InCK (Integrated Care for Kids) Model

ValuesEdge Strategic Analysis | Pediatric Medicaid & CHIP Payment Innovation

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1. Executive Summary and Strategic Context

What Is This Model and What Problem Does It Solve?

The Integrated Care for Kids (InCK) Model is a child-centered local service delivery and state payment model launched by CMMI in January 2020 under the authority of Section 1115A of the Social Security Act. The model runs for six years through December 31, 2026, covering a two-year pre-implementation period (2020–2021) followed by a five-year implementation period (2022–2026). Seven award recipients across six states (originally eight cooperative agreements, one of which did not progress to implementation) collectively received nearly $126 million in cooperative agreement funding, with each awardee eligible for up to $16 million over the model period. Critically, this funding supports infrastructure and planning only—not direct service delivery to beneficiaries.

The model addresses a structurally well-documented failure in pediatric Medicaid: one in three children enrolled in Medicaid and CHIP have behavioral health needs, yet only one-third of those in need receive care. Children with complex behavioral, physical, or social needs have historically relied on emergency departments as their primary care access point and face disproportionate risk of avoidable hospitalizations and out-of-home placements (OOHP)—including foster care, residential facilities, and behavioral health inpatient stays. The current system's fragmentation is structural: programs operate separately, eligibility criteria differ, enrollment processes are siloed, and information is rarely shared across health, education, child welfare, and social service domains.

InCK's answer is a tiered, population-wide care integration framework that deploys Service Integration Coordinators as single points of contact for high-risk children, uses risk stratification into three Service Integration Levels (SILs) to tier intervention intensity, and mandates the development of state-specific pediatric Alternative Payment Models (APMs) to create sustainable provider accountability. The model also explicitly targets opioid crisis prevention in children and adolescents, as it was designed in part as a multi-pronged federal anti-opioid strategy; adolescent opioid overdose deaths were a named motivating factor in the original funding announcement.

Strategic Significance for the VBC Market

InCK represents CMMI's most architecturally ambitious effort to apply value-based care principles specifically to the Medicaid pediatric population—a segment that has been systematically underinvested in the shift from fee-for-service to alternative payment. Several features distinguish it from adult-focused models:

Cross-sector integration is structurally required, not optional. The model obligates Lead Organizations to coordinate across clinical care, behavioral health, early childhood education, schools, child welfare, food, housing, mobile crisis response, and Title V agencies. This is not a care management bolt-on; it is a mandated redesign of how child-serving systems interact.

The APM requirement is non-negotiable and state-level. Every award recipient must develop or adapt a pediatric APM within Medicaid (and CHIP where applicable). This requires negotiating with Managed Care Organizations—a process the evaluation found more time-consuming and technically demanding than anticipated. As of 2023, most award recipients had contracts in place with some but not all MCOs serving their populations. For context: IL-Village InCK's APM covered 50% of its attributed population, NY InCK's covered 22%, and OH InCK's covered 50% at the end of 2023.

Population size and complexity vary dramatically across award recipients. Attributed populations at end of 2023 ranged from 11,366 beneficiaries (IL-Village InCK) in rural southern Illinois to 160,458 beneficiaries (NJ InCK) in Monmouth and Ocean Counties—a 14-fold difference. This variability, combined with deeply different local contexts (urban/rural, racial composition, area deprivation, MCO market structure), means InCK is not testing a single replicable intervention but rather a framework for locally-adapted pediatric care integration.

The early evaluation data as of 2023 shows limited measurable population-level impact in the first two implementation years. Only three of seven award recipients (IL-All Hands, IL-Village, NC InCK) had reached sufficient engagement levels for impact assessment. Among those: IL-Village InCK demonstrated a 4.8% relative reduction in total cost of care, driven by slower growth compared to a comparison group. NC InCK showed a 2.9% relative increase in well-child visits but also a 3.3% increase in total cost of care, suggesting that enhanced engagement and preventive care access in the short term generates cost before it generates savings. These results are early and must be interpreted carefully, as most APMs were still distributing first payments in 2023–2024.

Political Context and Administrative Alignment

The InCK Model was designed, funded, and launched under the Biden administration's predecessor (the Obama-era CMMI mandate) and was operationally stood up under Biden. It is now in its final implementation years under the Trump administration led by HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz, with CMMI under Director Abe Sutton.

