CMS Offers Roadmap for States to Help Connect Children with Complex Medical Conditions to Critical Medicaid Services

Agency issues guidance on a new optional Medicaid “health home” benefit that can help connect children with cerebral palsy and other complex medical conditions to care.

The U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), today unveiled guidance on a new Medicaid health home benefit for children with medically complex conditions. This new optional benefit helps state Medicaid programs provide Medicaid-eligible children who have medically complex conditions with person-centered care management, care coordination, and patient and family support. CMS anticipates that the new benefit will help these children receive the care they need, including across state lines.

Children with medically complex conditions — including serious health concerns like cerebral palsy, cystic fibrosis, blood diseases, and mental health conditions that can severely impact a child’s ability to function — often require tremendous care coordination and highly specialized treatment. Finding needed services often requires traveling well beyond a family’s home, and often care is only available for these children out-of-state. The new health home services are expected to give these children and their families help in coordinating and managing care.

“Every child deserves the care and support they need to stay healthy and thrive. This new Medicaid health home benefit will give states new options and financial incentive to improve care for children with complex medical conditions. At HHS, we are committed to providing families with access to appropriate pediatric specialty and subspecialty medical services, including when those services are needed across state lines,” said Health and Human Services Secretary Xavier Becerra.

“CMS and our state partners are doing all that we can to provide whole-person care through Medicaid and the Children’s Health Insurance Program (CHIP),” said CMS Administrator Chiquita Brooks-LaSure. “This new state plan option is about ensuring that children and families can get coordinated, high-quality care — particularly children with complex medical conditions. CMS is committed to working with states interested in pursuing this option to ensure they can quickly and efficiently get kids the care they need.”

 As outlined in today’s letter to state Medicaid directors, states will have the option to offer the new health home services benefit for children with medically complex conditions beginning October 1, 2022. The services provided under the new benefit include providing access to the full range of pediatric specialty and subspecialty medical services, including services from out-of-state providers, as medically necessary.

The guidance issued today provides information to states about the new health home benefit, including about payment methodologies, provider standards, provider and state reporting, state monitoring, and state assurance requirements. States with approved Medicaid state plan amendments (SPAs) to cover the new health home benefit will receive a 15 percentage point increase in federal matching for their expenditures on health home services during the first two fiscal year quarters that the SPA is in effect. CMS also has committed to offer ongoing technical assistance to states about implementation of the new benefit.

CMS has engaged with stakeholders since January 2020 on this opportunity. CMS issued a Request for Information to obtain feedback from the public, including advocates, families, and states, on best practices for coordinating care provided by out-of-state providers to Medicaid-eligible children with medically complex conditions and, in October 2021, issued a bulletin on those best practices.

To learn more about CMS’ latest guidance, consult the state Medicaid director letter available on https://www.medicaid.gov/federal-policy-guidance/downloads/smd22004.pdf