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Where we share our weekly news debriefs and discussions with industry experts. These are lo-fi recordings aimed at giving our readers more opportunities to engage with our analysis and a view into some of the conversations that shape it.
Martin: Michelle from Here and
Now Health, how are you today?
Michelle: I'm doing great.
How are you both doing?
Martin: Doing great.
Awesome.
So I used to work for Medicaid, and I
thought I knew a lot about Medicaid,
and then we had our first conversation,
and I learned about a whole new
side of Medicaid- ⦠that I did
not know, which is that, uh, foster
children are entitled to Medicaid,
uh, or youths that age out of, uhâ¦
And in some states it's run by special
plans, like sort of carve-out plans.
Can you give us aâ¦
Before we get into Here and Now Health,
which is fascinating- Yeah ⦠can
you give us a little bit of a sort of
history and overview of how Medicaid
and the foster system interact today, in
the past, and, and what the trends are?
Michelle: Yeah, absolutely.
So you're not alone, Martin, for starters.
A lot of people that know a
lot about Medicaid, um, this
is actually new to them.
And so, um, if you think about it, whatâ¦
We'll go back a little bit to what
happens when a child comes into the
foster system, and essentially what states
are saying in those cases is that, "We
can do a better job being this child's
parents than their biological parents."
And so while not getting too much
into the politics of that, you know,
i- i- as a thesis, um, the, the state
is, is literally taking custody of
the child, and as that child's pseudo
parents or caregivers, they then
give that child their insurance.
I mean, that's kind of the
easiest way to look at this.
And so children who come into the
foster system are automatically eligible
for that state's Medicaid program.
And a lot of people don't realize
this, but, um, it's not just
kids within the foster system.
When youth age out of foster care or
they turn 18 and essentially become
adults, um, and at that point were still
in cu- the custody of, of the state's
child welfare system, they take that
Medicaid with them, much like if your
child turns 18, they remain, you know,
eligible for your insurance while they're
in college, and oftentimes beyond.
And so those youths stay
on Medicaid until 26.
Um, the other subset is actually children
that are adopted out of the foster system.
Almost all children who are adopted
out of foster care also remain
eligible until 18 or even 21.
So as we'll probably talk a little bit
more about, you know, my background
for starting Here and Now Health,
my husband and I have six children.
Four are adopted out of foster care.
Even though my husband is a naval officer,
so all of our kids have TRICARE, our four
who are adopted also have Medicaid until
they're n- they're 21 here in the State
of Virginia, and that is because of their
own connection to the foster system.
So it is, it's a federal mandate, um, and
just kind of as a baseline for what we're
talking about today, that eligibility
is based on the child or that young
adult's connection to the foster system,
and not based on income requirements,
not based on work requirements, or
anything really from their, their
parents or the adults in their lives.
Kevin: One just more level
setting question from me on
the foster program writ large.
Um, you said federal mandate, but a
lot of it sounds state implemented.
Obviously, Medicaid has a lot of state
dynamics and also federal dynamics.
Um W- what is each, what, what's the
federal government's role in the foster
program right now, and how does it work
with states in ensuring consistency across
programs, and what's kind of current
state of that federal state partnership?
Michelle: Yeah, so it's, I mean, we could
talk for probably several hours about
some of the- ⦠nuances of this, but-
Yes ⦠really, in like in its simplest
form, um, federally it's mandated that
this population is covered, and just
like almost everything else within a-
Medicaid, states have a lot of kind
of autonomy in how they roll it out.
Yeah.
How they actually cover this population.
So in some states, this, kids or
young adults are, are put on, um,
Medicaid plans just alongside any other
Medi- eligiment, eligible Medicaid
members, so they're auto-enrolled.
You know, there might be three or
four MCOs that are a part of that, um,
you know, broader Medicaid contract.
The really interesting thing about
this population is there, there's
about 15, 16, 17, depending on how you
look at it, states that actually take
this population and they carve them
out and create a specialized plan.
And so most states call that either foster
specialty plans or sole source plans,
and they open it up as a competitive RFP.
They're actually very competitive.
Medicaid MCOs go after them pretty hard.
And they're awarded as sole
source contracts, typically
for five years or longer.
And so what that means is every child
or young adult in a state that has
Medicaid because of their connection
to the foster system is on the same
plan or is covered by that one MCO.
