Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
JAMA Netw Open. 2022 Oct 3;5(10):e2239270. doi: 10.1001/jamanetworkopen.2022.39270.
Families of children with medical complexity (CMC) report barriers to accessing affordable coverage for the full range of services their children may need to optimize their health outcomes. Medicaid enrollment through medical need-based eligibility mechanisms can help cover these service gaps. Understanding state-by-state variation in how CMC access Medicaid may allow policy makers and pediatricians to help families navigate needed services for CMC.
To clarify how eligibility and coverage for CMC differ for Medicaid beneficiaries across states with different policies and managed care penetration.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study used semistructured interviews with state Medicaid representatives from 23 states and Washington, DC, from February 1, 2020, to March 1, 2021. Enrollment pathways and coverage processes were discussed. Interviews were transcribed and content analysis was performed. Participants included Medicaid directors, a designee, or a state-identified policy leader with expertise in and/or responsibility for child-focused programs.
State variation in Medicaid eligibility and delivery policies.
Eligibility pathways and coverage mechanisms for CMC in each state.
A total of 43 informants from 23 states and Washington, DC, participated, which permitted data collection regarding almost half of the US. Four distinct eligibility pathways were characterized, with 3 specific to CMC, and the pathways that include the presence of waiting lists were distinguished. In addition, 3 coverage types at the state level were identified, consisting of fee-for-service, Medicaid managed care, or both. Two main connections between pathways and coverage mechanisms for CMC were described.
The findings of this qualitative study suggest that state patterns in Medicaid eligibility and coverage for CMC have implications for access, including some states with substantial waiting periods for these families. Future work is needed to understand the implications of these differential Medicaid medical need-based eligibility pathways and subsequent coverage mechanisms on use of health care resources and expenditures, as well as considerations regarding challenges families of CMC face due to state-by-state variation.
患有医疗复杂性（CMC）的儿童的家庭报告称，在获得他们的孩子优化健康结果所需的全方位服务方面，他们在获得负担得起的覆盖范围方面存在障碍。通过基于医疗需求的资格机制加入医疗补助计划可以帮助填补这些服务空白。了解各州在 CMC 获得医疗补助的途径方面的差异，可以让政策制定者和儿科医生帮助家庭为 CMC 获得所需的服务。
阐明各州的医疗补助资格和覆盖范围在政策和管理式医疗渗透率不同的情况下，对于 CMC 受益人的差异。
设计、地点和参与者：这项定性研究使用了来自 23 个州和华盛顿特区的 23 个州的 Medicaid 代表的半结构式访谈，时间为 2020 年 2 月 1 日至 2021 年 3 月 1 日。讨论了入学途径和覆盖流程。访谈记录被转录，并进行了内容分析。参与者包括 Medicaid 主任、指定人员或州内负责儿童相关计划的政策专家。
医疗补助资格和交付政策的州际差异。
每个州 CMC 的资格途径和覆盖机制。
来自 23 个州和华盛顿特区的 43 名知情人参与了调查，这几乎涵盖了美国的一半。确定了四种不同的资格途径，其中三种是专门针对 CMC 的，并且区分了存在候补名单的途径。此外，还确定了州一级的三种覆盖类型，包括按服务收费、医疗补助管理式医疗或两者兼而有之。描述了 CMC 途径和覆盖机制之间的两个主要联系。
这项定性研究的结果表明，医疗补助资格和 CMC 覆盖范围的州模式对获得医疗补助的机会有影响，包括一些州对这些家庭有大量候补名单。未来需要开展工作，了解这些不同的基于医疗需求的 Medicaid 资格途径和随后的覆盖机制对医疗保健资源和支出的使用以及家庭面临的挑战的影响，因为各州之间存在差异。
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