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Medicaid Contract Purchasing Specifications

Immunizations
May, 1998

These sample purchasing specifications for immunizations services, have been prepared by the George Washington University Center for Health Policy Research in consultation with officials from the Centers for Disease Control and Prevention, the Health Care Financing Administration, state Medicaid agencies, state and local health agencies, and other experts. This document should be viewed as a tool to assist managed care purchasers identify key issues and decision points as they prepare their purchasing agreements. The specifications provide a broad menu of draft provisions for contracts, RFPs, and intergovernmental agency agreements. They can be used either singly or in combination with one another.

Certain provisions are set forth in bold and italic as alternative approaches or additional options for inclusion in contracts and service agreements. While all of the contents of this document are purely optional and exemplary, the textual emphasis on certain alternatives and options is intended to identify for purchasers certain specification options which they may want to consider in addition to the basic choices that the sample specifications present.

These specifications, which are part of a Sample Purchasing Specification Series, can be obtained in diskette format from:

The George Washington University Medical Center
Center for Health Policy Research
2021 K Street N.W. #800
Washington D.C. 20006

Table of Contents

§001. Application of Specifications; Deemed Compliance for Contractors with Effective Immunization Programs: Establishes the scope of application of the specifications as well as the inclusion of a performance-based system for deeming contractor compliance with numerous specifications contained in the document.
§002. Deemed Compliance by Contractors with Effective Immunization Programs: Describes the performance-based measurement system for deemed compliance.
§003. Immunization-Related Service and Coverage Activities: Describes the basic scope of coverage for immunization-related screening, evaluation and vaccine administration services as well as rules on coverage.
§004. Participation in Vaccines for Children (VFC) Program and Other Publicly Purchased Vaccine Programs: Specifications applicable to state Medicaid purchasers, as well as other purchasers in states that offer universal vaccine distribution programs. Sets forth approaches to specifying the relationship between managed care organizations and the Medicaid Vaccines for Children program, as well as universal vaccine distribution programs in relevant states.
§005. Immunization-Related Information for Members: Specifies a range of options related to the provision of educational and other information to members.
§006. Immunization Services Furnished by Non-Network Providers: Specifies possible arrangements for ensuring MCO payment immunization services furnished by one or more classes of non-network providers
§007. Immunization-Related Access Standards: Sets forth sample specifications relating to service time frames and access to immunization services.
§008. Immunization-Related Quality Measurement and Improvement: Sets forth specifications related to the elements of the quality measurement and improvement program that contractors may be expected to maintain.
§009. Immunization-Related Data and Reporting: Specifies elements of data collection and reporting arrangements that contractors may be expected to maintain.
§010. Financial Incentive Plans; Network Selection: Identifies elements of provider network selection and payment arrangements that may be related to immunization performance.

§001. Application of Specifications; Deemed Compliance for Contractors with Effective Immunization Programs

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to establish an alternative compliance system that uses performance based measurement, this language is for your consideration.

  1. In general -- These specifications apply to Contractor, immunization providers within Contractor's network, and all providers, regardless of network status, to whom Contractor refers members for immunization services set forth in §003.

  2. Deemed compliance -- A Contractor that is able to demonstrate an effective immunization program in accordance with the provisions of §002 shall be deemed to be in compliance with specifications identified in §002.

  3. Definitions - As used in this section the term "immunization provider" means:

    1. a primary care provider in the Contractor's network (including any specialty provider who has been designated as a member's primary care provider);

    2. any other network provider (regardless of the primary care status of such provider), who is qualified or licensed to furnish immunizations under state law and who, in the course of furnishing care for any illness or condition, determines that a member needs one or more immunizations.

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§002. Deemed Compliance by Contractors with Effective Immunization Programs

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to establish performance-based specifications, this language is for your consideration.

  1. Contractors deemed in compliance - a Contractor that can demonstrate satisfactory performance in accordance with the performance targets described in subsection (b) of this section, and using data that have been derived and audited for accuracy and completion in accordance with the most current HEDIS measures and audit standards, shall be deemed to be in compliance with the following provisions:

    [Alternative A]

    1. §005 (Information to Members) (with the exception of subsection (d), relating to Vaccine Information Statements required under the Childhood Vaccine Injury Compensation Act);

    2. §006 ( Immunization Services Furnished by Non-Network Providers);

    3. §007 (Immunization-Related Access Standards); and

    4. §008 (Immunization-Related Quality Improvement and Measurement)1.

