Examples of Program Linkages
Introduction
Head Start and Medicaid programs have collaborated in a variety of ways in locations across the country. This chapter describes and compares several examples of linkages between local Head Start and Medicaid programs. While not an exhaustive list, these particular examples were chosen because they demonstrated the scope of possible arrangements for these partnerships. Although the number of examples provided in this guide is small, these examples may contribute to an understanding of workable, practical approaches to building relationships between Medicaid and Head Start.
When reviewing the examples, Head Start programs should consider the following questions about the structure of the linkage:
What EPSDT-related services are provided in the Head Start program? Which services are reimbursed by the Medicaid program? What types of providers are used? Who bills Medicaid for services? How will Head Start serve children whose families choose other providers. or who may be served by Medicaid managed care arrangements?
These questions will be examined more fully in the comparison that follows the descriptions of the individual partnerships.Examples of Linkages
AUSTIN, TEXAS
Summary
Child Incorporated (Child Inc.) in Austin, Texas, is a large, private, non-profit corporation providing Head Start services to over 1,500 children annually. Ninety percent of Child Inc. families meet the Federal poverty guidelines. Child Inc. became an EPSDT enrolled provider in June 1990. Child Inc. contracts with a private medical clinic to provide EPSDT screenings primarily through health fairs during Head Start enrollment. Outreach and case management are provided by Child Inc. staff. Child Inc. captures EPSDT reimbursement for health care services, such as the health screenings, and some treatment for acute health problems like middle ear infections.
DescriptionChild Inc. provides outreach, case management, and screening services to approximately 1,500 children enrolled in Head Start. Approximately 550 children and their families are enrolled in Medicaid. Each year when Child Inc. enrolls children in the Head Start program, approximately thirty percent are already enrolled in Medicaid and another 10 percent are provided assistance with enrollment. Other children use private providers, HMO's, or other managed care organizations for these services. Child Inc. has discovered that many families have access to these other providers, and that Medicaid policy directs that each family be able to choose from available providers. Child Inc. uses health component funds to pay for physicals if a child has no other provider and does not qualify for Medicaid.
Screening and diagnostic services are provided through a contract with Child Inc. by a Children's Evaluation and Therapy Center. The Children's Evaluation and Therapy Center is staffed by nurse practitioners, a physician, an audiologist, and an occupational therapist.
During enrollment each year, the Child Inc. staff organize a health fair for each Head Start center. Each child who is enrolled during the health fair in the Head Start program receives a medical screening, which includes a comprehensive physical, mental health and developmental history and assessment, laboratory tests (including lead screening), and vision, hearing, and dental screening. The Head Start physical meets all the requirements of the EPSDT comprehensive unclothed physical exam. If children do not receive the physicals at the time of enrollment, then health, services are provided on site in the Head Start Center. If a family uses another provider to conduct the child's required physical examination, they may bring the results of the physical examination to Child Inc. or sign a release allowing Child Inc. to request a report from the provider.
Some treatment is provided by the physician and the nurse practitioners through the evaluation and therapy medical clinic. However most of the treatment services are provided by private providers, such as hospitals or local physicians in the Austin area. Child Inc. establishes a log of services performed on each Head Start child which enables the staff to track the health status of each child and make referrals as needed for further diagnosis and treatment. The Health Coordinator and the health component staff make referrals and schedule appointments when treatment services are needed. Transportation is provided to treatment services by Child Inc. if the family does not have its own transportation and if another agency does not provide transportation.
In Texas the overall administration of the Medicaid program is the responsibility of the Department of Human Services, which contracts with a private insurance company to recruit providers, to make payment to providers, and to conduct provider relations. Child Inc. processes the billing statements for the EPSDT services provided to the Head Start children. All billing statements are forwarded to the private insurance company that performs claims payment. Overall, Child Inc. recovers a small portion of the total cost of the mandatory physicals through the EPSDT reimbursement.
