InCK NOFO FINAL 2019 02 25.pdf

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services

Center for Medicare and Medicaid Innovation

Integrated Care for Kids (InCK)

Notice of Funding Opportunity Type: New

Funding Opportunity Award Type: Cooperative Agreement

Notice of Funding Opportunity Number: CMS-2B2-20-001

Notice of Funding Opportunity Number CFDA: 93.378

Notice of Funding Opportunity Posting Date: 2/8/2019

Applicable Dates:

Electronic Application Due Date: 6/10/2019

3:00 PM Eastern U.S. Time

Anticipated Issuance Notice(s) of Award: 12/2/2019

Anticipated Period of Performance: 7 years or 84 months

Table of Contents

Executive Summary

Model Overview

A. Program Description

A1. Purpose……………………………………………………………………………………………………………………………………………..6

A2. Authority

A3. Background

A4. Program Requirements

A5. Technical Assistance and Information for Prospective Applicants

B. Federal Award Information

B1. Total Funding

B2. Award Amount

B3. Anticipated Award Dates

B4. Period of Performance

B5. Number of Awards

B6. Type of Award

B7. Type of Competition

C. Eligibility Information

C1. Eligible Applicants (select all that apply)

C2. Letter of Intent

C3. Ineligibility Criteria

C4. Single Application Requirement

C5. Continued Eligibility Requirements

C6. EIN, DUNS, and SAM Regulations

C7. Foreign and International Organizations

C8. Faith-Based Organizations

C9. Other Eligibility Requirements

D. Application and Submission Information

D1. Address to Request Application Package (select one)

D2. Content and Format of Application Submission

D3. Unique Entity Identifier and System for Award Management (SAM)

D4. Submission Dates and Times

D5. Intergovernmental Review

D6. Cost Restrictions

D7. Mandatory Disclosure

D8. Other Submission Requirements (if applicable)

E. Application Review Information

E1. Application Review Criteria

E2. Review and Selection Process (select one)

E3. Federal Awardee Performance Integrity Information System (FAPIIS)

F. Federal Award Administration Information

F1. Federal Award Notices

F2. Administrative and National Policy Requirements

F3. Terms and Conditions

F4. Cooperative Agreement Terms and Conditions of Award

F5. Reporting

G. CMS Contacts…………………………………………………………………………………………………………………………….67

G1. Program Questions

G2. Administrative/Budget Questions

Appendix A. Guidance for Preparing a Budget Request and Narrative

Appendix B. Application and Submission Information

Appendix C. Application Check-Off List Required Contents

Appendix D. Business Assessment of Applicant Organization

Appendix E. Review and Selection Process

Appendix F. Program Duplication Assessment Questionnaire

Appendix G. Reporting Milestones

Appendix H: Timeline for Data Reporting Chart(s)

Appendix I: Glossary

Appendix J: 504 Compliance ………………………………………………………………………………………………………..….. 98

Executive Summary

The Integrated Care for Kids (InCK) Model provides funding opportunities to states and local organizations to test whether payment supporting integrated service delivery across behavioral health, physical health, and other child services reduces Medicaid and Children’s Health Insurance Program (CHIP) expenditures and improves the quality of care for covered children. The InCK Model will assist states and local communities in addressing priority health concerns for children, such as behavioral health challenges, including opioid and other substance use, and the effects of opioid use on families.

CMS will support Awardees in developing state-specific pediatric alternative payment models (APMs) that incorporate provider accountability and focus on meaningful improvements in care quality and health outcomes. Successful Awardees will use model funding to support infrastructure investments and activities necessary to support model planning and operations including (but not limited to): state and local investments in information technology, strategic planning and analysis for model design, model operations and staffing, and federal evaluation activities.

The InCK Model aims to empower states and local organizations to 1) Improve performance on priority measures of child health, including rates of substance and opiate use; 2) Reduce avoidable inpatient hospitalizations and out-of-home placements resulting from issues such as family instability driven by substance use; and 3) Create sustainable Alternative Payment Models (APMs) that ensure provider accountability for cost and quality outcomes. To achieve these goals, the InCK Model uses the following mechanisms:

1. Early identification and treatment through population-level surveillance, assessment, and risk stratification of children with multiple physical, behavioral, or other health-related needs and risk factors.

2. Integrated care coordination and case management across physical health, behavioral health, and other local service providers for children with health needs that impact their functioning in schools, communities, and homes.

a. Coordination of child health services across Medicaid and CHIP physical and behavioral health providers and federal, state, and local child services (e.g., schools, child welfare agencies, child nutrition programs);

b. Intensive, team-based case management for children at-risk for, or already in, out-of-home placement.