    [Alternative B]

    1. §005 (Information to Members) (with the exception of subsection (d) relating to Vaccine Information Statements required under the Childhood Vaccine Injury Compensation Act);

    2. §007(Immunization-Related Access Standards); and

    3. §008 (Immunization-Related Quality Improvement and Measurement).

  2. Performance targets applicable under this agreement - the following performance targets are applicable:
    1. Effective programs for infants and toddlers -

      [Alternative A - absolute performance measure] During the reporting year, ___% of members (to be specified by the purchaser) have received each separate immunization specified for two-year-old children.

      [Alternative B - relative performance measure for states with comparable baseline data] During the reporting year, Contractor has achieved a ___% increase over the prior applicable reporting year in the proportion of members who have received each immunization specified for two year old children2.

    2. Effective program for adolescents --

      [Alternative A - absolute performance measure] During the applicable reporting year, ___% of members received each immunization specified for adolescents.

      [Alternative B - relative performance measure in states with comparable baseline data] During the applicable reporting year, Contractor has achieved a ___ percent increase over the prior applicable reporting year in the proportion of members who received each immunization specified for adolescents3.

    3. Effective program for the elderly --

      [Alternative A - absolute performance measure] - During the applicable reporting year, ____% of members ages 65 and older have received an influenza vaccination during the reporting year.

      [Alternative B -relative performance measure in states with baseline dat]) - During the applicable reporting year, Contractor has achieved a ____% increase in the proportion of members ages 65 and older who received an influenza immunization4.

    4. Effective program for non-elderly adults -

      [Alternative A - an absolute measure using the HEDIS primary care access measure for adults] -- During the applicable reporting year, ___ % of all enrollees ages 20-44 years of age and 45-64 years of age as of December 31 of the applicable reporting year have had a preventive visit with a primary provider who is a member of Contractor's network5.

      [Alternative B - relative measure using the HEDIS primary care access measure for adults in states with baseline data] - During the applicable reporting year, Contractor has achieved a ____ % increase in the proportion of all enrollees ages 20-44 years of age and 45 through 64 years of age who have had a preventive visit with a primary provider who is a member of Contractor's network.

  3. Definitions -

    1. Applicable reporting year - the year designated for reporting in accordance with standards set forth in the most current version of HEDIS.

    2. HEDIS - Health Employer Data and Information Set, published by the National Committee on Quality Assurance, Washington D.C.

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§003. Immunization-Related Service and Coverage Duties

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to adopt detailed specifications regarding the elements of immunization coverage, this language is for your consideration. This language covers the basic amount and scope of services, deferral of immunizations, laboratory testing for vaccine-preventable disease services, allowable limitations and exclusions relating to immunizations, and individual determinations of coverage for immunizations,

  1. In general - Contractor shall cover and provide the services enumerated in this section.

  2. Screening and evaluation services - At each non-emergency clinical encounter between a member and an immunization provider as defined in this section, Contractor shall screen the member and evaluate the member's need for immunization services in accordance with:

    [Alternative A]

    1. the most current ACIP Recommendations6.

    [Alternative B]

    1. the most current ACIP Recommendations; and

    2. any additional recommendations issued by a public health agency with jurisdiction over Contractor's service area7.

  3. Administration of immunizations - Following the provision of screening and evaluation services, Contractor shall administer the immunizations described in this subsection:

    1. Routine immunizations in accordance with:

      [Alternative A]

      1. the most current ACIP Recommendations.

      [Alternative B]

      1. the most current ACIP Recommendations, and

      2. any additional immunizations required specified by a public health agency with jurisdiction over Contractor's service area8.

    2. Accelerated immunizations for children whose screens and evaluations indicate a lack of age appropriate immunization status

      [Alternative A]
      in accordance with ACIP Recommendations;

      [Alternative B]
      in accordance with ACIP Recommendations as well as any applicable recommendations issued by a public health agency with jurisdiction over Contractor's service area9;

    3. Immunization of members whose screens and evaluations reveal increased risk for any vaccine preventable disease (VPD) or its complications. At a minimum, such individuals are:

      1. infants born to women who are HBsAg-positive or whose HBsAg status is unknown, and

      2. household contacts or sexual partners of an individual who is HBsAg positive.