So here in Virginia, Anthem
HealthKeepers, um, owns that contract.
And so all youth in the foster
system, adopted out and aged out,
are now on Anthem HealthKeepers
on that specialized plan.
So that's where it gets really interesting
from a kind of state by state perspective.
Martin: Can you give us some
perspective on w- why it might make
sense to do a carve out like this?
What are the, the needs that, uh,
foster-connected youth or young adult
have that are different from the
sort of general Medicaid population?
Michelle: Yeah, so what's really
interesting about this, that al- that,
another thing that kind of surprises a
lot of people is that more conservative
states actually championed this early.
So Texas is actually, from my
understanding, the first one
that had a foster specialty plan.
It was about 16, 17 years ago, and Centene
has actually owned it the entire time.
So they also have a lot of longevity
with these, with these contracts.
And you can also kind of look
at it as, okay, we have this
population that we have to cover.
Again, we don't have a choice
because it's federally mandated.
We have some autonomy as a state
in how we're going to cover them.
And so what it s- seems kind of like
to me has happened is in some states
that tend to have fluctuating coverage,
especially for their pediatric population.
They sort of take this population
separately, say, "Okay, if we, if we
put them on a separate plan, we can
follow those, again, federal mandates.
We can make sure they're covered even
if the, the coverage for the rest
of our pediatric, pediatric Medicaid
population may not be super consistent."
And so that's where we've seen,
again, it's, it's sometimes states
that actually don't have the best
Medicaid coverage for their pediatrics
that have these specialized plans.
But it's become more diverse.
You've got states like Illinois,
Washington, North Carolina was a
newcomer in 2025, so it's geographically,
politically pretty diverse in
terms of who has sole source plans.
Um, from the need aspect, you've got
a population that tends to have very
high levels of, um, you know, both
physical and mental health needs.
You've got teens in foster care
that have up to 80% of mental health
diagnoses as a population as a whole.
You also have very low levels of
access, so there's a lot of transiency.
So if you think about it, one of
the, one of the aspects of a child
or really anyone's life that make
it difficult to have continued
healthcare access is transiency.
So a child or an adult, if they move
pretty frequently, it makes it very
hard, everything from wait lists to
having consistent providers to having
providers that know medical history.
And so that's a very common thing, of
course, for children within the foster
system is to, to have a lot of moves,
unfortunately, or a lot of transiency.
Um, so when you couple those, those,
you know, higher acuity needs, higher
diagnosis rates, less stability, um, you
c- you really kind of come up with a, a
oftentimes perfect storm for not getting
great care, and that's a lot of what
these, these plans are, these sole source
plans are really built around fixing.
Kevin: Michelle, I, I, I wanted to turn
a little bit more to Here Now and the
model that y'all are building there.
Um, Iâ¦
It's funny, you know, having written
about the healthcare innovation space
writ large for every weekend for 10
years now, foster care is not something
that I think has ever come up before.
Mm-hmm.
Not that, you know, I, I, um, it's not
an important program, but you don't see
much startup activity targeting the space.
I, I would, I would love to hear
how you thought about approaching
the foster care market, how youâ¦
As my understanding is virtual care
model for mental health for foster kids.
Um, how did you land on that
as the initial build-out?
How are you thinking about the model?
What is Here Now up to, uh, today?
How does the business
look like at this moment?
Michelle: Yeah.
So it was really intentional,
the build-out, I will say.
Um, I've been in
healthcare my whole career.
I spent about six years helping to build
a company called Hazel Health, the largest
provider of school-based telemedicine.
So, you know, a lot of my background was
in pediatric virtual behavioral health.
But the background on
Here Now really goes back.
In 2013, my husband and I became
foster parents in the state of
Georgia, and over about five years,
we fostered over 40 children.
Um, four of our six, as I mentioned,
are adopted out of foster care.
And when we closed our home to
fostering, I became a CASA volunteer,
or Court Appointed Special Advocate,
advocating for system-impacted families
in the juvenile justice system.
So I had, you know, different
interactions, different roles
kind of within the child welfare
system across several years.
And what I found was even though I was
working in the healthcare system every
day- I was literally working at an FQHC
while we were foster parents, so at
the ground level of safety net care.