3. Development of state-specific APMs that align payment with care quality and support accountability for improved child health outcomes and long-term health system sustainability.

a. State participants in the InCK Model will work with local providers to tailor innovative payment approaches to their local contexts and priorities. Potential approaches include episode-based, shared savings, and population-based payment arrangements that incorporate meaningful quality measures and are designed in a manner that incents providers to adopt high-value, patient-centered practices.

Item Description

HHS Awarding Agency Centers for Medicare & Medicaid Services (CMS)

CMS Awarding Center Center for Medicare & Medicaid Innovation

Notice of Funding Opportunity Title Integrated Care for Kids

Authorization Section 1115A of the Social Security Act (the Act) as added by Section 3021 of the Patient Protection and Affordable Care Act (P.L. 111-148)

Funding Opportunity Type New

Funding Opportunity Number

CMS-2B2-20-001

Type of Award Cooperative Agreement

Catalog of Federal Domestic Assistance 93.378

Letter of Intent to Apply Due Date (if applicable) N/A

Application Due Date & Time 6/10/2019 3:00 PM Eastern U.S. Time

Anticipated Issuance Notice(s) of Award 12/2/2019

Anticipated Period of Performance 1/1/2020 12/31/2026

Anticipated Total Available Funding (subject to the availability of funds) $128,000,000

Estimated Award Amount: $14,500,000 up to $16,000,000

Estimated Number of Awards Maximum Eight (8)

Model Overview

The InCK Model is a child-centered state payment and local service delivery model aimed at reducing expenditures and improving the quality of care for children covered by Medicaid and CHIP through early identification and treatment of priority health concerns like behavioral health conditions, substance use, and physical health needs. CMS will award InCK Model cooperative agreements to partnerships between state Medicaid agencies and local organizations (hereafter called the “Lead Organization”) to leverage and build on existing child service programs. One or more state-driven alternative payment models (APMs) will support these partnerships to improve the coordination and quality of care through accountability for costs and outcomes. Model Awardees will develop local care delivery approaches and infrastructure to:

• Identify, assess, and risk-stratify children with or at-risk for significant behavioral health, substance use and physical health needs and utilization within their service area;

• Deliver integrated care coordination and case management across local child services, supported by child and family-centered information sharing and alignment of program eligibility and enrollment processes;

• Increase local capacity to shift care for children at-risk for, or already in, out-of-home placement to less costly and more effective home and community-based settings; and

• Implement one or multiple APMs that support the local integrated service delivery model and promote accountability for improved outcomes, such as lower rates of opiate and other substance use, as well as long-term health system sustainability.

A. Program Description

A1. Purpose

The Centers for Medicare & Medicaid Services (CMS), through its Center for Medicare and Medicaid Innovation (CMMI), will implement a new Medicaid and CHIP state payment and local service delivery model that supports state and locally-driven innovations to improve the health of children. The Integrated Care for Kids (InCK) Model will test whether combining a local service delivery model coordinating integrated child health services and a state-specific alternative payment model (APM) to support coordination of those integrated services reduces health care expenditures and improves the quality of care for pediatric Medicaid and CHIP beneficiaries.

A2. Authority

Section 1115A of the Social Security Act authorizes the Secretary of the U.S. Department of Health and Human Services to test innovative payment and service delivery models that reduce Medicare, Medicaid and CHIP expenditures while preserving or enhancing the quality of care.

A3. Background

Behavioral health conditions such as substance use disorders have a serious impact on the health and wellbeing of the American population. Early detection and intervention is critical for the prevention and treatment of behavioral health and substance use disorders. A study of individuals aged 18 to 30 admitted for the treatment of a substance use disorder found that 74 percent of those being treated began their substance use by the age of 17, with 10.2 percent starting by the age of 11 or earlier (Substance Abuse and Mental Health Services Administration, 2014). Furthermore, research has found that half of all lifetime cases of mental illness and substance use disorders start by the age of 14 (Kessler, Chiu, Demler, Merikangas, & Walters, 2005).

Opioid misuse has had a particularly high impact on communities across the country. In 2016 an average of 3.6 percent of adolescents 12-17 years of age misused opioids during the previous year; however, this rate increased to 8 percent by age 21 (Center for Behavioral Health Statistics and Quality, 2017). Early identification and intervention for at-risk children are challenging for children’s health care systems, but critical to improving behavioral health care, treating substance use disorders, stemming the opioid epidemic and improving the health of the next generation. This model offers states and local organizations a framework, funding, and support to address key health priorities like substance use and mental illness through child-centered care integration across behavioral health, physical health, and other child providers for Medicaid and CHIP beneficiaries up to age 21.

