January 12). Frequently Asked Questions (FAQs): Health
Services Initiative. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/faq11217.pdf.
⁷³ Massachusetts Department of Public Health. (n.d.). Youth Violence Prevention Through Positive Youth Development. Retrieved from https://www.mass.gov/service-details/youth-violence-prevention-throughpositive-youth-development.
⁷⁴ Maine Center for Disease Control & Prevention. (n.d.). Maine Families Home Visiting. Retrieved from https://www.maine.gov/dhhs/mecdc/health-equity/hv/index.shtml.
⁷⁵ Oklahoma Health Care Authority. (2018, October 31). Press Release: Reach Out and Read Coming to More SoonerCare Members. Retrieved from http://www.okhca.org/about.aspx?id=22619.
⁷⁶ Centers for Medicaid & Medicaid Services. (2015, July). Questions and Answers: Administrative Claiming Related to Training and Registry Costs. Retrieved from https://www.medicaid.gov/medicaid/finance/downloads/qa-training-registry-costs-071015.pdf.