And I had, you know, access
arguably, you know, more than most
people to the healthcare system.
I was failing to get kids in our
own home the mental healthcare they
needed, and it wasn't a coverage issue.
You know, 100% of kids, of course,
that came to us were, were covered
by Medicaid, but it was, it
was literally everything else.
We would almost never get
a Medicaid card with them.
And so I'd go to sign them up and
community providers would say,
"Oh, uh, until you have a physical
Medic- Medicaid card, we can't
put them on a, on an intake list."
Or I'd have different birth dates
on different forms that were given
to me, so we literally would not
know which one was the correct
birth date or which one was given to
Medicaid to be able to match that up.
Um, and then just wait lists.
We, we had one therapist in our
county in, in North Georgia who
accepted Medicaid, and he oftentimes
had a six-month wait list.
Not to mention, he was an older white
male, so a lot of our teens and middle
schoolers, especially our females
that came to us, weren't comfortable
opening up, especially ones that
had been victims of, of, of males.
And so there were just all of
these different things that would
keep us from getting kids in care,
and then we saw the escalation.
Um, we were constantly told to go to
the emergency room because, again,
we have a really high level of
accountability for this population.
So the child welfare system, our
caseworkers would say, "If all else
fails, just, just go to the ER.
They can't turn you away."
But then you see kids who show up
to the emergency room for behavioral
health issues, they get hospitalized.
They end up in residential care, and
oftentimes because it's the only bed for
them to sleep in, because we have to have
a bed for kids in foster care to sleep.
And so it wasâ¦
You know, again, I was, I was seeing
this kind of unravel in front of my eyes.
Um, later on, I, I found the stat
that we spend about 10X the medical
spend on behavioral health for kids
who have a foster care connection
in comparison to the rest of
Medicaid, and it makes sense, right?
We-- I saw we were paying
for it in crisis care.
We were constantly at the emergency room.
Kids were being hospitalized
and not released simply
because they had nowhere to go.
So I started to just ideate, like, what
would it look like if we did this better?
Um, this is a population where if
you talk to almost anyone in a state-
Politicians, stakeholders, Medicaid, and
you ask them, "Who are you most concerned
about when it comes to our youth?"
They will almost inevitably say
kids that are in the foster s-
system or kids that are connected.
And so I knew that the, the, the
desire was there to do better,
but like you said, Kevin, n- no
one is innovating in this space.
Mm-hmm.
And so I just started to look
at it as like what would, what
would make this make sense?
And so intentionally virtual, really
specialized care that we can get to
kids early and often, so within 48 hours
of when they enter the foster system,
that can stay with them even if they
move, so kids don't have to retell
their story, was what I knew was needed.
And I knew that we had done this
in other areas Within virtual care.
Mm-hmm.
It had just never been built truly
for, um, for the foster system.
And so that is what Here Now Health is.
We provide intentionally virtual
specialized care early and often
for any child or young adult that
has a, has their Medicaid because
of their foster care connection.
We partner with specialized Medicaid
health plans that hold these sole
source contracts to not only help
improve their outcomes, but reduce
their costs by preventing the crisis
care that we know happens too often.
And we include caregivers.
So if that is a foster mom, if that
is a grandma that has custody, if that
is a bio dad that's working a case
plan to get their child back home,
we include that adult, adult because
we know that that is the only way to
really stabilize the child's world.
Martin: I know we have you
a couple minutes after time.
If you have a couple more
minutes, I would- Yeah, I
Michelle: do.
Yeah
⦠Martin: great.
Great.
Great, great.
I would be curious to hear a little bit
about, you know, so it, it seems like
there's a, a sort of nice benefit from,
um, having a sole source contract in
that you have a single payer that you're
working with, so you can get them the
help right away and intervene right away.
I'm curious how you go about, um, like
the, the sort of contracting with them.
Like historically Medicaid, it's been
hard to get providers, not just because
of regions, but also just because
the reimbursement rates are low.
Right.
I'm curious how you kind of address
that and get the, these foster impacted
youth and their caregivers the sort of
level of care that they, they deserve.
Michelle: Yeah.
So we, when it comes to getting
them the level of care, we, we often
say we don't take no for an answer.
We are built around the realities
of foster impacted youth, and
you can't do that by accident.
You, you have to really intentionally
build it from the ground up.