The current administration has not publicly terminated InCK, and the model is listed as Active with a page last modified May 12, 2026, indicating continued operational status. However, the model's alignment with Trump-era CMMI priorities is complex. The opioid crisis prevention angle—explicitly cited as a founding rationale for InCK—has persistent bipartisan relevance. The focus on early identification and prevention over institutional care is consistent with broad federal cost-containment goals. However, the model's explicit orientation toward Medicaid expansion-era beneficiary populations, community-based organization funding, and cross-sector social service integration does not map cleanly onto the current administration's preference for Medicaid structural reform and DOGE-driven efficiency mandates.

Strategically, organizations participating in or adjacent to InCK should monitor CMMI's posture toward the model through 2026, particularly whether the administration pursues early termination, modification of APM requirements, or simply allows the model to conclude on schedule.

Market Transformation Implications

The InCK model is materially advancing two capabilities that will persist beyond 2026 regardless of the model's formal outcomes: pediatric risk stratification infrastructure and cross-sector data sharing agreements. Organizations that have built SIL stratification processes, MCO APM contracts, Partnership Councils, and closed-loop referral platforms (such as the Unite Us platform used by multiple award recipients) are establishing durable operational infrastructure.

For Medicaid managed care plans, InCK's APM negotiations have created a template for pediatric incentive payment structures. The PMPM-plus-quality-incentive architecture adopted by most award recipients—ranging from preventive care measures to total cost of care benchmarks—provides a replicable contracting model for states looking to expand pediatric value-based care beyond InCK geographies. For children's hospitals and health systems operating outside InCK regions, the evaluation data on what it takes to actually move well-child visits and reduce out-of-home placements at scale provides operationally important intelligence.

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2. Model Architecture and Payment Structure

Participation Structure

InCK is structured around three mandatory participant categories whose roles are distinct and non-interchangeable.

State Medicaid Agencies (SMAs) must participate in every InCK award, either as a Lead Organization or as a supporting partner. SMA responsibilities include: providing population-level Medicaid data for the geographic service area; supporting development of information-sharing arrangements and infrastructure; aligning support across child-focused state agencies; and co-developing the pediatric APM. SMAs cannot opt out of participation; the model requires their formal engagement regardless of whether they hold the lead role.

Lead Organizations are HIPAA-covered local entities that receive cooperative agreement funding directly. They are responsible for convening community partners, developing service integration protocols, administering needs assessments, managing SIL stratification, and holding accountability for population-level care quality and outcomes. Lead Organizations in the active cohort include a range of entity types: children's hospitals (Ann & Robert H. Lurie Children's Hospital of Chicago, Nationwide Children's Hospital, Montefiore Medical Center, Hackensack Meridian Health), state Medicaid agencies acting as their own Lead (New York State Department of Health, Ohio Department of Medicaid), a community health center (Egyptian Health Department), a university health system (Duke University), and a behavioral health clinic (Clifford W. Beers Guidance Clinic).

Partnership Councils are convened by Lead Organizations and must include representatives from all Core Child Services (CCS) domains, community stakeholders, and Medicaid payers. Their primary responsibility is devising strategies and processes to achieve cross-sector service coordination. The evaluation found that maintaining consistent family and youth engagement in Partnership Councils was a persistent challenge across all award recipients through 2022–2023.

Attributed Population Eligibility: Award recipients must serve all Medicaid-covered children from birth to age 21 residing in the designated service area, regardless of health plan enrollment type (fee-for-service, MCO, or health home). Awardees may optionally include CHIP beneficiaries and Medicaid-covered pregnant women over age 21. Notably, NY InCK does not include CHIP beneficiaries in their attributed population; all other award recipients do.

