DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard 
Mail Stop S2-26-12  
Baltimore, Maryland 21244-1850 
CMCS Informational Bulletin 
 
DATE:  October 20, 2021 
 
FROM:  Daniel Tsai, Deputy Administrator and Director  
 
SUBJECT:  Guidance on Coordinating Care Provided by Out-of-State Providers for Children 
with Medically Complex Conditions  
 
 
The Centers for Medicare & Medicaid Services (CMS) is releasing this Informational Bulletin 
and accompanying guidance document in accordance with section 1945A(e)(1) of the Social 
Security Act (the Act), as added by the Medicaid Services Investment and Accountability Act of 
2019 (Pub. L. No. 116-16, enacted April 18, 2019).  Section 1945A(e)(1) requires the Secretary 
of Health and Human Services (HHS) to issue guidance to states, and to update it as the 
Secretary determines necessary, on the following topics: 
 
(A) Best practices for using out-of-state providers to provide care to children with 
medically complex conditions; 
(B) Coordinating care for children with medically complex conditions provided by out-
of-state providers (including when provided in emergency and non-emergency 
situations); 
(C) Reducing barriers that prevent children with medically complex conditions from 
receiving care from out-of-state providers in a timely fashion; and  
(D) Processes for screening and enrolling out-of-state providers in the respective state 
plan (or a waiver of such plan), including efforts to streamline these processes or reduce 
the burden of these processes on these providers.  
 
The attached Guidance on Coordinating Care Provided by Out-of-State Providers for Children 
with Medically Complex Conditions provides a description of best practices and other 
implementation considerations related to coordination of care from out-of-state providers for 
children with medically complex conditions.  These best practices and other considerations were 
informed by public comments received in response to a Request for Information (RFI) issued by 
CMS in January 2020, in accordance with section 1945A(e)(2) of the Act. 
   
Background 
 
Under section 1945A of the Act, beginning October 1, 2022, states have the option to cover 
health home services for Medicaid-eligible children with medically complex conditions.  A child 
with medically complex conditions is defined in section 1945A(i)(1) to be an individual under 21 
years of age who is eligible for medical assistance under the state Medicaid plan (or under a 
waiver of such plan), and who has at least (1) one or more chronic conditions that cumulatively  Page 2  Best Practices for Children with Medically Complex Conditions 
 
affect three or more organ systems and severely reduces cognitive or physical functioning (such 
as the ability to eat, drink, or breathe independently) and also requires the use of medication, 
durable medical equipment, therapy, surgery, or other treatments; or (2) one life-limiting illness 
or rare pediatric disease, as defined at 21 U.S.C. 360ff(a)(3).  Often, children with medically 
complex conditions require specialized diagnostic or treatment services that may not always be 
readily available from providers within their state of permanent residence (home state). 
 
January 2020 Request for Information 
 
Section 1945A(e)(2) of the Act directed the Secretary to issue an RFI to seek input from children 
with medically complex conditions and their families, states, providers (including childrens 
hospitals, hospitals, pediatricians, and other providers), managed care plans, childrens health 
groups, family and beneficiary advocates, and other stakeholders with respect to coordinating the 
care provided by out-of-state providers to children with medically complex conditions.  On 
January 21, 2020, CMS issued this RFI (85 Fed. Reg. 3330).  The initial comment period on this 
RFI closed on March 23, 2020, but, in light of the COVID-19 pandemic and stakeholder requests 
for additional time, on May 4, 2020, CMS reopened and extended the comment period on this 
RFI for 30 days, until June 3, 2020 (85 Fed. Reg. 26438), 
https://www.federalregister.gov/documents/2020/05/04/2020-09392/coordinating-care-from-out-
of-state-providers-for-medicaid-eligible-children-with-medically-complex.  
 
The full RFI can be found here: https://www.federalregister.gov/documents/2020/01/21/2020-
00796/coordinating-care-from-out-of-state-providers-for-medicaid-eligible-children-with-
medically-complex  and the fact sheet can be found here: https://www.medicaid.gov/state-
resource-center/downloads/technical-assistance/cms-2324-ifc3-fact-sheet.pdf  
 
Guidance for States  
 
The Guidance on Coordinating Care Provided by Out-of-State Providers for Children with 
Medically Complex Conditions includes CMS recommendations for best practices based on the 
comments received in response to the CMS RFI.  These best practices align with the topics 
specified in section 1945A(e)(1) of the Act.  Stakeholders also provided other suggestions for 
consideration related to coordination of care for children with medically complex conditions who 
receive care from out-of-state providers.  CMS is also sharing some of these suggested 
implementation considerations in the guidance document in an effort to be helpful to states. 
Overall, the guidance is aimed at assisting states as they develop protocols, procedures, and 
agreements that will help to ensure that children with medically complex conditions receive 
prompt, high-quality care from out-of-state providers when needed.   
 
As further discussed in the guidance document, CMS recommends the following best practices: 
 
1.  Person-Centered Service Plan.  States, managed care plans, and providers should ensure 
person-centered service planning; this planning should include a multi-disciplinary 
treatment team using an interoperable electronic health record to allow the individual, 
family members or guardians, and the entire care team to access information in real-time. 
 