For more information, please contact:Stuart W. Reynolds, Ph.D.
Health Coordinator, Child Incorporated
818 East 53rd Street
Austin, Texas 78751
(512) 451-7361
MAINE
Summary
In the State of Maine, an agreement between the Bureau of Medical Services and the State Office of Head Start enables the 13 Head Start Programs in the State to provide and bill for EPSDT outreach, case management, screening, diagnostic, and treatment services. (The interagency agreement has been in effect since March 1993.) The Bureau of Medical Services administers the Medicaid program in the State of Maine, including provider enrollment and reimbursement. A Head Start Collaboration Project funds the position of Director of the State Office of Head Start. The Director is responsible for coordinating and developing integrated policies and guidelines for the provision of EPSDT services in the 13 Head Start Programs in the State. These Head Start Programs are reimbursed for both administrative and targeted case management.
DescriptionThe State Office of Head Start reports that 81 percent of the State's 3,000 Head Start children are enrolled in Medicaid. Each of the 13 Head Start programs bill for a full range of EPSDT services on the HCFA Form 1500.
In the area of outreach, the Maine Head Start programs bill for such activities as: informing Medicaid eligible families about the Medicaid program; informing Medicaid eligible pregnant women of the EPSDT program for children under the age of five; developing and disseminating materials to families who for any reason cannot read or understand printed material; informing eligible families about transportation opportunities; and developing transportation resources for Medicaid eligible families.
Case management in Maine's Head Start programs is discussed at length because, at the time of this manual's publication, very few Head Start Programs are being reimbursed for case management. Case management is reimbursed under the heading of administrative case management or targeted case management. Administrative case management involves the activities related to the Preventive Health Program. The service is designed to assure the availability and accessibility of required health care resources and to help families use the services which are available to them for the health of their child. Administrative case management is reimbursed according to a standard percentage determined by studies of time spent on Medicaid reimbursable functions. Targeted case management is reimbursed according to the actual amount of time devoted to managing the case of a particular Head Start child. Case management is typically conducted by staff in the Health, Social, and Parent Involvement components.
Service delivery varies considerably in the 13 Head Start programs, although the typical services include health screening, examinations, treatment, and counseling. The agreement between the State Office for Head Start and the Bureau of Medical Services includes an integrated program for services to children with disabilities who qualify under P.L. 99-457. Examples of services under screening, treatment, and counseling include vision and hearing screening, primary health care services, EPSDT partial screenings, speech therapy, occupational therapy, physical therapy, psychological testing and evaluation, and counseling for children and their parents. The providers who serve the 13 Head Start Programs include staff hired by Head Start and staff contracted by Head Start.
For additional information, please contact: Nancy Fossett
Director, Maine State Office of Head Start
Department of Human Services
Bureau of Children and Family Services
221 State Street
Augusta, Maine 04333
(207) 287-5060
MINNEAPOLIS, MINNESOTA
Summary
Parents in Community Action, Inc. (PICA) Head Start serves over 2,000 low-income children and families in Hennepin County, Minnesota. The Department of Human Services (DHS) manages-Medicaid EPSDT and contracts with providers to provide screening services. PICA has been a Medicaid EPSDT service provider since the 1970's; In the beginning, PICA received reimbursement for outreach, vision and hearing, heights and weights, and developmental screenings. Local providers (i.e., physicians, nurse practitioners, and dentists) would provide immunizations, physical examinations, laboratory tests, and. other screenings. Those providers would bill for their services. In the late 80's, DHS stopped reimbursing PICA and other. providers for outreach but continued reimbursement at a negotiated rate for the other screenings. Counties now receive funding to provide outreach.