Award Recipient Characteristics and Population Sizes

Award Recipient	Lead Organization	Attributed Region	2023 Population
IL–All Hands InCK	Ann & Robert H. Lurie Children's Hospital	Two ZIP codes in Chicago (60639, 60651)	41,478
IL–Village InCK	Egyptian Health Department	Gallatin, Hamilton, Saline, Wayne, White Counties, IL	11,366
NC InCK	Duke University	Alamance, Durham, Granville, Orange, Vance Counties	112,057
CT InCK	Clifford W. Beers Guidance Clinic	Two ZIP codes, New Haven, CT	11,960
NJ InCK	Hackensack Meridian Health	Monmouth and Ocean Counties	160,458
NY InCK	Montefiore Medical Center	Three ZIP codes, North-Central Bronx	56,710
OH InCK	Nationwide Children's Hospital	Licking and Muskingum Counties, OH	33,857

Service Integration Level (SIL) Stratification Framework

The core clinical architecture of InCK is a three-tier risk stratification system:

• SIL 1: All attributed beneficiaries with no or few identified needs. Receive referrals from Service Integration Coordinators or via helplines as needed. This is the baseline tier covering the vast majority of attributed populations.
• SIL 2: Beneficiaries with functional symptoms or impairments and multi-sector needs. Receive integrated care coordination from community-based Service Integration Coordinators serving as a single point of contact.
• SIL 3: Beneficiaries meeting SIL 2 criteria who also exhibit at least one of: current or imminent risk of OOHP, or prolonged/multiple inpatient admissions. Receive the most intensive integrated case management, typically from MCO care coordinators.

Needs assessment to assign SILs must cover 10 CCS domains annually: Physical Health, Behavioral Health, Maternal and Child Health, Functional Symptoms, Functional Impairments, Special Education/Early Intervention, Child Welfare, Imminent or At Risk of OOHP, Housing Instability, and Food Insecurity. Assessment methods include screen-based assessments (direct beneficiary contact via phone, in-person, or online) and administrative assessments (drawn from Medicaid claims and other administrative data). CMS introduced model flexibilities in 2021 allowing administrative data to satisfy needs assessment and SIL stratification requirements for the first three years of implementation.

As of end-of-2023, SIL 2 and SIL 3 assignment rates varied substantially by awardee. IL-All Hands InCK had ~7.7% of its population assigned to SIL 2 or 3; IL-Village InCK had only ~1.0% assigned to SIL 2 or 3; OH InCK had approximately 4% in SIL 2 or 3; CT InCK had fewer than 11 beneficiaries assigned to SIL 2 or 3 (suppressed for privacy); NJ InCK had less than 1% in SIL 2 or 3; and NY InCK had less than 1% confirmed in SIL 2 or 3.

Alternative Payment Model Architecture

Every award recipient is required to design and implement a state-specific pediatric APM covering at minimum beneficiaries in SIL 2 and SIL 3. APMs are not Alternative Payment Models as defined under 42 CFR §1305 (the Quality Payment Program framework); they are Medicaid-specific payment innovations. The APMs leverage existing mandatory and optional Medicaid and CHIP benefits and must cover care coordination, case management, and mobile crisis response and stabilization services.

Six of the seven award recipients designed per-member-per-month (PMPM) payment models with quality incentives. The seventh (NY InCK) designed a shared savings model aligned with existing ACO contracts.

Award Recipient	APM Structure	Key Payment Details	Implementation Status (End 2023)
IL–All Hands InCK	PMPM quality + TCOC incentive	$3.00 PMPM quality incentive + $1.50 PMPM TCOC incentive; later expanded to $4.50 PMPM total for PCPs; distributed to PCPs (50%), BH providers (25%), CBOs (25%)	Full: Payments distributed in 2023; $246,421 distributed in first payments
IL–Village InCK	PMPM quality incentive	Incentive for preventive care, BH care, and care coordination; covers ~50% of attributed population (2 of 4 MCOs)	Partial: Payments expected 2024
NC InCK	PMPM quality incentive	Six quality measures; incentive for upstream health screening, preventive services, reduced utilization	Full: Payments expected 2024
CT InCK	PMPM for SIL 2/3 care coordination only	Not population-wide; FFS state, so all beneficiaries potentially impacted; first payments distributed end of 2023	Full (SIL 2/3 only)
NJ InCK	PMPM: PCP incentive for screen-based assessment review + PMPM for care coordination/case management	Provider payments started 2022; rates increased 2023; Advanced Care Management Team serving ~250 beneficiaries simultaneously	Full: Covers full attributed population
NY InCK	Shared savings with quality incentives	Measures include preventive care, upstream health screening, clinical depression screening/follow-up; covers ~22% of attributed population (one MCO)	Partial: One MCO's provider payments expected 2024
OH InCK	Incentive payment	Incentivizes completion of health risk assessments and ADHD quality measures; covers ~50% of attributed population	Partial: Contracts in place early 2023; payments planned 2024