  Page 3  Best Practices for Children with Medically Complex Conditions 
 
2.  Provider screening and enrollment.  States should screen and enroll out-of-state 
providers within an abbreviated timeframe to help ensure that Medicaid-eligible children 
with medically complex conditions can access care from these providers in a timely 
fashion. 
3.  Agreements between states.  States should develop standard agreements with other states 
governing coverage and payment for services furnished to Medicaid-eligible children 
with medically complex conditions living in each state by providers screened and 
enrolled in the other state(s). For example, states could streamline the process of 
enrolling out of state providers by relying on the enrollment screening conducted by other 
states based on criteria outlined in agreements between states.  
4.  Telehealth.  States should take steps to encourage arrangements to promote access to 
services provided via telehealth from out-of-state providers, when appropriate, to 
improve access to care from these providers and enhance care coordination for children 
with medically complex conditions.   
5.  Electronic health records (EHR) and data interoperability.  States should encourage both 
home state and out-of-state providers to use EHRs and other interoperability methods to 
automate access to and sharing of health information and to support other care-related 
activities directly or indirectly using various technology tools, as is consistent with 
sections 1945A(f)(2) and 1945A(i)(4)(B)(vi) (e.g., data sharing networks can provide 
care alerts regarding patients).  
6.  Economic and efficient provider payment rates.  States must establish economic and 
efficient provider payment rates to ensure access to care and services available under the 
state plan and, under certain circumstances, provide coverage and payment when services 
are provided by out-of-state providers who serve children with medically complex 
conditions, consistent with section 1902(a)(30)(A) of the Act and 42 CFR  431.52.  
States use a variety of payment methods to set rates paid to out-of-state providers and 
these methods should be clearly described in the Medicaid state plan.   
 
It is important to note that states that elect to offer a health home under section 1945A of the Act 
will need to report on their use of the best practices described in the guidance, as required in the 
statute.  Specifically, states will need to submit to CMS no later than 90 days after a state has an 
approved state plan amendment under section 1945A, and make publicly available on the states 
website, a report on how the state is implementing this guidance, including through any best 
practices adopted by the state.  
 
CMS expects to issue future guidance to states on the development of health homes serving 
children with medically complex conditions in accordance with section 1945A of the Act and 
will also be available to provide technical assistance to states.  For technical assistance, please 
contact Sara Rhoades, Technical Director for the health homes program at 
sara.rhoades@cms.hhs.gov. 
 
 
Disclaimer Language 
The contents of this document do not have the force and effect of law and are not meant to bind the public 
in any way, unless specifically incorporated into a contract.  This document is intended only to provide 
clarity to the public regarding existing requirements under the law. 
 
   
 
 
 
Guidance on Coordinating Care Provided By  
Out-of-State Providers for Children with Medically 
Complex Conditions 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Guidance on Coordinating Care Provided by Out-of-State Providers for 
Children with Medically Complex Conditions  
 
Purpose   
 
Under section 1945A(e)(1) of the Social Security Act (the Act), as added by the Medicaid 
Services Investment and Accountability Act of 2019 (Pub. L. No. 116-16, enacted April 18, 
2019), the Secretary of Health and Human Services (HHS) is required to issue guidance to states, 
and to update it as the Secretary determines necessary, on the following topics:  
 
(A) Best practices for using out-of-state providers to provide care to children with medically  
complex conditions; 
(B) Coordinating care for children with medically complex conditions provided by out-of-state 
providers (including when provided in emergency and non-emergency situations); 
(C) Reducing barriers that prevent children with medically complex conditions from receiving 
care from out-of-state providers in a timely fashion; and  
(D) Processes for screening and enrolling out-of-state providers in the respective state plan (or a 
waiver of such plan), including efforts to streamline these processes or reduce the burden of 
these processes on these providers.  
 
This guidance, which is required under section 1945A(e)(1) of the Act, provides a description of 
best practices and other implementation considerations related to coordination of care from out-
of-state providers for children with medically complex conditions.  Consistent with section 
1945A(e)(2) of the Act, these best practices and other considerations were informed by public 
comments received in response to a Request for Information issued by the Centers for Medicare 
& Medicaid Services (CMS) in January 2020.   
 
Background 
 
Under section 1945A of the Act, beginning October 1, 2022, states have the option to cover 
health home services for Medicaid-eligible children with medically complex conditions.  A child 
with medically complex conditions is defined in section 1945A(i)(1) to be an individual under 21 
years of age who is eligible for medical assistance under the state Medicaid plan (or under a 
waiver of such plan), and who has at least: (1) one or more chronic conditions that cumulatively 
affect three or more organ systems and severely reduces cognitive or physical functioning (such 
as the ability to eat, drink, or breathe independently) and also requires the use of medication, 
durable medical equipment, therapy, surgery, or other treatments; or (2) one life-limiting illness 
or rare pediatric disease, as defined at 21 U.S.C. 360ff(a)(3).  Often, children with medically 
complex conditions require specialized diagnostic or treatment services that may not always be 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
1  readily available from providers within their state of permanent residence (which CMS refers to 
below as the childs home state).   
 