CMS released a public Request for Information (RFI) on the design of a pediatric APM in February 2017 in order to understand the challenges and opportunities encountered by providers and child health systems on the front lines of care. CMMI also directly engaged groups representing state Medicaid agencies, children’s health systems, and pediatricians (see RFI responses). Responses yielded consistent recommendations on the best approaches that promote healthy development and mitigate the risks of substance use early in life:

• Put children and families first and at the center of coordinated care across child programs: local innovators have demonstrated cost savings and quality improvement by coordinating care across state and federal child programs;

• Integrate physical and behavioral health care: pediatric behavioral health conditions are often undertreated, increasing risk for substance use and driving significant health care utilization;

• Prioritize home and community-based care: these services are often less expensive and more effective than care delivered in residential and inpatient settings.

These stakeholder recommendations directly informed InCK Model development. They demonstrate broad support for a framework that can guide states and communities to implement the best approaches that promote healthy development and mitigate the risks of substance use early in life.

A 3.1 Statement of Need

Behavioral health conditions and the use of opiates and other substances by children and youth drive significant morbidity, health care utilization, and premature death. Adolescent deaths from drug overdose are increasing, and opioids caused over half of drug-related overdoses among youth in 2015 (Department of Health and Human Services, n.d.). The National Institutes of Health (NIH) reports young adults ages 18-25 as the biggest abusers of prescription opioids, Attention Deficit Hyperactivity Disorder (ADHD), and anti-anxiety drugs; and half of lifetime mental illnesses and substance use disorders develop prior to adulthood by age 14 (National Institutes of Health, 2016). Estimates suggest that there are 119 emergency department visits and 22 treatment admissions for every young adult overdose death, suggesting the solution to this problem might go beyond access to care and instead rest in what care is accessed (Department of Health and Human Services, n.d.). There is a strong relationship between health-risk behaviors like substance use and poor physical and mental health outcomes like serious emotional disturbances, chronic medical conditions, and medically complex conditions.

Substance use is often co-occurring with mental illness and both share risk factors. Substance use prevention and coordinated treatment are crucial to reducing the number of deaths and related health care utilization among young Americans. Medicaid and CHIP, as the health insurers for one in three American children, play a significant role in ensuring that pediatric health systems focus on prevention and coordinated treatment (Department of Health and Human Services, 2016).

Preventive measures delivered during the earliest years of life can mitigate the effects of childhood trauma or adverse childhood experiences (ACEs) that contribute to increased risk of high rates of https://innovation.cms.gov/Files/x/pediatricapm-rfi.pdf https://downloads.cms.gov/files/pediatricapm-rficomments.pdf https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences behavioral health diagnoses in adolescence and adulthood. Examples of ACEs include household substance abuse; having unemployed parents; being born to teenage parents; being in foster care; and experiencing traumatic life events such as child abuse or exposure to violence. The number of children in the United States that are in foster care has steadily increased each year, with 437,465 children in foster care as of 2016 (Administration for Children and Families, 2016). ACEs are associated with the development of behavioral and physical health conditions in childhood, sometimes leading to substance use disorders and suicide attempts later in life. The greater a child’s exposure to ACEs, the greater their risk of developing substance use disorder and other behavioral and physical health conditions later in life (Felitti, et al., 1998).

Medicaid and CHIP cover some of the nation’s most vulnerable children: estimates show that more than one in three Medicaid-covered children have emotional or behavioral challenges. Less than one-third of these children currently receive behavioral health care (Center for Health Care Strategies, Inc, 2013), yet these services account for 38% of health care costs ($19.3 billion in Medicaid spending) (Lloyd, Simon, & Parker, 2015; Medicaid and CHIP Payment and Access Commission, 2015). CMS and states have demonstrated commitment to addressing child health through care redesign and program innovation, such as the Medicaid Health Home state plan benefit, the Medicaid Innovation Accelerator Program, home and community-based services (HCBS) programs, and CMMI models such as the State Innovation Models, the Strong Start for Mothers and Newborns Initiative, and several Health Care Innovation Awards. However, the ongoing opioid crisis has highlighted an opportunity for CMS to foster further innovation to improve the quality of care provided to pediatric Medicaid and CHIP beneficiaries at-risk for, or with, behavioral health challenges.

A 3.2 Considerations for Pediatric Care Innovation

Local, state, and federal child-focused programs such as Medicaid and CHIP, Head Start, child welfare services, and school-based nutrition programs offer children and their families services that can help address ACEs and other health-related needs that drive the development of significant behavioral and physical health conditions. Medicaid-covered children are often eligible for a variety of child service programs such as the Supplemental Nutrition Assistance Program, child care subsidies, or special education; however, access to these services and coordination across them can be challenging for families and providers because each program operates distinctly, may have different eligibility criteria and enrollment processes, and often do not share information with other programs, even for the purposes of care coordination or case management (Petitgout, 2013; Bethell, 2011). Lack of coordinated services leaves children at-risk of developing significant behavioral and physical health challenges, indicating a need for innovation in building the linkages between child programs that would provide children and their families an integrated care experience.