EPSDT, now called Child & Teen Check Up, has changed in Minnesota. Most Medicaid clients in Minnesota are pre-placed in Managed Care Plans with some exemptions from this rule, for example, foster care children. In Hennepin County, there are three Plans, U-Care (affiliated with the University of Minnesota>, Metropolitan Health Plan (MHP, affiliated with Hennepin County), and Medicaid (a physician payer organization). PICA bills the State of Minnesota for screening for those children who are exempt or who haven't chosen a-Plan. If a child is on a Plan, PICA cannot receive reimbursement from the State. DHS has made provision in its contracts with each Plan that services may be subcontracted. After three years negotiation, PICA secured a contract with one of the Managed Care Plans and bills for screening and psychological services. PICA is still in negotiation with the other two plans.
DescriptionAt Parents in Community Action, Inc. (PICA), EPSDT or Child & Teen Check Up screening is only one part of the agency's mission to serve children and families. The screening (later assessments and diagnosis, if necessary) occurs in collaboration with parents, the child's primary health care provider, and PICA's staff. When enrolling at PICA, a child is required to have a complete physical examination. They are also given plenty of time to be screened. If a child is ill or timid, staff can attempt the screening on another day. And because PICA provides door-to-door transportation, missed appointments are never a problem; if one child is missing, another child can be screened instead. And finally, because the environment is supportive and children see classmates being screened, they are more receptive to the process and cooperate when it is their turn.
Once children are screened, the results are shared with the child's parent(s)/guardian and are managed in a computer tracking system. If the results are abnormal, the parent(s)/guardian is advised to bring the information to the child's primary health care provider. PICA staff ensure that any screening abnormality is followed-up. Each classroom is made up of a head teacher, assistant teacher, an advocate, and driver. Working with the parent(s)/guardian, the team helps to get the child to the child's primary health care provider. For -example, the driver may give the parent(s)/guardian and child a ride to. an appointment, or the advocate may arrange for translation services for a non-english speaking parent(s)/guardian. If a abnormality is discovered using the developmental screening, the head teacher observes the child, gathers more information, and then completes a detailed assessment. If more resources are required, PICA has, in a collaboration with the Minneapolis Department of Health and Family Support, two half-time public health nurses available to assist the team members to follow-up on the screening.
If the provider does find a health problem, this information is used in developing a child's Individual Education Plan (IEP), a tool developed jointly by the parent(s)/guardian and staff for all PICA children. If there is a health problem, adaptations are made for that child.
For more information, please contact:Bryan G. Nelson
Director of Health and Transportation Services
Parents in Community Action, Inc.
700 Humboldt Avenue, North
Minneapolis, Minnesota 55411
(612) 377-7422
PORTSMOUTH, OHIO
Summary
The Portsmouth City Health Department, through an Agreement with the Scioto County Head Start Program in Portsmouth, Ohio; conducts physicals on children prior to their enrollment in Head Start. However, in compliance with Medicaid policy, all families are allowed to choose any Medicaid provider available to them. In June, parents who are interested in enrolling their children in the Head Start Program in August are provided applications.
Parents are oriented concerning the requirements for enrollment when they receive the application packet. The parents who are interested in enrolling their child in the Scioto County Head Start Program are directed to take their child to the City Health Department or a provider of their choice for a physical. The City Health Department is a Medicaid enrolled provider, and 95 percent of the children enrolled in the Head Start program are Medicaid eligible. Although the Scioto County Head Start Program does not capture any Medicaid reimbursement for outreach, case management, or service delivery, all children who are enrolled obtain physicals at no cost to the Head Start Program.
DescriptionStarting in May or June, the Scioto County Head Start Social Services Component begins an outreach program to recruit children and their families for enrollment in the Head Start program. Parents are provided application packets at that time. The packets contain an application for enrollment, a pre-enrollment form for WIC, a directory of services in the community, and other brochures concerning immunization, well child clinic, poison control, and others. The packets also contain information concerning the Medicaid program, including how to enroll.