Um, and that goes from everything
from our technology and our product.
We have a no login experience.
Um, and, and that was intentional because
as a foster mom, I was locked out of
almost every single child's EMR, you know,
account that came into our home because
that EMR was set up by three foster homes
ago, and nobody could get the login.
And so we've in- we intentionally built
a login-free experience, and that's
really hard from a product standpoint.
It's, it's not easy to do.
But again, we did it really
intentionally from, from the beginning.
Our care model we built alongside
the, um, Florida Institute for
Child Welfare based on very specific
research that showed what clinical
models work within this population.
Um- And so we, um, so yeah, so
we, you know, I just believe very
strongly that you can't accidentally
do well by this population.
We have a less than 10% no-show rate,
and in, in Medicaid across the board,
it's typically around 30% to 40%.
But we call our aged-out youth the
day before their appointments and
tell them we're excited to see them.
Um, we, you know, help our, our teens
and aged-out youth oftentimes get a
no-cost cell phone from their Medicaid
health plans because they aren't able
to l- to, you know, join their sessions
when their cell phone gets cut off.
We have gotten our therapists licensed
in new states when a child is getting
moved to a, you know, a kinship or
a family placement in a new state
so they can continue with that care.
We, we do whatever needs to be done.
And so we go to health plans,
and we let them know this, that
there's no one-size-fits-all fix
when it comes to this population.
We are going to uniquely care for
every family that we work with.
Um, and in doing so, we're again
gonna help them improve their
outcomes and, and therefore re-win
these sole source contracts and s-
and save on behavioral health costs.
But they have to work with us, um, in kind
of the, the same kind of unique way that
we are s- we are supporting their families
Martin: I would imagine it is a lot less
expensive for them to pay your therapists
good rates than it is to have foster
children staying in inpatient psychiatric-
Michelle: Ex- exactly.
They pay about the same for one, um, full
month of Here Now health care as they
do for one day in a residential setting.
So it's that, you know, it's that
1 to 30 ratio that is, is helpful.
Um, we are truly the lowest
cost care, and that'sâ¦
I mean, that's our thesis.
We believe that most kids
actually need lower cost care.
They don't need IOP.
They don't need hospitalization.
They need a really healthy
therapeutic relationship from day one.
'Cause again, we're dealing with
a population that has 80%-plus
mental health diagnoses, and
they deserve the very best care.
Kevin: Yeah.
Michelle, last question from me.
Um, A, kudos to you for focusing on this.
Like, this is really cool.
Like, I love this conversation.
Um, uh, but I'm, I'm curious.
W- what's biggest bottleneck that
stops this from being available f- to
every foster kid in the country today?
Like, what, what do we need to solve
so that programs like this can, can
roll out to more of the population?
'Cause it seems like such a
unambiguously good thing to me
that we should have more of.
Michelle: Yeah.
So I would say, like, for us personally,
it is that state by state we have to
have buy-in from that health plan.
And as you all know, that even if you
can say- Yeah ⦠"Look, we've- Exactly
⦠we're almost guaranteeing you lower
costs in the long run," it, it, it's
still not usually a simple conversation.
Um, contracting and credentialing, you
know, is, is not easy with Medicaid.
And so we are going by a state, state
by state strategy of where can we have
truly the largest impact, where can
we have a really deep partnership?
'Cause we're al- we're building to be the
healthcare partner of these Medicaid MCOs.
We're not just building to
be a, a telehealth vendor.
Um, and so we're very strategically
launching state by state, and we're
not trying to just do a land grab
of how can we get into 50 states
in the next two to three years.
But from more systematic, um,
I would say that y- you know,
again, states have autonomy for
how they cover this population.
And so more and more states are
moving toward sole source plans.
Again, we had the very first
one about 16, 17 years ago, and
now we have- 17 plus with a few
RFPs coming up in the next year.
So states are realizing this is a, it's
a good way to cover this population
with the care they need and deserve,
and it's also a, a good way to hold a
health plan accountable for we're going
to give you this whole population.
But I would say that's also the risk.
Like, that, that's the
benefit and the risk, right?
If you're gonna have a sole source
contract, you have to hold that
sole source owner m- to a h-
very high level of accountability
because they don't have competition.