Improved prevention, identification, and treatment of physical and behavioral health challenges and substance use in pediatric populations requires: 1) population-level surveillance and screening for children with multiple physical, behavioral, or other health-related needs and risk factors, 2) child-centered enrollment and coordination of aligned health care and health-related service providers, and

3) intensive engagement of HCBS and other health-related supports1 to reduce rates of inpatient

1 For the purposes of this model, “health-related supports” are non-clinical services that support child health and are not covered by Medicaid 1915(c) home-and-community based services. Examples include SNAP, Head Start, and local child welfare.

hospitalization, residential treatment, and out-of-home placement. Pediatric accountable care organizations (ACOs) and behavioral health systems integration models are two promising pediatric care delivery models that demonstrate elements of these strategies. This model combines elements of these models to form an integrated care coordination and case management model supported by state-specific APMs.

A4. Program Requirements

CMS will use a competitive process to award cooperative agreements to successful applicants (Awardees) to design and implement the InCK Model in their community. Awardees may use funds only to support model planning and implementation activities such as staff time and infrastructure costs.

Awardees may not use model funds for the direct provision of services to beneficiaries. Cooperative agreements will consist of up to seven, one-year budget periods. Awardees who achieve satisfactory progress on program milestones will receive additional funding through budget periods two through seven, based on the availability of funds. Awardees must achieve satisfactory performance, as determined by CMS, on required program milestones designated for each performance quarter and year to continue receiving annual funding. Additional funding, which will be tied to Awardee performance on a set of specific program milestones, will be available during budget periods five, six, and seven of the model.

The InCK model will have the following key participants:

Awardee

CMS will award funding for InCK Model implementation through a cooperative agreement to a single entity, either a Lead Organization (see below) or a state Medicaid agency, depending on which of these parties submits the application. The Awardee will be responsible for determining the budget allocations for staff time and infrastructure costs consistent with the terms of the cooperative agreement, and demonstrating how the state Medicaid agency and Lead Organization will use funds to accomplish their respective roles in model implementation. The Awardee will be responsible for the receipt and management of CMMI funding in accordance with the model terms and conditions and applicable federal grant laws. The Awardee will be ultimately responsible for the achievement of all proposed milestones in both pre-implementation and implementation periods on a quarterly or annual basis as stipulated in this NOFO.

• During the Pre-Implementation period the Awardee must:

Hire and train Service Integration Coordinators sufficient to administer its state-specific

InCK program as detailed in the applicant’s proposal and any subsequest completed amendments to the proposal;

Hire and train sufficient administrative, ancillary and technical support staff to administer its program as detailed in the applicant’s proposal and completed amendments;

Implement streamlined eligibility and enrollment (E&E) measures and/or systems as detailed in the applicant’s proposal. This may include the functional deployment of any proposed publically-facing technologies, if proposed;

Deploy a functional crisis hotline with appropriately trained staff to ensure available 24/7/365 coverage for its attributed population;

Deploy a mobile response system with appropriately trained staff to ensure available 24/7/365 coverage for its target population;

Meet CMS expectations for attendance and participation in scheduled Project Officer calls, timely and complete submissions for quarterly progress reports, attendance at required learning events, and assisting with all CMS model support contractors;

Report any substantive operational impediments related to model implementation to CMS Project Officer;

Determine needs assessment tools providers will use to determine Service Integration Level (SIL) eligibility;

Develop informational materials for clinicians and health-related service providers;

Develop promotional materials for prospective beneficiaries (including notice of privacy practices);

Sufficiently meet all proposed milestones as detailed in their CMS-approved proposal and completed amendments by the end of their first performance year prior to receiving second performance year funds;

Finalize agreed processes and authorization/consent forms for model participation.

Awardees must adhere to all applicable Federal, state and local laws and ordinances, and should work with their counsel to determine what patient authorizations and reauthorizations may be required to implement the model as designed. Awardees will be responsible for monitoring and adhering to changes in these and all other applicable laws and regulations over the course of the model.

• During the Implementation period the Awardee must:

Implement the InCK Model; unless otherwise specified, maintain the infrastructure, processes, and programs established during the model pre-implementation period throughout the tenure of the model. As detailed above and throughout this notice, these include, but are not limited to, maintaining and supporting required staff to implement the model, continuing E&E measures and/or systems, continuing crisis hotline and mobile response systems, and meeting CMS expectations for attendance and participation in InCK model activities.

Lead Organization

A Lead Organization must be an existing or newly-created business entity (such as a hospital system, managed care plan, or local health department) that meets the definition of a covered entity subject to privacy laws under the Health Insurance Portability and Accountability Act (HIPAA). The Lead Organization will: serve as a community integrator, a trusted organization that can understand and represent the needs of the community; engage all the relevant service providers within a community (including health care services, public health, and human services); and leverage data-driven, community-level quality improvement across sectors toward shared goals for a defined population. The Lead Organization will be responsible for convening and representing the community, and will partner with the state Medicaid agency in developing the InCK Model application and implementing the model if awarded.