The All Hands InCK PMPM payment structure illustrates the tier distribution: PCPs earn $3.00 PMPM if they reach the HEDIS 90th percentile on quality measures, or a partial incentive for achieving 75% of the HEDIS performance rate or a 4.0–6.9% improvement from the prior year. PCPs earn $1.50 PMPM for maintaining TCOC at or below 100% of the prior year (with a 2% trend assumption). All Hands' APM is classified as a Health Care Payment Learning & Action Network Category 2C (quality incentive payment linked to performance metrics).

Performance Measures

Quality measures vary by award recipient but span common domains:

IL–All Hands InCK PCP Measures: Well-child visits in first 30 months of life (HEDIS W30); Child and adolescent well-care visits; Childhood immunization status – Combination 3; TCOC; ED visits per 1,000; inpatient admissions per 1,000. Behavioral health measures include community-based BH visits per 1,000, BH ED visits per 1,000, and BH inpatient admissions per 1,000 (methodology still being refined as of end 2023).

NC InCK: Six quality measures covering screening for upstream health drivers, preventive services, and utilization reduction.

OH InCK: Health risk assessment completion rates; ADHD quality measures.

NY InCK: Preventive care rates; screening for upstream health drivers; clinical depression screening and follow-up.

The Out-of-Home Placement (OOHP) measure is the model-wide composite outcome measure: rate of new OOHP episodes per 1,000 attributed beneficiaries per year, incorporating (1) long-term care facility placements (residential care centers, nursing facilities, ICFs); (2) inpatient behavioral health hospitalizations (psychiatric, children's, or general hospitals); and (3) foster care custody episodes.

Model Timeline

Period	Model Years	Dates	Key Activities
Funding Opportunity	—	NOFO released February 8, 2019; applications due June 10, 2019	Competitive award process
Pre-Implementation Period	Years 1–2	January 1, 2020 – December 31, 2021	State authority establishment; infrastructure development; needs assessment design; APM planning
Implementation Period	Years 3–7	January 1, 2022 – December 31, 2026	Full model implementation; needs assessment and SIL stratification; APM payment distribution; required data reporting
Model End	—	December 31, 2026	Model conclusion

Funding Constraints

Cooperative agreement funding (up to $16 million per awardee; ~$126 million total) is restricted to infrastructure and implementation activities only. Allowable uses include: staff time for training; infrastructure costs for data sharing; service integration process planning; preparation for implementation. Funding may not be used to deliver clinical services to beneficiaries. This constraint is operationally significant—it means Lead Organizations must rely on existing Medicaid billing, APM payments, and non-InCK funding streams to actually deliver the care coordination and case management services the model requires.

Key Implementation Challenges Documented Through 2023

The evaluation identifies several systemic challenges relevant to any organization assessing InCK replicability or designing successor models:

Beneficiary engagement at scale is structurally difficult. Screen-based assessment completion rates ranged from under 1% (NJ InCK, NY InCK) to 12.6% (IL-Village InCK) of attributed populations by end of 2023. Phone-based outreach was consistently ineffective; in-person community presence through trusted partners was more effective but slower to scale. Only 7 of 5,720 families who received email or text outreach from All Hands InCK completed screen-based assessments through the online platform.

APM MCO contracting took longer than anticipated across all awardees. Barriers included: limited internal expertise; time required for government coordination; and MCO resistance to pediatric APMs. No award recipient identified facilitators for provider contract negotiation.

Data infrastructure is inadequate for real-time performance measurement. All Hands InCK was unable to share interim performance data with network providers due to PCP attribution errors, delaying 2022 incentive payment distribution. CBO-level data collection remained almost entirely manual and family-level rather than individual-level, complicating provider performance attribution.

Service Integration Coordinator caseloads are far lower than anticipated. All Hands InCK Service Integration Coordinators served a range of 3–26 beneficiaries per month versus the 60–90 originally projected. This reflects the labor-intensity of true care coordination for complex pediatric populations and has direct implications for workforce sizing and cost modeling in any expansion or successor design.