An enrollment letter accompanying the application packet tells parents how to proceed. Parents must complete the pre-enrollment forms and provide proof of income, copies of insurance or Medicaid cards, and copies of the child's birth certificate and immunization record. After the Head Start program has processed the enrollment application, parents are notified to pick up physical and dental forms and complete the application forms. Parents will be notified of the child's orientation date after Head Start receives completed physical and dental forms.
All of the information obtained on the children is placed on a computer. Scioto County Head Start reports that they get 95 percent of the applications returned with completed physicals and dental screening. If a parent does not return the application or the completed physical and dental forms, the child is placed on a waiting list and the Head Start program continues to contact the parent.
The Health Coordinator of the Head Start program reviews the application and physical and dental forms. Then, if the child needs -further diagnostics or treatment, arrangements are made for the child to receive the necessary services. Head Start case management may identify children who need further health or mental health services, arrange appointments for children, provide transportation, and make follow- up appointments as needed.
The City Health Department conducts most of the physicals on children who enroll in Scioto Head Start. The City Health Department is an enrolled Medicaid provider, and receives reimbursement for performing Head Start physicals. The health department has physicians, nurses, nurse practitioners, and a speech and language pathologist on staff. The Scioto Head Start is not an enrolled Medicaid provider.
Scioto County Head Start has been involved with the linkage with the Portsmouth City Health Department for seven years and finds the collaboration and networking to be extremely' valuable for the health of the children enrolled in the program. In addition, the Head Start program is linked with the local Department of Human Services to facilitate the enrollment of children and their families in the Medicaid program.
For additional information, please contact:Patricia Yinger
Head Start Director, Scioto County Head Start
CAG Head Start
Post Office Box 1525
Portsmouth, Ohio 45662
(614) 782-6341
RUSSELLYILLE, ARKANSAS
Summary
Child Development Incorporated (CDI) in Russeliville, Arkansas, has three nurses on staff who work in conjunction with a local physician to conduct Head Start physicals. The local physician volunteers his time to work with the CDI nursing staff to conduct physicals in 11 counties for 951 children. The Head Start physicals are equivalent to the EPSDT comprehensive unclothed physical exam. CDI bills Medicaid for children who are eligible for Medicaid, but are not being served by another Medicaid provider or managed health care organization. Parents are given the choice of which provider they go to for the Head Start physicals. However, CDI reports that very few of its children have other providers or are enrolled in a managed health care organization.
DescriptionIn early spring, CDL starts their outreach program to recruit children for enrollment in Head Start in August. During the recruitment phase, parents are encouraged to apply for Medicaid if they are not currently eligible. In August, CDI staff organize an. enrollment day during which 70 to 75 percent of the children are given Head Start physicals. The Head Start physicals are equivalent to the EPSDT comprehensive unclothed physical exam. Four teams of CDI staff conduct the physicals in 11 counties on 951 children. CDI has been billing Medicaid for the health screenings for four years. This year the local health department in-each county is making a nurse available during the physicals to give immunizations and to enroll eligible children and their parents in WIC. The remaining 25 to 30 percent of children who do not receive physicals during enrollment receive physicals in the Head Start Center. All physicals are completed within the 45 days of enrollment as required by the Health Component Performance Standards.
All Medicaid billing is done electronically by computer. Billing information is transferred by modem to the main frame computer of the Arkansas Department of Human Services. The Arkansas Department of Human Services is the agency that administers Medicaid reimbursement.
If a child is identified as needing further evaluation or treatment, the child. is referred to the local health department or to a private provider. If a child is not Medicaid eligible, the child and parent are assisted in obtaining financial assistance to pay for the needed services. At the present time, CDI does outreach and case management but is not reimbursed for it by Medicaid.
For additional information, please contact:Mary Lynne Hawkins, R.N.
Health Coordinator
P.O. Box 211O
Russellville, Arkansas 72801
501-968-6493
Comparison of Linkages
The purpose of this comparison is not to evaluate which program has created the most effective linkage or which program most effectively captures Medicaid reimbursement for the services provided. The purpose of the comparison is to help Head Start programs understand the alternatives which may be available to them through the Medicaid program. The comparison is organized utilizing the five questions listed in the introduction of this chapter.