The Lead Organization will serve a crucial leadership role in convening partners to integrate the coordination and management of the InCK Model’s core child services for the attributed population. It must be able to convene community partners under a shared mission and vision to integrate child health services at the system level, beyond the individual or practice level. The Lead Organization will be responsible for improving population-level care quality and outcomes, convening and sustaining a Partnership Council (see below), and creating service integration protocols and processes.

The Lead Organization will collaborate with State Executive Office, state Medicaid agency, Medicaid payers (including managed care plans), and other state agencies as appropriate to align the service delivery model with a payment model. This collaboration is particularly important for purposes of identifying children at-risk for significant behavioral health, substance use and physical health needs among attributed populations, and stratifying those who meet the criteria thresholds defined by CMS into SILs.

• During the Pre-Implementation period the Lead Organization must:

Execute a formal contract with the state by the end of model year one. The Awardee must submit the executed contract to its Project Officer along with their Non-competitive Continuation Application for model year two.

Execute all business associate agreements (BAAs) with any persons or entities that will perform operations under the model that involve the use or disclosure of protected health information on behalf of, or provide services to, the Lead Organization.

Establish a Partnership Council and conduct regularly-scheduled meetings to implement the model and conduct ongoing process improvement.

• During the Implementation period the Lead Organization must:

Maintain the Partnership Council and conduct regularly-scheduled meetings to implement the model and conduct ongoing process improvement.

Continue to support the model as a representative of the community and a partner to the state, fulfilling all ongoing responsibilities initiated during the pre-implementation period for improving population-level care and quality outcomes.

State Medicaid Agency

The state Medicaid agency must commit to partnering with the Lead Organization to implement the InCK Model. The state Medicaid agency will be responsible for supporting local implementation of the model by providing data on the attributed population (e.g., number of Medicaid enrollees), supporting the development of information sharing arrangements and infrastructure, aligning support for the model across child-focused state agencies, and designing and implementing the pediatric APM. States using Medicaid managed care must use the pre-implementation period to work with managed care plans in their InCK Model service area to support APM implementation and ensure that existing managed care plan care coordination and case management efforts are incorporated into the efforts of the Awardee.

• During the Pre-Implementation period the state must:

Work with the Lead Organization to conclude a formal contract with the state by the end of model year one. The Awardee must submit the final signed contract to their Project Officer with their Non-Competing Continuation (NCC) application for model year two;

Conclude all business associate agreements (BAAs) as needed to conduct all operations;

Provide the Lead Organization population-level data;

Provide CMS (either directly or through the Lead Organization) with complete and timely claims and encounter data with unique, traceable identifiers for the model’s attributed population and comparison group;

- Develop a plan to share required claims and encounter data with the CMS Evaluation Contractor in the event of significant difficulties meeting this requirement through the Transformed Medicaid Statistical Information System (T-MSIS); and

Begin design of the APM(s) including contacting CMCS to initiate securing any necessary state plan amendments (SPAs) and/or waivers as soon as possible after award. CMS will not approve NCC applications for model year three unless any and all SPAs and/or Medicaid waivers necessary for model implementation are in place. The Awardee must inform their Office of Aquistions and Grants Management (OAGM) grants manager and CMS Project Officer of all milestones and any difficulties in meeting the proposed timeline for these requirements;

Note: States that predominantly use Medicaid managed care delivery systems will be expected to use the model pre-implementation period to work with the managed care plans as necessary to support implementation of the APM and ensure that existing managed care plan care coordination and case management efforts are aligned with the efforts of the InCK Model.

• During the Implementation period the state Medicaid agency must:

Implement the APM(s) for the InCK model population. Specifically, beginning in year 4

(year 2 of performance period) or sooner, all Awardees must implement their APMs, which means at a minimum that Medicaid payments to providers furnishing integrated care coordination and case management services to beneficiaries in SILs 2 and 3 will be paid through the APM(s); and

Continue to provide CMS required evaluation data, including complete and timely claims and encounter data for the model’s attributed population and comparison group, either through the Transformed Medicaid Statistical Information System (T-MSIS) or other acceptable means approved by CMS.

Partnership Council

The Lead Organization will convene one or multiple Partnership Councils (For more information, see section A 4.2.1.1.4 Partnership Council Convening) that will operate for the tenure of the model. The Partnership Council will comprise of child service system representatives with a vested interest in children’s welfare and community-level service integration. The Partnership Council must include representatives from at least each of the model’s Core Child Services and any optional service types the Lead Organization elects to include as defined in section A 4.2.1.1.4. The Partnership Council must also include representatives that serve children in the designated geographic service area from the local health department, community stakeholder representatives, and Medicaid payers, including managed care plans in positions that allow them to effect change within their organizations to support the Lead Organization. The Partnership Council’s primary responsibility will be to devise strategies for its assigned community to achieve the coordination of service types as described in this NOFO.