  4. Deferral of immunization services - Contractor shall furnish all immunizations specified under this agreement unless:

    1. Immunization is deferred or exempted because:

      1. administration of one or more vaccines is clinically contraindicated in the member's case;

      2. a deferral or exemption is required under applicable state or local law;

      3. the member withholds consent in writing.

    2. The immunization provider shall indicate the basis for such deferral or exemption in writing in the member's medical record.

  5. Laboratory services - Contractor shall conduct all VPD diagnostic tests at qualified laboratories and in accordance with the VPD Surveillance Manual of the CDC10.

  6. Coverage determinations - In determining the medical necessity of immunization services, Contractor shall comply with the following provisions:

    1. Immunization screening, evaluation, and administration coverage determinations shall be made

      [Alternative A]
      in accordance with ACIP recommendations

      [Alternative B]
      in accordance with ACIP recommendations and any applicable recommendations issued by a public health agency with jurisdiction over Contractor's service area11.

    2. No prior authorization for immunization services - Contractor may not require immunization providers who are members of Contractor's network to obtain prior authorization for assessment and evaluation or immunization administration services described in subsections (b) or (c) of this section.

    3. Denial of coverage for immunization services prohibited -- Neither Contractor nor its network providers or subcontractors may

      1. deny coverage for any immunization service enumerated under this section on the basis that

        1. the service is required as a condition of entry into school, employment or job training, Head Start, child care, camp, or other activity which require one or more immunizations under local, state or federal law;

        2. the service is required as a result of a determination by a public health agency with jurisdiction over the service area that epidemiological conditions in Contractor's service area warrant provision of one or more vaccines; or

        3. the service is available free of charge through a public program such as a school, local health agency, or publicly assisted health clinic.

      2. refer any member for any immunization service described in this section on the basis that such service is available through any provider, program, or agency either free of charge or at a substantial discount .

    4. Permissible limits on coverage of immunization services -

      [Alternative A]
      Nothing in this subsection shall be construed as prohibiting Contractor from requiring non-network immunization providers who are eligible for payment for immunization-related services under this contract to notify Contractor at the time immunization services are furnished, as a condition on payment.

      [Alternative B]
      Nothing in this subsection shall be construed as prohibiting Contractor from requiring non-network immunization providers who are eligible for payment for immunization services under this contract and who furnish immunization services to children to notify Contractor at the time immunization services are furnished, as a condition of payment.

      [Alternative C]
      Nothing in this subsection shall be construed as prohibiting Contractor from requiring non-network immunization providers to obtain prior authorization before furnishing immunization services to members12.

  7. Definitions -

    1. ACIP - Advisory Committee on Immunization Practices to the Centers for Disease Control and Prevention13.

    2. Child - an individual under age (19) (21)

    3. Immunization provider -

      1. a primary care provider in the Contractor's network (which shall include any specialty provider who has been designated as a member's primary care provider); and

      2. any other network provider (regardless of the primary care status of such provider), who is qualified to furnish immunizations and who, in the course of furnishing care for any illness or condition, determines that a member needs one or more immunizations.

    4. Non-emergency health care encounter - an encounter that is for a condition other than a condition which is defined in §1932(b)(2)(C) of the Social Security Act (42 U.S.C. §1396v(b)(2)(C)).

    5. Vaccine preventable disease (VPD) - a disease for which there is a vaccine approved by the U.S. Food and Drug Administration (FDA).

    6. HBs Ag positive - an individual who is determined to be carrying the Hepatitis B surface antigen.

    7. HBsAg status unknown - an individual whose Hepatitis B surface antigen status is unknown.

    8. Qualified laboratory - a laboratory that is certified under the Clinical Laboratory Improvement Act of 1988 (CLIA), §353 of the Public Health Service Act, and that has been deemed competent to carry out all necessary VPD testing.