General Overview: Medicaid Services and Out-of-State Provider Provisions 
Early and Periodic Screening, Diagnostic and Treatment Benefit 
Medicaid generally provides broad coverage to eligible children, both through required benefits 
packages for eligible children, and through the Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT) benefit.  Through the EPSDT benefit, states must provide any service listed 
in section 1905(a) of the Act to eligible beneficiaries under age 21, when the service is 
determined to be necessary to correct or ameliorate an identified condition, and in any amount 
that is medically necessary, regardless of whether the service is covered in the state plan. For 
example, the state must cover under EPSDT medically necessary services to correct or 
ameliorate health conditions, including physical and mental illnesses, discovered through 
screening.  This includes services that maintain or improve a childs current health condition, or 
that prevent conditions from worsening, prevent development of additional health problems, or 
reduce pain, if deemed medically necessary through the screening process.  Examples of such 
services may include adaptive equipment to prevent ulcers or pressure sores, bed/bathroom rails, 
augmentative communication devices, rehabilitative services, and physical or occupational 
therapy.  In some cases, children with medically complex conditions may require specialized 
diagnostic or treatment services that are not available from providers in their home state.  
Out-of-State Providers 
Federal statutory and regulatory provisions govern coverage of services provided by out-of-state 
providers under Medicaid.  The statutory provision at section 1945A of the Act, which creates 
the new state option to cover health home services for children with medically complex 
conditions, specifically mentions services provided by out-of-state providers, as is further 
discussed below.  In addition, section 1902(a)(16) of the Act requires states to include provisions 
in the state plan with respect to the furnishing of medical assistance under the state plan to 
individuals who are residents of the state, but are absent from the state; the state plan provisions 
on this topic should be consistent with CMS regulations at 42 CFR  431.52.   
Under 42 CFR  431.52, any one of the following circumstances requires a state to pay for out-
of-state services furnished to beneficiaries who are residents of the state, to the same extent the 
state would pay for services furnished within its boundaries:  
  Medical services are needed because of a medical emergency. 
  Medical services are needed and the beneficiarys health would be endangered if required 
to travel to their state of residence.  
  The state determines, on the basis of medical advice, that the needed medical services, or 
necessary supplementary resources, are more readily available in the other state.  
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
2    It is general practice for beneficiaries in a particular locality to use medical resources in 
another state.   
These provisions governing out-of-state providers also apply with respect to services provided to 
Medicaid-eligible children with medically complex conditions as defined under section 1945A of 
the Act, who may need access to out-of-state care based on circumstances mentioned above, such 
as when the state has determined that the beneficiary needs unique, innovative specialty services 
that are more readily available outside the home state.  Cooperation among states is necessary to 
assure they establish procedures to facilitate the furnishing of medical services to individuals 
who are present in the state and are eligible for Medicaid under another states plan. 
Managed Care  
Under Medicaid managed care, 42 CFR  438.206(b)(4) provides that if the provider network of 
a plan is unable to provide necessary services covered under the contract to an enrollee, the 
managed care plan must adequately and timely cover the services out-of-network for the enrollee 
for so long as the managed care plans network is unable to provide those services.  Furthermore, 
42 CFR  435.930(c) and 438.114(c), require coverage by state Medicaid agencies (SMAs) and 
Medicaid managed care plans of needed emergency services as defined in regulations.  In the 
case of an individual with an emergency medical condition, managed care plans must cover 
and pay for emergency services, and in some instances post-stabilization care services, 
regardless of whether the provider that furnishes the services has a contract with the managed 
care plan, whether in-state or out-of-state, when the managed care contract requires the plan to 
be responsible for those services. 
Health Homes for Children with Medically Complex Conditions 
Section 1945A of the Act includes provisions specific to out-of-state providers.  Section 
1945A(b) of the Act lists health home qualification standards, including, at paragraph (b)(5), a 
requirement that health homes be able to coordinate care for children with medically complex 
conditions with out-of-state providers furnishing care to such children to the maximum extent 
practicable for the families of such children and where medically necessary, in accordance with 
CMS guidance issued under section 1945A(e)(1) (including this document) and 42 CFR 
431.52.  Under section 1945A(f)(3), a state must develop and include in its section 1945A health 
home state plan amendment a methodology for tracking prompt and timely access to medically 
necessary care for children with medically complex conditions from out-of-state providers.   
Section 1945A(g)(2)(A)(v) of the Act requires states to report on the number and characteristics 
of designated providers, teams of health care professionals operating with such providers, and 
health teams selected as health homes pursuant to section 1945A, including the number and 
characteristics of out-of-state providers, teams of health care professionals operating with such 
providers, and health teams who have provided health care items and services to children 
receiving services from section 1945A health homes.  Section 1945A(i)(4)(B)(ii) of the Act 
defines health home services for children with medically complex conditions to include (among 
other services) care coordination, health promotion, and providing access to the full range of 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
3  pediatric specialty and subspecialty medical services, including services from out-of-state 
providers, as medically necessary.  
 
Request for Information (RFI) 
Section 1945A(e)(2) of the Act directed the Secretary to issue an RFI to seek input from children 
with medically complex conditions and their families, states, providers (including childrens 
hospitals, hospitals, pediatricians, and other providers), managed care plans, childrens health 
groups, family and beneficiary advocates, and other stakeholders with respect to coordinating the 
care provided by out-of-state providers to children with medically complex conditions.  On 
January 21, 2020, CMS issued this RFI (85 Fed. Reg. 3330).  The initial comment period on this 
RFI closed on March 23, 2020, but, in light of the COVID-19 pandemic and stakeholder requests 
for additional time, on May 4, 2020, CMS reopened and extended the comment period on this 
RFI for 30 days, until June 3, 2020 (85 Fed. Reg. 26438), 
https://www.federalregister.gov/documents/2020/05/04/2020-09392/coordinating-care-from-out-
of-state-providers-for-medicaid-eligible-children-with-medically-complex.   
The full RFI can be found at: https://www.federalregister.gov/documents/2020/01/21/2020-
00796/coordinating-care-from-out-of-state-providers-for-medicaid-eligible-children-with-
medically-complex, and the fact sheet can be found at: https://www.medicaid.gov/state-resource-
center/downloads/technical-assistance/cms-2324-ifc3-fact-sheet.pdf. 
In response to the RFI, families, providers and other stakeholders noted various challenges that 
could prevent children with medically complex conditions from receiving prompt care from out-
of-state providers.  The overarching theme across the comments was that there is a need to 
reduce unnecessary burdens and streamline administrative processes in order to support 
expedited approval of and timely access to services from out-of-state providers for children with 
medically complex conditions.  Families and advocates noted challenges such as delays in 
treatment due to prior authorization requirements, the expense of traveling out-of-state, 
difficulties sharing electronic health records (EHRs) across all treating providers to ensure 
appropriate medical treatment, and inconsistent utilization of telehealth to allow for access to 
out-of-state expertise.  The providers who serve children with medically complex conditions 
noted administrative and fiscal barriers that prevent children from receiving care in a timely 
fashion from out-of-state providers.  Providers commented that they spend significant time and 
resources to overcome the administrative burdens related to enrolling in Medicaid across state 
lines, due to complex enrollment processes and requirements that can vary significantly across 
states.   
 
