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On January 6, The Centers for Medicare & Medicaid Services (CMS) approved Medicaid State Plan Amendment . The SPA authorizes the California Department of Health Care Services Service (DHCS) to use an alternative payment methodology (APM) to pay Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and Tribal Health Programs at the Medi-Cal fee-for-service (FFS) rate for dyadic services. FQHCs and RHCs will receive a separate payment for dyadic services in addition to their standard prospective payment system (PPS)/all-inclusive payment rates in certain circumstances. This SPA is retroactively effective to March 15, 2023.

Key provisions are as follows:

• 颁补濒颈蹿辞谤苍颈补鈥檚 new set of dyadic benefits supports relationship-based caregiver and family surveillance and family-based interventions that bolster child development, recognizing the importance of the parent/caregiver and child dyad to support healthy child development. Dyadic health care services are ideally provided in the context of routine well child care in pediatric settings, meeting families where they regularly receive health care and related services.
• Services are linked to a child鈥檚 Medi-Cal coverage, providing a basis for revenue recovery for primary care pediatric settings and for cases in which the parent/caregiver may not be a Medi-Cal beneficiary.
• Services are exempt from the same day exclusion applied to FQHC and RHC settings. If FQHCs or RHCs have met their visit per day limit, then dyadic services provided to Medi-Cal-eligible members (children or parents/caregivers) will be reimbursed at the FFS rate. Any dyadic services that are provided to a non-Medi-Cal-eligible parents/caregivers for the direct benefit of Medi-Cal-eligible children will be reimbursed at the FFS rate.
• Payment for dyadic FQHC and RHC services will be reimbursed at the applicable FFS rate in addition to Medi-Cal member visits, which are reimbursed at the applicable PPS rate.

In addition, the dyadic care benefit provides a pathway for families to access additional supports via the new . Family therapy is a psychotherapy service that managed care plans provide under Medi-Cal鈥檚 Non-Specialty Mental Health Services benefits. Family therapy services support members younger than age 21 to receive up to five family therapy sessions before a mental health diagnosis is required. More importantly, children and youth (younger than age 21) may receive family therapy without the five-visit limitation if they (or their parents/caregivers) demonstrate certain risk factors, including separation from a parent/caregiver because of incarceration, immigration status, or death; foster care placement; food insecurity; housing instability; exposure to domestic violence or trauma; maltreatment; severe/persistent bullying; and discrimination.

量子资源网 (量子资源网) has been proud to partner with HealthySteps, as a DHCS-recognized model, to provide an evidence-based ( approach to implementing the new dyadic care benefits. Contact our experts below to learn more.

Ohio Medicaid is no stranger to change. Over the last several years, there have been several broad policy changes, from a new managed care system, to new programs like OhioRISE, to an expansion of MyCare Ohio. And, during this time, there have been complicating factors like the covid-19 public health emergency and the resultant impact of inflation on the basic delivery of services and care. Now, as the Trump administration comes in for the second time, questions arise as to what to expect in Medicaid policy and how it may impact Ohio.

While it鈥檚 often overlooked, federal rule making has a significant impact on the operations of states. Just in the last couple of years, the Biden Administration has implemented policies including:

• 罢丑别听, such as the 80/20 policy, implementation timelines, and other questions regarding Home and Community Based Services waivers that states and certain stakeholders elevate to the Centers for Medicare & Medicaid Services (CMS).
• 罢丑别听, which聽addresses Medicaid聽managed care聽access, financing, and quality, including strengthening standards for timely access to care and states鈥� monitoring and enforcement efforts.
• The Long-Term Care Facility (聽requires minimum聽聽for nursing facilities.
• Two rules streamline Medicaid enrollment and renewal processes for the聽聽(MSP) and for聽. Each rule is expected to increase Medicaid enrollment by about one million people.

These rules are set to be implemented over several years. The Trump Administration could delay implementation of certain provisions, which would eliminate regulations while rolling back enrollee protections, payment transparency, and improved access. Alternatively, the Trump Administration could adjust their enforcement strategy or issue new regulations that would undo or augment these final regulations.

Beyond regulation, there is still the potential for fundamental policy change to the program鈥檚 financing. Notably, the concept of block grants or per-capita caps has reemerged as a potential option, where states would no longer receive federal 鈥渕atch鈥�, but rather a fixed amount based on historical averages. In fact, Energy and Commerce as an area of active conversation in the House Republican Caucus.

Making a fundamental, national change in the financing arrangement of Medicaid would require an act of Congress. Many think this movement away from a traditional reimbursement structure was one of the main reasons for the failure to repeal the Affordable Care Act during the first Trump administration. Notably, as Ohio is a 鈥渞ecipient鈥� state, meaning it receives more in federal taxes than it provides for the Medicaid program, this could significantly impact the long-term financial stability in future state budgets. Often, this challenge is why block granting is usually associated with additional state powers around curbing enrollment, services and coverage, so states may more easily cut the program to accommodate tighter financing.

Depending on how all of these changes would unfold, Medicaid programs, including Ohio鈥檚 may have to adopt their systems to accommodate. However, the Trump administration may also pursue greater flexibility for states to design and innovate in Medicaid in ways that are consistent with their goals. This could include greater flexibility to limit covered services, raise cost-sharing requirements, limit enrollment or require more frequent determination of eligibility. There may also be programmatic refocusing away from initiatives which center health equity and expanded coverage, including alternatives to 鈥淢edicaid expansion鈥�, as well as a fundamental reorientation of the use of waivers.

Speaking of waivers, there is likely going to be a dramatic change in the way waivers are applied and executed. This can include, but is not limited to, waivers that test new policies the prioritize cost-cutting measures over access and coverage, including waivers which change how the Medicaid expansion group is managed in states. Included in this are 鈥淲ork Requirement鈥� waivers, something . While examples from other states have shown that such waivers are , the Trump administration and many policymakers see these requirements as a way to ensure labor force participation. Though there is evidence to suggest

As Ohio providers, plans and policymakers gear up for the next state budget, the landscape of Medicaid policy will be something to pay attention to. While Medicaid represents nearly 48% of the total state budget, . What鈥檚 more, nearly 1 in 3 Ohioans rely on the program, disproportionately in rural communities, and it supports Ohio鈥檚 second largest industry in healthcare. Make sure you stay on top of the latest updates to the program in Ohio and beyond and sign up for 量子资源网s Weekly Roundup.

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