• During the Pre-Implementation period the Partnership Council must:

Enter into written data-sharing arrangements with other Partnership Council members as detailed in their proposal and completed amendments;

Report all obstacles, proposed modifications, or significant functional impediments to the Lead Organization and/or Awardee for communication to the CMS Project Officer;

Develop processes for managing care coordination services across Core Child Services;

and Work cooperatively for the overall achievement of model goals.

• During the Implementation period the Partnership Council must:

Continue to support the model and include representatives from all previously listed stakeholder entities, meet regularly with and advise the Lead Organization with regard to its responsibilities under the model.

A 4.1 Application Submission Requirements

A Lead Organization and a state Medicaid agency must partner in completing a single InCK Model application and choose which partner will submit the application. Though there will be one Awardee, the state Medicaid agency and Lead Organization must commit to work together to implement the model if awarded. Each application for the InCK Model must include the documents outlined in Section D2: Content and Format of Application Submission. Applicants will need to review and address the programmatic requirements listed and described below from A 4.2.1 to A 4.2.3 for submission of the following required documents: Project Narrative, Memorandum of Understanding, Partnership Council, and Program Duplication Questionnaire.

A 4.2.1 Model Implementation Plan

A 4.2.1.1 State and Local Community Engagement

A 4.2.1.1.1 Model Service Area A 4.2.1.1.2 Organizational Capacity A 4.2.1.1.3 Memorandum of Understanding A 4.2.1.1.4 Partnership Council Convening

A 4.2.1.2 Service Integration Plan

A 4.2.1.2.1 Care Map A 4.2.1.2.2 Stratification Plan A 4.2.1.2.3 Information Sharing Infrastructure

A 4.2.1.3 Medicaid and CHIP Authorities and Alternative Payment Model Proposal

A 4.2.2 Model Impact Analysis

A 4.2.2.1 Root Cause Analysis

A 4.2.2.2 Health Outcomes and Cost Savings Projections

A 4.2.3 Program Duplication Questionnaire

A 4.2 Application Sections

CMS expects that upon award the state Medicaid agency will use Medicaid and CHIP authorities to support model implementation. States may already have the necessary authorities for implementation, or they may need to work with CMS (in particular, the Center for Medicaid and CHIP Services (CMCS)) to amend their state plan or obtain waiver(s). InCK Model applications must include a description of the Medicaid and CHIP authorities that Awardees anticipate using to implement the model. These details are solely for the purpose of InCK Model application review and do not represent a formal request for a state plan amendment, waiver, or demonstration approval on the part of the state nor a commitment to approval on the part of CMS. If awarded, the state Medicaid agency will work with CMMI, CMCS, and the Consortium for Medicaid and Children’s Health Operations (CMCHO) to refine the concepts detailed in the Medicaid and CHIP authorities proposal during the pre-implementation period of the model.

Applicants should address the following areas as part of their application:

• What Medicaid services authorized under the Social Security Act will be provided?

• What coverage authorities would be necessary to implement these services?

• What is the payment methodology for these services? (Please note that payment methodologies must comply with all Medicaid statutory and regulatory requirements.)

• Who will be providing these services to Medicaid beneficiaries? (Please note that federal matching funds can only be provided for Medicaid authorized services provided by Medicaid qualified providers to eligible Medicaid beneficiaries.)

• What is the allowable source of funding for the non-federal share of the Medicaid payments?

• Will you be operating this model through managed care and/or fee-for-service?

Applicants should include sections covering the following areas:

A 4.2.1 Model Implementation Plan

Applicants must submit information on their ability to engage state and local community partners to support model implementation, their plan to achieve the InCK service integration model, and their approach to designing APMs and supporting model sustainability. Applicants must include all subsections of their implementation plan within their project narrative.

A 4.2.1.1 State and Local Community Engagement

Applicants must provide information to demonstrate state Medicaid agency and local Lead Orginization interest in partnering with CMMI to implement the InCK Model. This section should include a narrative description of the Lead Organization, its background as an organization, role in the community where the InCK Model will be implemented, and its capacity to implement the required model activities.

Applications should also include a Memorandum of Understanding, detailed in section A 4.2.1.1.3, demonstrating coordination and communication between the state Medicaid agency and Lead Organization, and information on the community-level partners the Lead Organization will convene as a Partnership Council to implement the model as detailed in section A 4.2.1.1.4.

A 4.2.1.1.1 Model Service Area

Applicants must define one or multiple state administrative division(s) that functions as their model service area for this model and an in-state comparison population that CMS could potentially use for InCK Model evaluation purposes.

