Opioid Exposed Newborn: Assessment and Pharmacologic Management,” Journal of Opioid Management, vol. 5, no. 1 (2009). Page 9 GAO-18-32 Newborn Health Figure 1: Non-Pharmacologic and Pharmacologic Treatment for Infants with Neonatal Abstinence Syndrome HHS has published several guidance and educational resources related to NAS and prenatal opioid use. These documents serve as tools to help stakeholders, including state entities and health care providers, who work with this population. For example, SAMHSA published a clinical report for health care providers in 2016 that provides recommendations to help them when making decisions regarding the evaluation, care, and treatment of women with opioid use disorders and infants with NAS.21 As of July 2017, SAMHSA is in the process of producing a clinical guide based on this report and expects to publish an updated report later this year. In another example, SAMHSA published a guidance document in 2016 that aims to support the efforts of states, tribes, and local 21SAMHSA, “Advancing the Care of Pregnant and Parenting Women With Opioid Use Disorder and Their Infants: A Foundation for Clinical Guidance,” Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. Federal Resources on NAS and Prenatal Opioid Use Page 10 GAO-18-32 Newborn Health communities in addressing the needs of pregnant women with opioid use disorders and their infants.22 Among other things, the document includes strategies and guidance to promote care coordination among stakeholders, including child welfare agencies and medical professionals, when treating infants with NAS. (See app. II for a list of federal educational resources related to NAS and prenatal opioid use published by HHS.) As we previously noted, more than 80 percent of NAS cases are paid for by Medicaid, which is a federal-state health care program that finances health care coverage for low-income and medically needy populations, including children and aged or disabled adults. States administer their Medicaid programs within broad federal requirements and according to a state plan approved by CMS, the federal agency within HHS that oversees Medicaid. The Medicaid program allows states to design and implement their programs within certain federal parameters, resulting in more than 50 distinct state-based programs.23 For example, states generally determine the type and scope of services to cover, set payment rates that different health care providers will receive for various covered services, and pay these providers for claims submitted for services rendered. In addition, states vary in the extent to which they enroll beneficiaries in managed care versus delivering care through the more traditional fee-for-service model. Under a managed care delivery model, states typically contract with managed care plans to provide a specific set of Medicaid-covered services to beneficiaries and pay them a set amount per beneficiary—referred to as capitation payments—to provide those services.24 Under fee-for-service, Medicaid pays health care providers a fee for each service provided to a Medicaid beneficiary. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit, which states 22SAMHSA, A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publications No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. 23Medicaid programs are administered by the 50 states, the District of Columbia, American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, Puerto Rico, and the Virgin Islands. 24Capitation payment is a payment the state makes periodically to a contractor on behalf of each beneficiary enrolled under a contract and based on the actuarially sound capitation rate for the provision of services under the state plan. The state makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. 42 C.F.R. § 438.2. Medicaid Program Overview Page 11 GAO-18-32 Newborn Health are required to provide, covers comprehensive health screenings, preventive health services, and all medically necessary treatment and services—for Medicaid eligible-children under the age of 21—to correct or ameliorate health conditions discovered through screenings.25 According to the literature we reviewed, most infants with NAS in the United States are treated in a hospital setting, often in the neonatal intensive care unit (NICU), which has a relatively high daily cost of care.26 Stakeholders we interviewed told us that these infants may also be treated in other hospital settings. According to state and perinatal collaborative officials in the four selected states we reviewed, infants diagnosed with NAS begin—and most complete—treatment for the condition in various hospital settings which provide different levels of care: a well newborn nursery (level I), special care nursery (level II), or 25The medically necessary treatment and services must be covered for an individual child regardless of whether the service is covered under the state’s Medicaid plan. 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(4)(B),1396d(r). 26For example, see V. N. Tolia, et al., “Increasing Incidence of the Neonatal