And so I would just say that's the, you
know, that's the risk to flag, um, when
it comes to states, is if you're going
to do this, you have to do it well, and
you have to, to really hold that, you
know, Medicaid MCO accountable for, for
providing the, the care that they're,
they're Obligated to provide, I guess
Kevin: I lied, can I ask
one quick follow-up on that?
Michelle: Absolutely.
Kevin: Keep it going.
I can keep going all day.
Hey, I've got all day, Kevin.
I promise, just the very last one.
Yeah.
I, um, who at the state Medicaid
agencies is responsible for this?
Like, is there a team that is
overseeing foster care and that
relationship with that MCO?
Is this, like, one person who
has broader responsibilities
that side a desk for them?
Like, what is the, the current
state of the state Medicaid agency
and resourcing for this program-
Michelle: Yeah.
So it's- ⦠from a people perspective?
It's interesting in that it's a f-
it's typically a few people, and
sometimes just like, you know, like
it's a little different in each state.
I'll use North Carolina for an example.
Um, the former secretary, Kody Kinsley-
Martin: Mm-hmm
⦠Michelle: was really the
champion for the, the RFP that
came out a couple of years ago.
And he really intentionally bu- I
know he was one of the ones that
really intentionally built in.
So it's usually a mix of the, the
Secretary of Health and Human Services,
the Medicaid director, um, you know,
the Commissioner for Behavioral Health.
Kind of a mix of who's really involved
in creating the Medicaid RFPs that
go out, and how they design them.
And so just using that as an example,
I know he was a really big champion for
how that, the State of North Carolina
designed their most recent RFP, which
is where they implemented the, the
state's first f- um, specialty plan.
And the one other thing I'll say
about that, which is what Iâ¦
I'll, I'll create a question for myself
of what, what, what should happen more
often in states, or what would I love
to see more often in states, is that
they're using it more for prevention.
So the f- the foster specialty plan in
North Carolina doesn't just cover kids
in foster care, aged out youth, and those
adopted, it after, actually covers kids
on safety and family preservation plans.
So what that means is, if a family is
being investigated for suspected abuse
or neglect, and it, there's something
that's found to be a risk, but not enough
to pull that child into foster care.
So they usually create a
safety or preservation plan.
And what that means is, we're
gonna keep an eye on this family,
but we're gonna try to give them
the resources to stay together.
One of those resources they give them
now in the State of North Carolina is
Medicaid coverage for the children.
And think about that.
It makes so much sense.
If, if not having healthcare is a
reason we're gonna pull a child into
foster care, and this happened to us,
we had a teen that came to us because
her grandma couldn't get her the
mount, mental healthcare they needed.
Why would we not just give
them that healthcare at home?
Keep that family together.
It's cheaper, it's better for the
child, it's better for the family.
So now that's written into
the foster specialty plan
eligibility in North Carolina.
So a child in the home that's at
risk of foster care is put on the
foster specialty plan so they can
then access a broader array of
the healthcare services they need.
It also does something really cool,
which is it's, it's gonna be providing
coverage actually for the parents.
So anything that would keep, again,
that family from being separated is able
to be billed to the child's Medicaid.
Um, so again, like, the more we can funnel
this Medicaid coverage to prevention, the
better for families, and in the long run,
the cheaper, cheaper for states as well.
So I, I kinda like created
my last two questions.
I hope it's okay.
Martin: Abso- absolutely.
I think we're already looking
forward to having you back,
watching the story closely.
But in the meantime, where can people
find you if they wanna learn more or
are a state Medicaid director and wanna
bring Here Now Health to their state?
Michelle: Yeah, absolutely.
I'm pretty active on
LinkedIn, um, Here Now Health.
My email is michelle@herenow.health.
That's also our web address.
And you can go on there, you can
actually see our, our referral
form and how simple we've made it.
Again, as, you know, just
that intentionality behind
making it as accessible and
low to no barrier as possible.
But I would, I'd love to chat,
whether it's about, you know, bringing
Here Now Health to your state, or
even just Medicaid policy, child
welfare, you name it, I'm game.
Martin: Awesome.
Thanks so much for your
time today, Michelle.
Michelle: Absolutely.
Appreciate you, Michelle.
Thanks a lot.
Yeah.
Yeah.
Thanks Kevin and Martin.
Martin: See you.
Bye.
Michelle: Appreciate it.