GUIDANCE ON COORDINATING CARE FOR CHILDREN WITH 
MEDICALLY COMPLEX CONDITIONS  
 
I. BEST PRACTICES   
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
4   
CMS recommends the specific best practices described below, based on the comments received 
in response to the CMS RFI.  These best practices align with the four topics listed in section 
1945A(e)(1) of the Act. 
 
Person-Centered Service Plan   
States, managed care plans,1 and providers should ensure person-centered service planning; this 
planning should include a multi-disciplinary treatment team using an interoperable electronic 
health record (EHR) to allow the individual, family members or guardians, and the entire care 
team to access information in real-time. 
 
States and providers commented that successful health outcomes can result from implementing a 
multidisciplinary, person-centered care model for children with medically complex conditions in 
accordance with systematically reviewed, data-driven clinical practice guidelines.  This model 
employs a team of dedicated health care professionals, such as primary care providers, mental 
health specialists, pulmonologists, respiratory therapists, dieticians, social workers, program 
coordinators, and other specialists as needed.  Care management teams that help the child and 
family navigate the health care system can ensure timely and appropriate care that promotes 
wellness.  Establishing a team of providers and specialists to best meet the needs of the child is 
the foundation of appropriate person-centered planning.  Such a team could include both in-state 
and out-of-state providers, to ensure access to out-of-state providers who provide specialty 
services not readily available in the home state of the child.  
Health home qualification standards in section 1945A(b)(2) of the Act require section 1945A 
health home providers to demonstrate to the state their ability to develop an individualized 
comprehensive pediatric family-centered care plan for children with medically complex 
conditions that accommodates patient preferences.  CMS recommends that all states encourage 
or require the use of a person-centered service planning process when any type of Medicaid 
provider, including a section 1945A health home, develops a care plan for children with 
medically complex conditions.  A person-centered service plan is generally understood in the 
health care community and by CMS to mean a written record of the agreements and decisions 
reached through a person-centered service care planning approach by the enrollee, the enrollees 
family member or guardian (if applicable), and the interdisciplinary team.  The person-centered 
service plan should reflect services to address enrollee needs identified on the basis of a 
comprehensive needs assessment and should reflect the enrollees values, preferences, and goals.  
The care planning process should be directed by the individual enrollee, with assistance, as 
needed or requested, from a representative of the individuals choosing (including a family 
member or guardian responsible for the minor child).  It should identify the strengths, capacities, 
preferences, and needs of the individual enrollee, and desired measurable outcomes for the 
                                                           
1 Managed care plans is used here to collectively reference managed care organizations, prepaid inpatient health 
plans, and prepaid ambulatory health plans as defined in 42 C.F.R.  438.2. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
5  individual.  The process may include other persons, freely chosen by the individual, who are able 
to serve as important contributors to the process.   
 
The principles of whole-person care and person-centered care planning support the incorporation 
into the service plan of all care providers and specialists who best meet the needs of the child, 
including out-of-state providers and the services they provide.  As part of care coordination, 
health home providers should assist children with medically complex conditions and their 
families and caregivers to identify and consider out-of-state treatment options to be included in 
the person-centered service plan.  Care coordination includes attention to all areas of a persons 
life and should be provided in a manner that is interdisciplinary, family-centered, community 
based, and culturally competent.  CMS recommends, based on RFI comments, that all states, 
including those with health homes for children with medically complex conditions, encourage or 
require Medicaid providers, including section 1945A health homes, to develop a person-centered 
service plan like that described in 42 CFR  441.725(a) and (b) for children with medically 
complex conditions.    
 
To ensure that a childs care team can readily access information in real-time, CMS also 
recommends that the care team use an interoperable EHR in service planning.  More information 
is provided below about best practices related to EHRs and section 1945A health homes.  
 
Provider Screening and Enrollment 
States should screen and enroll out-of-state providers within an abbreviated timeframe to help 
ensure that Medicaid-eligible children with medically complex conditions can access care from 
these providers in a timely fashion.  For example, states could streamline the process of 
enrolling out-of-state providers by relying on the enrollment screening conducted by other states 
based on criteria outlined in agreements between states.    
 
Another best practice for states seeking to reduce barriers to timely access to out-of-state 
providers for children with medically complex conditions is to screen and enroll out-of-state 
providers within an abbreviated timeframe.  SMAs should consider an expedited screening and 
enrollment process with respect to out-of-state providers, to help ensure that beneficiaries, 
including Medicaid-eligible children with medically complex conditions, who need out-of-state 
care can receive it promptly.  
 