An applicant’s model service area may be contiguous or non-contiguous, but it may not be statewide or cross state borders. Awardees must obtain prior approval from CMS before altering their service area during the entire seven-year model period. Awardees must be prepared to serve all Medicaid and, if specified in the Awardee’s application, CHIP beneficiaries from the prenatal period up to 21 years of age residing within their model service area; these beneficiaries will make up the attributed population.

Throughout this NOFO, CMS will refer to the pediatric beneficiaries residing in the model service area as attributed “child” or “children.” Applicants must include all Medicaid- and CHIP-covered children residing in the model service area in their attributed population from birth until their 21st birthday.

Including the prenatal period is optional, however, if elected Awardees must define the prenatal period as inclusive of both the health of the fetus and Medicaid-covered pregnant woman, regardless of her age. Awardees may not include any beneficiaries who are aged 21 or older in their attributed population unless they are Medicaid-covered pregnant women.

Applicants must identify a comparison population in their application that mirrors their attributed population as closely as possible on factors such as demographics and prevalence of targeted conditions (see section F 5.2: Model Evaluation Data for the in-state comparison group requirement). Applicants must clearly designate their proposed model service area and the comparison group in the form of zip codes, counties, metropolitan statistical areas, or other designation that denotes a state administrative division. This information should be submitted as part of the root couse analysis as detailed in section A 4.2.2.1.

This model does not require beneficiaries to change care providers as a result of inclusion in a model’s attributed population, or participate in model intervention activities such as integrated care coordination or case management services. However, Awardees must assess the needs of, and collect data on, all attributed beneficiaries for InCK Model monitoring and evaluation purposes. The InCK Model offers Awardees the flexibility to identify subpopulations of their attributed population that may benefit from targeted services as part of broader population health strategies to achieve cost and quality goals.

The Awardee must provide CMMI, or its designated contractor, on an annual basis with 1) a retrospective list of all attributed beneficiaries that had Medicaid (or CHIP, if applicable) coverage for at least one month during the previous 12 months, and 2) a retrospective list of all comparison group beneficiaries that had Medicaid (or CHIP, if applicable) coverage for at least one month during the previous 12 months. Awardees must submit these two lists annually when they submit their Annual Progress Report to CMMI. The retrospective lists must specify the duration of each child’s Medicaid or CHIP coverage during the last 12 months and contain a unique identifier for every attributed and comparison group child such that evaluators can trace the beneficiary’s claims and encounter data longitudinally.

A 4.2.1.1.2 Organizational Capacity

Each applicant must demonstrate an existing, strong partnership between the Lead Organization and the state Medicaid agency, and significant experience in community leadership and engagement.

Applicants should illustrate that they have the capacity to bring community stakeholders together with the Lead Organization and state Medicaid agency to develop population-level goals and implement successful interventions to remove access barriers to integrated care for the pediatric Medicaid population with significant health needs.

A 4.2.1.1.3 Memorandum of Understanding

Applicants must provide a signed Memorandum of Understanding (MOU) between the Lead Organization and the state Medicaid agency that demonstrates evidence of a strong relationship and joint commitment to InCK Model implementation. The MOU must establish the Lead Organization and the state’s roles and describe in detail how the entities will work together throughout the model performance period until successful completion. The MOU must also include a statement that describes any restrictions on sharing of protected health information (PHI) and personally identifiable information (PII), for example, any applicable state laws or IRB approval processes. The statement must include an explanation of whether those barriers would prevent the state, Lead Organization, or any community partners participating in the Partnership Council from fully participating in model implementation or evaluation activities. The statement must include, at a minimum:

• Acknowledgement of the obligation of both the state Medicaid Agency and Lead Organization to share attributed individual- and population-level data with CMS and its contractors, as outlined in Section F5 of the NOFO;

• Commitment to providing unique identifiers for the attributed population and comparison group that allow evaluators to trace beneficiaries’ claims and encounter data across time; and

• Any anticipated barriers to providing CMMI monitoring or evaluation data, including data lag and legal or other regulatory barriers, and how the applicant proposes to mitigate any negative effects those barriers have on achieving the goals of the model.

A 4.2.1.1.4 Partnership Council Convening

Lead Organizations will convene a Partnership Council comprised of a group of Core Child Service representatives with a vested interest in children’s welfare and community system change. Partnership Councils serve as an advisory body to the Lead Organization’s population health management strategies, including procedures and processes to integrated care coordination and case management across Core Child Services. At the Lead Organization’s discretion, there may be a Lead Organization member who serves on the Council as well.

Partnership Council members must be local leaders in positions that empower them to affect change within their organizations—including coordinated eligibility and enrollment across their child-serving programs—and contribute to InCK Model formation. Existing community groups that meet Partnership Council criteria may serve this role, or be newly convened for the purposes of the InCK Model. In the event that a Lead Organization plans to serve a large service area that contains multiple smaller communities, it may convene a distinct Partnership Council per community, provided that the membership of each Partnership Council have full membership from its community as described here.