    9. VPD testing - screening and diagnostic testing for infection with or susceptibility to vaccine preventable disease.

      Contract compliance measure: Provide copies of all manuals and other informational materials instructing network providers on the extent of coverage for services related to the prevention of vaccine preventable diseases under this agreement.

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§004. Participation in Vaccines For Children (VFC) Program and Other Publicly Purchased Vaccine Programs14

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to address the relationship of the contractor's services to the Vaccines for Children program or any other publicly purchased vaccine program in your state, this language is for your consideration.

    [Alternative A - affirmative duty to participate]
    Contractor shall ensure that all network providers who are immunization providers:

  1. with respect to vaccine eligible children (as the term is defined in §1928(c) of the Social Security Act, (42 U.S.C. §1396s(c)) who are members of Contractor's plan, participate in the Vaccines for Children (VFC) program, §1928 of the Social Security Act (42 U.S.C. §1396s); and

  2. with respect to other individuals who are members of Contractor's plan, participate in any publicly purchased vaccine program that is available in Contractor's service area and that is available to one or more classes of such individuals.

    [Alternative B - prohibition on use of premium for vaccines]
    No portion of the capitation or premium paid to Contractor may be used to pay for:

  1. any vaccine that is available to Contractor's provider network under the VFC program with respect to members who are vaccine eligible children (as the term is defined in §1928(c) of the Social Security Act (42 U.S.C. §1396s(c)); or

  2. vaccines available through any publicly purchased vaccine program that is available in Contractor's service area and that covers one or more classes of members enrolled in Contractor's plan15.

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§005. Immunization-Related Information for Members

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to include specifications related to the immunization information and educational material which contractors must furnish to members, this language is for your consideration. These sample specifications cover general information material, materials related to the National Childhood Vaccine Injury Act, additional materials for persons who are positive for hepatitis B, and information for persons whose primary language is not English.

  1. Immunization education materials for members -- Contractor shall furnish information written at a ___th16 grade reading level regarding vaccine preventable diseases, the importance and recommended timing of immunization services, and how to schedule an immunization appointment with a provider.

    (additional option)

  2. Recipients of education materials - Contractor shall ensure that immunization education materials are furnished to:

    1. Newly enrolled members;

    2. Members who are pregnant; and

    3. Members during each non-emergency clinical encounter17.

    (additional option)

  3. Reminders and recall notices - Contractor shall:

    1. use written or telephone reminders for members who are scheduled for an immunization visit;

    2. use written or telephone recall notices for members who have missed a visit during which an immunization was scheduled to occur18.

  4. Vaccine Information Statements - during each visit at which an immunization occurs, Contractor shall furnish a member with a Vaccine Information Statement (VIS) for each immunization which is administered in accordance with the Childhood Vaccine Injury Compensation Act.

  5. Education materials for members who are HBsAg positive - Contractor shall ensure counseling of members who are HBsAg-positive regarding transmission of hepatitis B virus infection and the need to advise household members and sexual partners regarding the need for medical evaluation.

  6. Adaptation of written materials for persons whose primary language is not English or who have visual related impairments - Contractor shall comply with the requirements of this Agreement regarding translation of all written materials.

  7. Definitions -

    1. Vaccine Information Statements - federally approved vaccine information materials furnished to patients or the parents of such patients at the time of administration of each dose of vaccine covered by the National Childhood Vaccine Injury Compensation Program, in accordance with the provisions of the National Childhood Vaccine Injury Act, 42 U.S.C. §800aa et. seq19.

    2. Non-emergency clinical encounter - a clinical encounter for a condition other than an emergency medical condition as defined in §1932(b)(2)(C) of the Social Security Act (42 U.S.C. §1396v(b)(2)(C)).

      Contract compliance measure. Contractor shall submit for prior review all member immunization education materials, immunization recall and reminder notices and Vaccine Information Statements.

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§006. Immunization Services Furnished by Non-Network Providers

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to address the issue of contractor relationships with non-network providers that furnish covered services to members of the contractor, this language is for your consideration.

