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CMS Seeks Input on Out-of-State Care for Medically Complex Children

The Centers for Medicare & Medicaid Services (CMS) issued a request for information (RFI) seeking input on coordinating care from out-of-state providers for medically complex children who are eligible for Medicaid coverage.

Under the Medicaid Services Investment and Accountability Act of 2019 (MSIA), beginning in 2022, states will have the option to submit a Medicaid state plan amendment to cover health home services, with an enhanced federal match, for medically complex children enrolled in a health home. The statute defines “medically complex” as having:

  • one or more chronic conditions that affect three or more organ systems with severely reduced cognitive or physical functioning, and requiring medication, therapy, or other treatment; or
  • one life-limiting or rare pediatric disease.

The MSIA also directs CMS to issue guidance to states by October 2020 on best practices for coordinating care with out-of-state providers, reducing barriers for receiving care from out-of-state providers, and processes for screening out-of-state providers who provide care for medically complex children. This RFI is the agency’s first step in producing that guidance.

The RFI seeks input on:

  • best practices for using out-of-state providers to care for medically complex conditions;
  • coordinating care with out-of-state providers;
  • state initiatives that have promoted or improved care coordination;
  • administrative, fiscal, and regulatory barriers;
  • approaches to reduce barriers that prevent caregivers from accessing or navigating care from out-of-state providers;
  • approaches to reduce barriers related to individual financial burden, such as the costs for travel and lodging;
  • types of challenges and approaches to reduce barriers to screening and enrolling out-of-network providers; and
  • best practices for developing contracts and payment rates for out-of-state providers for both Medicaid fee-for-service and managed care.

The RFI was published in the Federal Register on Jan. 21 and comments are due March 23.

Contact Senior Director of Policy Erin O’Malley at or 202.585.0127 with questions.


About the Author

Zina Gontscharow is a former senior policy analyst for America's Essential Hospitals.

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