Partnership Councils must have at least one member from:

1) the local health department;

2) stakeholder representatives from families and caregivers living in the community;

3) Medicaid payers, including all applicable managed care plans and the state Medicaid agency; and

4) All applicable organizations delivering Core Child Services listed below

Applicants have the option, and are encouraged, to include other partners listed under the Recommended Optional Partners section.

The Partnership Council must include members that provide the following core child services:

Core Child Services:

(a) Clinical care (physical): At a minimum providers that deliver Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, including oral health, pre-natal services and reproductive health, primary care, well child visits, and emergency/crisis stabilization services. Lead Organizations should also include home-and-community-based services (often covered by Medicaid or Title V), such as care coordination, respite care, environmental modifications, nutrition services, rehabilitative and habilitative services, durable medical equipment and assistive technology, and other services that could benefit their populations.

(b) Clinical care (behavioral): Services that address mental and behavioral health needs such as those that address substance use, intergenerational transmission of trauma or toxic stress, genetic conditions requiring therapeutic services, acute or chronic mental disorders, and various challenges ranging from mild to severe such as emotional disturbance, post-traumatic stress disorder, oppositional defiant disorder, and/or substance use disorders.

(c) School district or equivalent: Health services delivered in schools, including but not limited to food and nutrition and Medicaid-covered services delivered in schools including school nursing services, if present, physical therapy/occupational therapy/speech therapy, and others. HCBS furnished in schools must not be otherwise available to the child through a local educational agency under the Individuals with Disabilities Education Improvement Act or the Rehabilitation Act of 1973.

(d) Housing: Community-based housing services that address any of the five HHS-defined housing instability conditions: high housing costs, poor housing quality, unstable neighborhoods, overcrowding, and homelessness.

(e) Food: Federal, state, and community-based programs that address food insecurity and nutrition such as the Supplemental Nutrition Assistance Program (SNAP), Women, Infants, and Children (WIC), and school lunch/breakfast programs.

(f) Early care and education: Federal, state, school-based and community-based programs that address infant, toddler, and/or young child development, including special education, Early Intervention, home visiting programs, and other related services (if present).

(g) Title V Agencies: Agencies that receive funds from the Maternal and Child Health (MCH) Services Block Grant (Title V of the Social Security Act) to support health and welfare services to mothers and children with special health needs.

(h) Child welfare: State and local child welfare programs.

(ii) Mobile crisis response services. Lead Organizations will develop a system for responding to the initiation of crisis/stabilization services. These services must include behavioral health crises as a minimum including substance use; communities may choose to offer these services for other crises, for example, eviction or domestic violence. The mobile response system must include the ability to send staff to a child’s residence to stabilize the crisis situation and perform a needs assessment. The mobile response system should also include a central hotline that is widely advertised in the target population and can be called to trigger service initiation. Awardees should consider additional pathways to initiate crisis/stabilization services, such as via a clinician, other provider, or law enforcement professional.

Awardees must set policies clarifying what types of crises are appropriate for the crisis hotline and which are best addressed by calling 9-1-1.

Recommended Optional Partners (Not Required) Lead Organizations may consider working with the following entities, if not otherwise represented in the Partnership Council, in order to coordinate child providers in their community.

(j) Law enforcement: Police are often first-responders to address behavioral health crises and/or child welfare issues.

(k) Family/Juvenile Courts: Family and/or juvenile court systems and detention centers are well-positioned to divert youth into community- and home-based services rather than the juvenile justice system.

(l) Civil Legal Aid: Civil legal aid has historically worked to address access to key health-related services, such as Medicaid and public benefits including SNAP.

(m) Other Community Partners: Awardees may identify other key partners, especially other partners that provide health-related child services in the community, to serve as members. Examples of such entities include domestic violence centers, faith-based entities, and therapeutic foster care providers.

As evidence of local engagement and commitment, applicants must submit a separate Partnership Council Charter signed by each participating member of the Council, including a description of the formation of the Charter, the Council’s focus and direction, and the core principles for working together.

The Partnership Council Charter should include a description of each member’s background and experience in integrating care for pediatric Medicaid beneficiaries, and detail their responsibility for care coordination under the model within the target community. The Charter should demonstrate each Council member’s commitment to participating in the service integration plan for the life of the model and their preparedness to improve the experience of children served.

A 4.2.1.2 Service Integration Plan

Lead Organizations must coordinate the systematic integration of the Core Child Services within their model service area for the purposes of integrated care coordination and case management as described in Section A 4.2.1.2.2 for SILs 2 and 3. CMS does not fund all of the Core Child Services; Lead Organizations and their community partners will need to coordinate these services so that families receive an integrated experience of care despite separate funding streams.