  1. In addition to immunization services furnished by network providers in accordance with this agreement Contractor shall:

    [Alternative A: Reimbursement of all publicly assisted providers]

    1. reimburse publicly assisted providers for immunization administration services (and for the cost of vaccines, where applicable) regardless of their status as a member of Contractor's network, unless Contractor is able to demonstrate through written evidence that the member already has received the immunization in question. As a condition of reimbursement Contractor may require that a publicly assisted provider notify contractor regarding the provision of immunization services at the time that such services are furnished. Contractor shall reimburse publicly assisted providers based upon either a negotiated rate or the Medicaid payment rate, as well as in accordance with payment timelines applicable under the Medicaid program.

    [Alternative B: mandatory inclusion of all local health agencies that furnish immunization services]

    1. reimburse public health agencies for immunization administration services (and for the cost of vaccines, where applicable) regardless of such provider's status as a member of Contractor's network unless Contractor is able to demonstrate through written evidence that the member already has received the immunization in question. As a condition of reimbursement Contractor may require that a public health agency notify contractor regarding the provision of immunization services at the time that such services are furnished regarding the provision of immunization services to members. Contractor shall reimburse public health agencies based upon a negotiated rate or the Medicaid payment rate, as well as in accordance with payment timelines applicable under the Medicaid program.

    [Alternative C: more open-ended specification permitting contractor broader latitude in the use of alternative sites]

    1. develop written arrangements for making available immunization services to plan members through one or more classes of publicly assisted providers furnishing care to residents of Contractor's service area. Contractor shall identify for the state each publicly assisted provider with which it has entered into an agreement and shall provide a detailed description of the agreement20.

     

  2. Definitions -

    1. Publicly assisted provider -- a provider that meets all of the following criteria: (1) the provider is a public health agency or a public or private non-profit agency or entity; (2) the provider furnishes services described under §002 either free-of-charge or on the basis of a published schedule of discounted charges adjusted for family income; (3)the provider receives funding under any federal, state or local program or under a privately-sponsored program to furnish health care to low income, medically underserved, or other specified populations.

    2. Public health agency - an agency established pursuant to state or local law.

    3. Immunization administration services - The following services are immunization administration services:

      1. screening and evaluation of the need for immunizations,

      2. identification of contraindications, member education and anticipatory guidance,

      3. administration of vaccines,

      4. provision of information required under the National Childhood Vaccine Injury Compensation Act,

      5. (additional option) activities related to compliance with data reporting requirements under state or federal law or in accordance with the terms of the agreement between the provider and the Contractor21.

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§007. Immunization-Related Access Standards

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to include specifications related to access to immunization services, this language is for your consideration.

  1. Immunization timelines -- in administering immunizations Contractor shall comply with the following timelines -

    1. Initial visits for new members who are children shall occur within ___ weeks22 of the date of enrollment, and missed appointments shall be scheduled to occur within __ weeks23 of the date that the appointment was originally scheduled to occur.

    2. Initial immunization screening and evaluation visits for new members who are not children shall be scheduled to occur in accordance with the timelines applicable under this agreement to preventive visits for new members.

    3. Immunization visits for members who request immunization services shall be scheduled to occur under this agreement in accordance with the timelines applicable to requests for non-urgent symptomatic office visits.

    4. Routine and accelerated immunizations shall occur according to recommended immunization intervals.

    5. Immunizations required as a result of epidemiological conditions shall occur as soon as possible following notification by a public health agency with jurisdiction over Contractor' service area.

    6. Deferred immunizations shall be administered as soon as is reasonably practicable in light of the basis for the deferral.

    7. Immunizations that are medically necessary shall be furnished at the visit at which the need for immunization is identified.

  2. Geographic access - Contractor shall comply with the geographic access standards applicable to primary care services under this agreement.

  3. Definitions -

    1. Child - an individual under age (19) (21)24.

    2. Non-urgent symptomatic - an illness, injury or condition that is not urgent (i.e., that does not require examination and treatment within ___ hours)25 but that produces symptoms for which timely diagnosis and treatment is medically necessary.

Contract compliance measure: Submit a description of the manner in which contractor notifies providers regarding immunization timelines under this agreement and the procedures that contractor uses to measure compliance with immunization timeline standards.

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§008. Immunization-Related Quality Measurement and Improvement

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to specify elements of a quality measurement and improvement program in the area of immunization practice, this language is for your consideration.

