A snapshot of the Babies Can't Wait Program [Feb. 2007]

A SNAPSHOT OF THE
Babies Can't Wait Program

Background

The Babies Can't Wait (BCW) program is administered by the Department of Human Resources, under the authority of Part C of the Individuals with Disabilities Education Act (IDEA). This is a federally funded grant program to assist states in providing early intervention services to infants and toddlers (birth to age three years) with developmental disabilities, or who are at risk of a developmental delay due to diagnosed physical or mental condition that has a high probability of poor outcomes.
Coverage of Services

Services Provided
Multi-disciplinary assessment and evaluation Service coordination Early intervention services (including speech, physical, and occupational therapy) that are identified as necessary, from the multi-disciplinary evaluation

Federal regulation requires that other sources of funding such as private insurance are utilized before using federal IDEA funds. Federal law also allows Medicaid to be a payer of first resort. However, there is no requirement that Medicaid pay for services that would not otherwise be covered by that program (e.g. services that are not medically necessary or otherwise provided).

Coverage Under CMOs

The Care Management Organizations (CMO) are required to cover services that are medically necessary to correct or lessen physical illnesses and conditions. Medically necessary means that the treatment is:
Appropriate and consistent with the diagnosis Omission of treatment could adversely affect the member's condition Compatible with the standards of acceptable medical practice Provided in a safe, appropriate and cost-effective setting Not provided solely for the convenience of the member or provider Not primarily custodial or supportive

The CMOs are not required to cover services solely because they are part of the child's Individualized Family Service Plan (IFSP) developed through BCW.

Care Management Under CMOs

The CMOs are required to provide case management services for infants and toddlers at risk for developmental delay They are not required to cover the services provided by the BCW service coordinator, but could if they determined them medically necessary and non-duplicative The CMO requirements for case management, as defined in the contract are:
Early identification of Members who have or may have special needs; Assessment of a Member's risk factors; Development of a plan of care; Referrals and assistance to ensure timely access to Providers;

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February 2007

A Snapshot of the Babies the Can't Wait Program
The CMOs are required to provide case management services for infants and toddlers at risk for developmental delay They are not necessarily required to cover the services provided by the BCW service coordinator The CMO requirements for case management, as defined in the contract are:
Early identification of Members who have or may have special needs; Assessment of a Member's risk factors; Development of a plan of care; Referrals and assistance to ensure timely access to Providers; Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed; Monitoring; Continuity of care; and Follow-up and documentation
Role of Care Management Organizations
The CMOs were implemented to control the rapidly escalating health care costs, achieve budget predictability, consolidate fragmented systems of care, and improve the overall health status of Medicaid and PeachCare for KidsTM members To achieve all of these goals, it is essential that the CMOs are able to coordinate and integrate all aspects of a member's care and treatment, strengthen the use of the medical home, and reduce fragmentation and duplication of care Achievement of these goals will also require that CMOs establish new patterns and linkages in the delivery of health care. This may result in increased utilization of some services and decreased utilization of others Requests to carve out specific types of care ultimately serve to protect the provision of a specific treatment or service as it has been previously utilized, at the expense of overall system-wide improvements in the delivery of health care and improved health status of the population
Effect of HB 456 on Babies Can't Wait
HB 456 seeks to require CMOs to: Contract with health departments; Pay Federally Qualified Health Center rates, including wrap around payments; Force certain services for pregnant women and their newborns to be allowed at public health departments, away from the PCP; and Treat BCW the same as a Title V - CMS program
Ultimately, HB 456 takes the opposite approach that health practitioners support - that every person should have a medical home. Additionally, the effort to carve out BCW would create duplicative case management systems that CMS could take money back for.