SMAs may reimburse otherwise payable claims from out-of-state providers not enrolled in their 
Medicaid programs if the following four criteria are met:  
1) The item or service is furnished by an institutional provider, individual practitioner, or 
pharmacy at an out-of-state/territory practice location (i.e., located outside the geographical 
boundaries of the reimbursing state/territorys Medicaid plan);  
2) The National Provider Identifier (NPI) of the furnishing provider is represented on the claim; 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
6  3) The furnishing provider is enrolled and in an approved status in Medicare or in another 
state/territorys Medicaid plan; and  
4) The claim represents services furnished and covered under the state plan. This includes 
medically necessary services for eligible children under age 21 under the EPSDT benefit, even if 
such services are not otherwise covered under the state plan (consistent with the definition of 
EPSDT at section 1905(r)).  
Additionally, the claim must represent one of the following: 1) a single instance of care furnished 
over a 180-day period or 2) multiple instances of care furnished to a single participant over a 
180-day period.  For instances of care that exceed these thresholds, or for SMAs that are unable 
to reimburse providers not enrolled in their Medicaid programs due to system limitations, those 
SMAs should refer to the sub-regulatory Medicaid provider enrollment guidance found in the 
Medicaid Provider Enrollment Compendium (available here: 
https://www.medicaid.gov/sites/default/files/2019-12/mpec-7242018.pdf) for guidance on the 
enrollment of out-of-state providers.  CMS encourages states to upgrade and/or update systems 
as needed when feasible.   
 
For emergency/urgent care, states can also refer to 42 CFR  435.930 and the Medicaid Provider 
Enrollment Compendium, which instruct SMAs to furnish Medicaid promptly without delay, to 
all eligible individuals, and to make arrangements to assist applicants and beneficiaries to get 
emergency medical care whenever needed.  The regulation at 42 CFR  431.52 and the 
Compendium further instruct SMAs to pay for services furnished in another state to the same 
extent they would pay for services furnished within their boundaries to a beneficiary that is a 
resident of the state, under conditions including and not limited to emergency services and 
services that are more readily available in another state.2   
 
Pursuant to 42 CFR  455.410(c), as part of the enrollment process, the SMA may, but is not 
required to, rely on provider screening performed by another states Medicaid Program or by 
Medicare.  If the state Medicaid agency opts not to rely on screening performed by either another 
states Medicaid agency or by Medicare, the state Medicaid agency must perform screening in 
compliance with the requirements within 42 CFR part 455, subpart E, as further detailed in the 
Compendium.  However, to ensure timely treatment for children with medically complex 
conditions, arrangements between states such as those identified in the next section will assist 
SMAs with the proper and efficient processing of non-urgent care provided by out-of-state 
providers for this population.  
 
CMS also reminds states to work with the CMS Center for Program Integrity (CPI) in order to rely on 
Medicare screenings to facilitate provider enrollment in the Medicaid program.  States can leverage 
CMS/CPI in the following ways: 1.) using the Provider Enrollment Chain and Ownership System 
(PECOS), 2.) taking advantage of the Medicare data compare service for provider screening, or, 3.) 
                                                           
2 https://www.ecfr.gov/cgi-bin/text-
idx?SID=4cc33b916dc4ccdcf0e0735e840cbd41&mc=true&node=se42.4.431_152&rgn=div8 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
7  participating in the CPI pilot project to screen Medicaid-only providers on behalf of states. For more 
information please contact MedicaidProviderEnrollment@cms.hhs.gov. 
 
Agreements between States 
States should develop standard agreements with other states governing coverage and payment 
for services furnished to Medicaid-eligible children with medically complex conditions living in 
each state by providers screened and enrolled in the other state(s).  
 
In order to facilitate and expedite access to care, states have had success in developing 
memoranda of understanding (MOU), state compacts or other types of arrangements or 
agreements with other states, in which two or more states agree on key topics related to coverage 
and payment for care furnished to children with medically complex conditions living in each 
state by providers screened and enrolled in the other state(s).  The topics in the agreement could 
also include the following:  care management, prior authorization, care coordination, and service 
delivery arrangements.  With regard to provider screening, states could streamline this process 
by relying on screening conducted by another state as permitted under 42 CFR  455.410(c).  
States may also be able to leverage, in their enrollment processes, information collected by 
another state such as the disclosures required under 42 CFR part 455, subpart B.  However, each 
state must still separately enroll and execute provider agreements with each provider. 
Agreements between states could be used in developing each states guidelines regarding out-of-
state providers. When developing these types of arrangements, it is important to consider 
whether all statutory and regulatory requirements for out-of-state care are met for the type of 
care being covered (i.e., urgent vs. standard).  Further, utilizing agreements with other states will 
not only help states develop protocols for covering emergent and non-emergent care provided by 
out-of-state providers but also help them establish expedited timelines for accessing out-of-state 
care and provide clear care coordination guidelines. 
 
Telehealth   
States should take steps to encourage arrangements to promote access to services provided via 
telehealth from out-of-state providers, when appropriate, to improve access to care from these 
providers and enhance care coordination for children with medically complex conditions.   
 