1. What EPSDT related services are provided in the Head Start Program?
The three services typically included in the Medicaid program are outreach, case management, and service delivery. Service delivery may include screening and referral, screening and treatment, or providing full scale services.
The most common EPSDT related service provided by Head Start is the physical examination. Head Start programs may hire staff to conduct the physicals, contract with a local provider, or conduct a portion of the services and contract for others. The Scioto Head Start Program in Portsmouth, Ohio, requires children to have completed a physical before they enroll. The Portsmouth City Health Department, which is a Medicaid enrolled provider, conducts most of the physicals for Scioto Head Start's children. In Russellville, Arkansas, CDI has three nurses on staff working with a physician who donates his/her time to conduct physicals for Head Start children.
Since Head Start also typically does outreach and case management for its own programs, most Head Start programs are well established to incorporate EPSDT outreach and case management. Many Head Start programs currently encourage Medicaid enrollment and perform EPSDT case management activities, such as making arrangements for treatment and providing transportation to appointments.
2. Which services are reimbursed by the Medicaid program?
Service delivery is the most common EPSDT related service reimbursed by Medicaid.
Service delivery reimbursements include Head Start physicals and some treatment of acute
medical problems. Child Inc. in Austin, Texas, CDI in Russellville, Arkansas, and PICA in
Minneapolis, Minnesota, receive Medicaid reimbursement for service delivery.Although most Head Start programs conduct EPSDT related outreach and case management, they do not typically get Medicaid reimbursement. Nevertheless, Maine Head Start programs are able to capture reimbursement for administrative and targeted case management because the Maine State Office of Head Start has an agreement with the Maine Bureau of Medical Services.
CHAPTER 4 Examples of Program Linkages
3. What types of providers are used?
Head Start programs may use hired staff or contract staff. Providers may include nurses, nurse practitioners, audiologists, physicians, speech and language pathologists, occupational therapists, and mental health professionals, among others. Child Inc. in Austin, Texas, contracts staff for most EPSDT related services, while Maine Head Start programs, CDI in Russellviile, and PICA in Minneapolis use both contract staff and hired staff.
4. Who bills Medicaid for services?
Head Start must be an enrolled Medicaid provider to receive Medicaid reimbursement for services. If Head Start is an enrolled provider, it may bill for and receive Medicaid reimbursement for services provided by its hired staff or by contracted providers. If Head Start is not an enrolled provider, it may have services provided by an organization or independent practitioner who is an enrolled provider. The enrolled provider who performs the services then bills for and receives Medicaid reimbursement. CDI in Russellville receives Medicaid reimbursement for services provided by hired staff. Child Inc. in Austin receives Medicaid reimbursement for services provided by contracted staff. Maine Head Start programs receive Medicaid reimbursement for services provided by both hired and contracted staff. Scioto County Head Start is not an enrolled Medicaid provider, but has its physicals completed by the Portsmouth City Health Department. The Portsmouth City Health Department is an enrolled provider who bills for and receives Medicaid reimbursement.
5. How will Head Start serve children whose families choose other providers, or who may be Served by Medicaid managed care arrangements?
Head Start can serve children who use all types of providers. If the physical is performed by another provider, parents may sign a release allowing Head Start to request a report from the physician, or they may hand carry the report to Head Start themselves. Head Start's initial strategy is to help families identify other available sources of reimbursement for the physicals, such as HMOs, other managed care arrangements, or Medicaid. When other sources are not available, Head Start has funds to cover the cost of physicals. Most treatment services are provided on a referral basis by providers in the local community. In the absence of a waiver, Medicaid policy allows people enrolled in the Medicaid program to choose their provider.
Refer to Appendix C for a checklist to help you identify current and/or future linkages with Medicaid/EPSDT.