  1. Dissemination of standards and guidelines - Contractor shall make available to all network providers:

    1. A full description of all immunization-related services and service duties set forth in this Agreement;

      (additional option)

    2. The practice guidelines that Contractor uses to establish provider performance; and26

      (additional option)

    3. The clinical protocols that Contractor uses to monitor provider performance27.

  2. Quality assurance evaluations - At least ____28, Contractor shall conduct clinical practice studies using

    [Alternative A]
    the most current HEDIS and/or CASA29-based methodologies

    [Alternative B]
    the most current HEDIS methodologies30

    and shall distribute the results to all network providers. Contractor shall ensure that immunization providers report immunization data in accordance with the time frame, and in the manner, required by the Contractor under its quality assurance program.

    Contract compliance measure: Contractor shall submit copies of all practice guidelines and protocols and the results of quality assurance studies

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§009. Immunization-Related Data and Reporting

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to specify minimum data and reporting standards as part of your purchasing specifications, this language is for your consideration.

  1. Medical records - Contractor shall assure maintenance of a paper or electronic medical record on the immunization status of each member, which is updated regularly to indicate the member's current address and telephone number, the provider's unique identifier, the immunizations that are furnished, the date, type of vaccine, vaccine manufacturer, vaccine lot number, anatomical site of administration and provision of the Vaccine Information Statement required under the National Childhood Vaccine Injury Act.

  2. Portable immunization record - Contractor shall furnish all members with portable immunization records which are updated at each visit at which an immunization occurs and which include the name of each vaccine and the date on which it was administered.

  3. Immunization registries - When an immunization registry administered by a public agency in accordance with CDC's National Immunization Program Registry Guidance is in use or under development in Contractor's service area and is also accessible to Contractor for its own use, Contractor shall participate in such registry or development effort and comply with registry requirements.

  4. Reports of adverse events following immunization - Contractor shall comply and shall ensure that network providers comply with all reporting requirements related to adverse events under the National Childhood Vaccine Injury Act.

  5. VPD reporting - Contractor shall ensure that network providers notify the public health agency with jurisdiction over vaccine preventable disease and immunization surveillance regarding any member who is suspected of, or diagnosed as having, a reportable vaccine preventable disease. Notice shall be furnished

    [Alternative A]
    within twenty-four hours of the individual's presentation

    [Alternative B]
    in accordance with the time frames established under state law31

    regardless of whether laboratory confirmation has been completed. Contractor shall make clinical and laboratory data related to treatment and diagnosis of VPDs available to state and local public health agencies at no charge.

  6. Reports on VFC participation -- Contractor shall comply with all VFC reporting requirements under federal and state law and as contained in applicable memoranda of understanding [reserved]32.

  7. (additional option) Reports on immunizations - Contractor shall make available to local public health agencies within its service area as well as public health agencies with jurisdiction over vaccine preventable disease and immunization surveillance all HEDIS and /or CASA reports on member immunization levels33.

    Contract compliance measure: Submit a description of the methods and procedures that Contractor will use to achieve compliance by network providers.

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§010. Financial Incentive Plans; Network Selection

If, as a purchaser, you are interested in addressing immunizations in your purchasing specifications and wish to specify provisions related to the relationship between financial incentives and immunizations or wish to address the role of immunization performance in the selection of network participants, this language is for your consideration.

  1. Prohibition against inclusion of certain expenditures in a financial incentive plan -- In administering a financial incentive plan that either withholds payment to network providers for expenditures considered excessive, unnecessary or inappropriate or that rewards providers for spending reductions, Contractor shall not include the cost of immunization services specified in §003 (b) and (c) in calculating a provider's incentive payment or penalty.

  2. Network selection practices - Contractor's network selection practices shall emphasize the inclusion of providers that demonstrate a high level of performance in furnishing both routine and as-needed, clinically indicated immunization services described in §003.

    Contract compliance measure: Submit a description of all physician incentive plans used and methods to calculate provider compensation. Describe the approach contractor uses to identify health care providers that achieve high rates of immunization practices.