Section 1945A(f)(2) of the Act specifies that a state must include in its section 1945A health 
home state plan amendment a proposal for use of health information technology (health IT) in 
providing health home services and improving service delivery and coordination across the care 
continuum (including the use of wireless patient technology to improve coordination and 
management of care and patient adherence to recommendations made by their provider).  Section 
1945A(i)(4)(B)(vi) of the Act also includes in the definition of health home services for children 
with medically complex conditions use of health IT to link services, as feasible and appropriate.   
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
8  Telehealth can be a useful tool to help coordinate and access care.  Based on the comments 
received on the RFI, CMS recommends the use of telehealth as a best practice to facilitate 
treatment from out-of-state providers, when appropriate.  Telemedicine or telehealth seeks to 
improve a patients health by permitting two-way, interactive communication between the 
patient and a physician or practitioner.  Although the dominant form of telehealth is generally 
thought of as two-way audio/visual communication, or a video chat, telehealth can be much 
broader than that. Other forms such as store-and-forward and remote patient monitoring have 
existed alongside this two-way modality.  Federal Medicaid policy supports the use of audio-
only communications to deliver services, as noted in the toolkit link below.  Telehealth may be a 
cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., 
face-to-face consultations or examinations between provider and patient).   
 
The Rehabilitation Act of 1973 (Section 504), the Americans with Disabilities Act (ADA) and 
Section 1557 of the Affordable Care Act (ACA) prohibit discrimination in health care services.  
In 2016, the HHS Office for Civil Rights published Guidance and Resources for Electronic 
Information Technology: Ensuring Equal Access to All Health Services and Benefits Provided 
Through Electronic Means 3 reminding covered providers that inaccessibility to their services 
through electronic information and technology may constitute disability discrimination.   
 
When providing services via telehealth, providers should practice within the scope of their State 
Practice Act; some states have also enacted legislation that requires providers using telemedicine 
technology across state lines to have a valid state license in the state where the patient is located. 
States should follow their state plan regarding payment to qualified Medicaid providers for 
services provided via telehealth.  States should also consider applicable federal and state privacy 
and consent laws and policies for services provided via telehealth.  The CMS Medicaid & CHIP 
Telehealth toolkit may also be helpful in developing telehealth agreements between states.   
 
States may request enhanced federal financial participation for certain state systems expenditures 
to support telehealth, provided they meet the conditions under 42 CFR part 433 subpart C.    
 
Electronic Health Records (EHR) and Data Interoperability   
States should encourage both home state and out-of-state providers to use EHRs and other 
interoperability methods to automate access to and sharing of health information and to support 
other care-related activities directly or indirectly using various technology tools, as is consistent 
with sections 1945A(f)(2) and 1945A(i)(4)(B)(vi) (e.g., data sharing networks can provide care 
alerts regarding patients).   
 
Providers and states have identified EHRs as a useful way to easily access a beneficiarys 
information, allowing home state and out-of-state providers to coordinate care in real time.  An 
EHR is an electronic version of a beneficiarys medical history that is maintained by a health 
                                                           
3 https://www.hhs.gov/sites/default/files/ocr-guidance-electronic-information-technology.pdf  
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
9  care provider over time, and it may include all of the key clinical data relevant to that persons 
care from that particular provider, such as demographics, progress notes, problems, medications, 
vital signs, past medical history, immunizations, laboratory data, and radiology reports.4 
 
An EHR automates access to information and has the potential to streamline the clinicians 
workflow.  An EHR also has the ability to support other care-related activities through various 
interfaces, including evidence-based decision support, quality management, and outcomes 
reporting. There are critical functionalities, data elements, and other requirements that should be 
present in health IT products to address health care needs specific to the care of children.  More 
information can be found in the Pediatric Health Information Technology: Developer 
Informational Resource and corresponding resource for providers.5 
 
The health home services listed in statute at section 1945A of the Act include use of health [IT] 
to link services, as feasible and appropriate.  Thus, under the health home service delivery 
model, care coordination could include the sharing of centralized information to coordinate 
integrated care by multiple providers through the use of EHRs that can be shared among all 
providers on the childs interdisciplinary care team.  It is important that the data across the entire 
health care system is shared with all treating providers to ensure whole person care is 
provided.  The use of EHRs allows the sharing of health information in real-time with the 
beneficiary and the interdisciplinary team to identify potential issues or gaps in treatment to 
promote wellness.  States should encourage the use of certified electronic health record 
technology (CEHRT) that utilizes common technology standards to ensure information is 
seamlessly shared across different systems, including EHRs and other health IT tools.  States 
may request enhanced federal financial participation for certain state Medicaid Enterprise 
Systems (MES) expenditures that support care coordination, provided they meet the conditions 
described in 42 CFR part 433 subpart C and 45 CFR part 95.  
 
An EHR is considered a type of electronic information technology that is required to be 
accessible under Section 504, the ADA, and Section 1557 of the ACA.  An EHR must be 
accessible to people with disabilities in a way so that all patients are able to access their records 
and communicate effectively with their providers.  
  
Economic and Efficient Provider Payment Rates 
States must establish economic and efficient provider payment rates to ensure access to care and 
services available under the state plan and, under certain circumstances, provide coverage and 
payment when services are provided by out-of-state providers who serve children with medically 
complex conditions, consistent with section 1902(a)(30)(A) of the Act and 42 CFR 
                                                           
4 https://www.cms.gov/Medicare/E-
Health/EHealthRecords#:~:text=An%20Electronic%20Health%20Record%20(EHR,progress%20notes%2C%20proble
ms%2C%20medications%2C 
5 https://www.healthit.gov/topic/health-it-pediatric-care-and-practice-settings 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
10   431.52.  States use a variety of payment methods to set rates paid to out-of-state providers and 
these methods should be clearly described in the Medicaid state plan.    
 
When establishing Medicaid payment rates, states must consider the impact on access to care for 
beneficiaries receiving care from out-of-state providers.  Establishing economic and efficient 
rates ensures access to services provided by out-of-state providers who serve children with 
medically complex conditions.  Federal regulations at 42 CFR  431.52 require state Medicaid 
programs to cover out-of-state care for beneficiaries when medical services are needed because 
of a medical emergency, when medical services are needed and the beneficiarys health would be 
endangered if he or she were required to travel to his or her state of residence, when the state 
determines on the basis of medical advice that needed medical services or necessary 
supplemental resources are more readily available in another state, or when it is general practice 
for beneficiaries in a particular locality to use medical resources in another state.  In such 
circumstances, the Medicaid agency must pay for services furnished in another state to a 
beneficiary who is a resident of the state.   
 
States not only cover section 1905(a) benefits that are included in the state plan for children, but 
must also cover medically necessary screening and follow-up services for eligible children under 
age 21 under the EPSDT benefit, even if such services are not otherwise covered under the state 
plan (consistent with the definition of EPSDT at section 1905(r)).  For example, the state would 
cover under EPSDT medically necessary services to correct or ameliorate health conditions 
including physical and mental illnesses discovered through screening.   
 
States might not be able to ensure that such children receive the full scope of coverage to which 
they are entitled unless states improve access to certain care and services offered by out-of-state 
providers.  For example, if providers in the home state do not offer innovative specialty services 
a child needs, an out-of-state provider could provide those services, consistent with 42 CFR  
431.52.  Additionally, when it is the general practice of beneficiaries in a particular locality to 
use medical resources in another state (as may occur when the locality closely borders another 
state), the out-of-state care must be covered to the same extent it would be within the boundaries 
of the state, consistent with 42 CFR  431.52.  And, if the state determines, based on medical 
advice, that a particular form of needed specialty care is more readily available in another state, 
the same regulation requires the state to cover the out-of-state care.   
 
Under Medicaid managed care, 42 C.F.R.  438.206(b)(4) provides that if the provider network 
of a managed care plan is unable to provide necessary services covered under the contract to an 
enrollee, the managed care plan must adequately and timely cover the services out-of-network 
for the enrollee for so long as the managed care plans network is unable to provide those 
services that includes the obligation to cover all but plan cost-sharing amounts, meaning the plan 
must pay the out of network provider a sufficient amount so there is no balance billing. 
 
Consistent with section 1902(a)(30)(A) of the Act, states have the flexibility to negotiate rates 
that are economic and efficient with out-of-state providers, including through state agreements 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
11  with other states and as set forth in the home states state plan.  SMAs must include a 
comprehensive description of their rate-setting methodologies in their state plan including 
payment methodologies for out of state providers, which must ensure that payments under the 
plan are consistent with requirements under section 1902(a)(30)(A) of the Act to be economic, 
efficient, and consistent with quality of care, and to ensure sufficient beneficiary access to care. 
 
II. OTHER IMPLEMENTATION CONSIDERATIONS FOR STATE 
MEDICAID PROGRAMS IDENTIFIED BY STAKEHOLDERS  
 
Commenters on the CMS RFI offered multiple suggestions and additional areas for states to 
consider when developing proposals for a section 1945A health home for children with 
medically complex conditions.  In this section, CMS is sharing some of these suggestions for 
states consideration.  States will not be required to report on their implementation of these 
suggestions as part of the report required under section 1945A(g)(2)(B).  CMS expects to 
provide future guidance on implementing a health home for children with medically complex 
conditions to meet the statutory requirements in section 1945A of the Act.   
 
Sharing Information with Stakeholders 
 
Commenters on the RFI also had the following suggestions about information that states could 
share with stakeholders: 
 
Contact Lists/ Registries  
States, themselves or through contracted Medicaid managed care plans, may want to 
develop lists with contact information of providers for caseworkers that are readily 
available to families of children with medically complex conditions, to allow 
caseworkers, families, and/or other team members to quickly locate specialists who know 
about their childs specific conditions and rare diseases.  Another idea commenters 
suggested was for the state to establish a registry of specialty out-of-state providers that 
would indicate in which states the provider is enrolled in Medicaid and in good standing. 
States should ensure that they compile any provider lists, registries, or networking 
resource materials in a fair and equitable manner. 
 
Websites for Stakeholders 
States may want to consider making networking resources available on state websites for 
beneficiaries, providers, and other stakeholders, noting which providers are available in 
the home state or out-of-state.  For example, states could provide newsletters for 
stakeholders and information about providers who serve rare and specialized 
conditions.  This information might help identify specialty providers and the type of care 
provided.  This might help providers and families to pre-plan for specific specialty care 
needs.  As a reminder, states should ensure that they compile any provider lists, registries, 
or networking resource materials in a fair and equitable manner. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
12   
Specialty Networks 
 
Commenters on the RFI noted that states may want to consider utilizing provider agencies that 
employ specialized hospital contracting teams to coordinate care from out-of-state providers 
when necessary for children with medically complex conditions.  For example, commenters 
suggested that these types of specialty agencies could be identified by states as part of the 
designated health home team in the health home state plan amendment.  In addition, commenters 
posited that these types of arrangements could help to provide children with medically complex 
conditions and their family members with access to the most appropriate out-of-state care, and 
help to provide them with follow-up care options, both in and out-of-state.  Another suggestion 
was to establish a specialty care coordination program that identifies high-risk beneficiaries and 
tiered support based on medical and social complexity. 
 