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Endnotes

  1. Drafter's note: offers purchasers two approaches to deemed compliance. Under Alternative A, satisfactory compliance will relieve contractor of duties specified in §§005-008 (with the exception of §005(d) relating to the Childhood Vaccine Injury Compensation Act. Under Alternative B, a Contractor would remain obligated to pay certain designated out-of-network providers on the theory that to the extent that out-of-network use is an important factor in achieving appropriate immunization status, certain designated non-network providers should receive compensation.

  2. Drafter's note: describes alternative performance standards, based on whether a purchaser desires to use an absolute (i.e., fixed) or relative performance measure.

  3. Drafter's note: See note 2.

  4. Drafter's note: See note 2.

  5. Drafter's note: See note 2.

  6. Recommendations of the Advisory Committee on Immunization Practices (http://www.cdc.gov/nip/publications/ACIP-list.html)

  7. Drafter's note: offers two alternative approaches to defining medically necessary coverage. Under the first approach, ACIP standards offer the sole measurement of what constitutes medical necessity. In Alternative B, the recommendations of public health agencies with jurisdiction over the service area are also taken into account in establishing the scope of coverage in order to ensure access to additional immunization services that may be warranted by local conditions.

  8. Drafter's note: see note 7

  9. Drafter's note: see note 7

  10. http://www.cdc.gov/nip/publications/surv-manual/.

  11. Drafter's note: see note 7

  12. Drafter' s note: offers three alternatives approaches to specifications regarding permissible limitations on coverage. Under the first alternative, the contractor would have to pay one or more specified classes of non-network providers for immunization services but could condition payment on concurrent notification of the provision of services. Under the second option, the payment rule would be limited to immunizations furnished to children. Under the third option, a contractor could condition payment of non-network providers on prior authorization for services (Option C and Option B could be combined, so that immediate immunization of children would be required, with prior authorization requirements permissible in the case of non-network providers furnishing services to adults).

  13. http://www.cdc.gov/nip/publications/ACIP-list.htm

  14. Drafter's note: the Vaccines for Children Program is applicable to Medicaid purchasers only

  15. Drafter's note: Offers two alternative approaches to MCO participation in the VFC program or other publicly financed vaccine distribution programs. Under the first alternative, MCOs have an affirmative duty to ensure participation by their network providers. Under the second alternative, MCOs are simply prohibited from using any portion of their premiums to pay for vaccines that can be obtained free of charge through the VFC or any other publicly financed vaccine distribution program.

  16. Drafter's note: Purchaser to complete

  17. Drafter's note: provides an additional option to identify certain members who must be furnished with materials.

  18. Drafter's note: provides an additional option to specify the manner in which reminders and recall notices must be furnished.

  19. http://www.cdc.gov/nip/publications/VIS/

  20. Drafter's note: offers three possible approaches to payment of non-network providers. Under the first approach, any publicly assisted provider would be eligible for payment for certain services on the theory that public funds should be preserved for uninsured patients. Under the second approach, the payment requirement would be limited to public health agencies. The third approach would create an open ended specification permitting the contractor complete discretion over its relationship with publicly assisted providers.

  21. Drafter's note: clarifies that part of a provider's duty is furnishing data and that the cost of such activities should be included when calculating the price paid for immunization administration services.

  22. Drafter's note: purchaser to supply time lines

  23. Drafter's note: purchaser to supply time lines

  24. Drafter's note: permits purchaser two options for defining who constitutes a child.

  25. Drafter's note: purchaser to supply time lines

  26. Drafter's note: ensures that practice guidelines are required to be distributed to providers.

  27. Drafter's note: ensures distribution of the protocols that a contractor will use to measure performance.

  28. Drafter's note: purchaser to supply time frame

  29. CASA - Clinical Assessment Software Application, a special software application developed by the CDC to help providers assess immunization coverage and practice. (www.cdc.gov/nip/casa)

  30. Drafter's note: offers two approaches to specifications related to quality assurance. Under the first, the contractor would be expected to rely on HEDIS. Under the second, a contractor could use either HEDIS or CASA to measure provider performance.

  31. Drafter's note: offers two alternative time frames for reporting VPD data.

  32. Drafter's note: separate specifications on memoranda of understanding between managed care organizations and public health agencies are under preparation.

  33. Drafter's note: additional option specifying provision of immunization reports to public health agencies.