Social Service Supports 
 
Commenters on the RFI suggested that states coordinate with social service agencies to help 
families with planning out-of-state care.  Specifically, commenters suggested that families help 
each other by sharing resources on travel costs, lodging, meals and forming connections with 
other parents who have a shared experience.  In addition, they suggested that states may want to 
establish dedicated care coordinators as part of the care team under the section 1945A health 
home benefit, to connect families with hospital and community resources, such as counseling 
services, palliative care, pastoral and social services, financial services, and out-of-state medical 
care.  Finally, commenters suggested that states establish travel protocols between states to 
determine arrangements related to, among other things, the equipment, vehicles, or staffing that 
may be needed when transporting children with medically complex conditions between states for 
their care.   Commenters cited family-centered Navigator programs and federally-funded Family-
to-Family Information Centers as models for the kind of support families of children with 
medically complex conditions would benefit from and stated that additional support for training 
would strengthen the benefits of these programs. 
 
Most Integrated Setting/Olmstead 
 
CMS reminds states that their Medicaid programs, including coverage of services for children 
with medically complex conditions, must comply with the integration mandate under Title II of 
the ADA and the Supreme Courts decision in Olmstead v. L.C., 527 U.S. 581 (1999).  
Commenters on the RFI noted that the ADA integration mandate requires states to administer 
services, programs, and activities in the most integrated setting appropriate to the needs of 
qualified individuals with disabilities.  Further, the Supreme Court has determined that systemic 
failures to develop an adequate array of community-based services, resulting in unnecessary and 
unwanted residential and institutional placements, may violate this mandate.6 
                                                           
6 Olmstead v. L.C., 527 U.S. 581, 605-606 (1999). 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
13   
Commenters who raised this issue stressed that it is important not only to cover and coordinate 
needed acute services for children with medically complex conditions, which might require 
travel out of state, but it is also important to facilitate seamless return to local communities and 
to ensure that these individuals can receive services locally to the maximum extent feasible.  
  
Prescription Drugs and Durable Medical Equipment 
 
Commenters on the RFI noted barriers to obtaining prescriptions from out of state providers for 
medications and durable medical equipment (DME).  These include comments on the difficulty 
of maintaining and/or replacing DME when travelling or receiving care across state lines, as well 
as onerous prior authorization and other utilization management controls.  States should engage 
in dialogue with families of children with medically complex conditions and related stakeholder 
groups to identify streamlined processes that help ensure continuity of care and expedite access 
to essential DME and prescription drugs across state lines, where appropriate (if the conditions in 
42 CFR  431.52 are met).  
 
Conclusion 
 
CMS reviewed and considered all stakeholder input provided through the RFI comments when 
developing this guidance.  CMS used the comments provided through the RFI process to identify 
and recommend best practices that are aligned with statute, CMS regulations, and agency policy.  
CMS expects that these recommended best practices will help SMAs develop protocols, 
procedures, and agreements that will help to ensure that children with medically complex 
conditions receive prompt, high-quality care from out-of-state providers when needed.  
 
CMS generally encourages states to take proactive steps to identify out-of-state providers who 
provide specialized services for children with medically complex conditions (as defined at 
section 1945A(i)(1) of the Act) and to develop guidelines and procedures for coordinating the 
care these providers furnish to children in their state in accordance with 42 CFR  431.52.  
Additionally, CMS recommends the specific best practices discussed above and summarized 
below. 
 
States should explore streamlined and abbreviated provider screening and enrollment processes 
for out-of-state providers to help ensure that Medicaid-eligible children with medically complex 
conditions can access timely care from out-of-state providers.   
 
A person-centered service plan is recognized by CMS, based on comments on the RFI, as a best 
practice.  Such a plan should accommodate patient preferences and be developed according to 
principles that support the incorporation into the service plan of all care providers and specialists 
who best meet the needs of the child, including out-of-state providers.  To ensure that a childs 
care team can readily access information in real-time, CMS also recommends that the care team 
use an interoperable EHR in service planning. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
14   
Another best practice CMS recommends is developing and utilizing agreements between states 
that govern coverage and payment for services furnished to Medicaid-eligible children with 
medically complex conditions living in each state by providers screened and enrolled in the other 
state(s).  These agreements could be used in developing each states guidelines regarding out-of-
state providers, and could include protocols for covering emergent and non-emergent care 
provided by out-of-state providers, payment rates for out-of-state providers, prior authorization 
for services provided by out-of-state providers, and clear guidelines for the coordination of care 
provided by out-of-state providers.   
 
CMS recommends as a best practice that states encourage both home state and out-of-state 
providers to use EHRs and other interoperability methods to automate access to and sharing of 
health information, and to support other care-related activities directly or indirectly using various 
technology tools. 
 
CMS recommends as a best practice that states leverage telehealth to facilitate access to 
Medicaid services furnished by out-of-state providers, thereby improving access to specialized 
services and enhancing care coordination for children with medically complex conditions.  
 
Finally, establishing economic and efficient reimbursement rates for out-of-state providers is 
required under section 1902(a)(30)(A), and will help states improve access to specialized 
services provided by out-of-state providers for children with medically complex conditions.  
 
States that elect to offer a health home under section 1945A of the Act will need to report on 
their use of the best practices described in this guidance under section 1945A(g)(2)(B).  
Specifically, states will need to submit to CMS no later than 90 days after a state has an 
approved state plan amendment under section 1945A, and make publicly available on the states 
website, a report on how the state is implementing this guidance, including through any best 
practices adopted by the state.  
 
CMS expects to issue future guidance to states on the development of health homes serving 
children with medically complex conditions in accordance with section 1945A of the Act and 
will also be available to provide technical assistance to states.  For technical assistance, please 
contact Sara Rhoades, Technical Director for the health homes program at 
sara.rhoades@cms.hhs.gov. 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law. 
 
15