CA
"6.7.8 LOCAL HEALTH DEPARTMENT
COORDINATION
6.7.8.1 Subcontract
Contractor shall execute
a Subcontract for the specified public health services with the Local Health
Department (LHD) in each county that is covered by this Contract. The Subcontract
shall specify the scope and responsibilities of both parties, billing and
reimbursements, reporting responsibilities, and Medical Record management
to ensure coordinated health care services. The Subcontract shall meet
the requirements contained in Article III, Sections 3.28, Subcontracts,
through 3.28.8, Disclosures. The specified public health services under
the Subcontract are as follows:
A. Family Planning Services: as specified in Section 6.7.4.7
B. STD services for the disease episode, as defined by DHS for each STD, including diagnosis and treatment of the following STDs: syphilis, gonorrhea, chlamydia, herpes simplex, chancroid, trichomoniasis, human papilloma virus, non-gonococcal urethritis, lymphogranuloma venereum and granuloma inguinale.
C. Confidential HIV testing...
D. Immunizations...
E. California Children Services (CCS)
F. Maternal and Child Health (MCH)
G. Child Health and Disability Prevention (CHDP) Program
H. Tuberculosis Directly Observed Therapy
I. Women, Infants, and Children (WIC) Supplemental Food Program
J. Population based Prevention Programs: collaborate in LHD community based prevention programs." CaliforniaContract, page 131.
CO
"IV. COVERED SERVICES.
C. Fee for Service Benefits
1. The Contractor shall
advise Subcontractors of EPSDT support services that are available through
local public health departments..." Colorado Contract, pages 18, 20
"XIV. SERVICE DELIVERY.
3. Coordination with the
EPSDT Program
a.. The following requirements
relate to the provision of EPSDT services and must be incorporated into
the Contractor's preventive health services:
1. The Department will assist
in facilitating arrangements and cooperation between the Contractor and
the Department of Public Health and Environment who currently provides
to Members in-depth information regarding EPSDT services and their importance
and administrative case management services as needed, to assist EPSDT
clients in overcoming barriers to obtaining services." Colorado Contract,
pages 46, 52.
CT
"3.17 Children's Issues and
EPSDT Compliance...
[T]he MCO shall: ...
g. Coordinate and enhance
the services provided to Members under 21 through the development and execution
of memorandums of understanding (MOUs) with the following programs: ...
* Other programs operated
by the Department of Public Health." Connecticut Contract, pages 26-28.
DE
"6.2.6 Coordination Between
MCOs and Public Health
Each MCO will be expected
to demonstrate effective coordination and linkages with the State public
health agency and the county public health units. Each MCO will plan to
participate with DPH in the design and implementation of ongoing (periodic)
community needs assessment to monitor access to health care and health
status. Each MCO shall develop a coordinated plan with DPH regarding population
based and community prevention strategies. Each MCO shallindicate its ability/intent
to assure that DPH regulations are carried out such as newborn screening,
disease reporting,
immunization, etc. Standards of care and Tuberculosis requirements are
in Appendix J.
Each MCO shall develop a Memorandum of Understanding with DPH that defines communication and coordination between public health and primary care providers regarding community outreach and family support services, assistance to enroll potentially eligible people into Medicaid or another State or Federal program and to provide continuity of care during times when Medicaid eligibility is discontinued. DPH has a significant role in the overall health care system. The core public health function to be considered by MCOs as they develop their responses are described in the Association of State and Territorial Health Officials (ASTHO) document in Appendix K." Delaware RFP, pages II.34-II.35.
"6.4.3 Universal Immunization
Program
The Federal Vaccines for
Children (VFC) Program began in Delaware on January 1, 1995. Under the
VFC Program, which is operationally located in the Division of Public
Health, certain groups of children under age nineteen (19) areeligible
to receive immunizations from VFC participating providers. These groups
are Medicaid eligible children, uninsured children, Native American Indians,
and underinsured children.
As a result of enrolling in the VFC Program, participating providers are supplied with vaccines at no cost to the provider. The immunizations provided to VFC-eligible children are provided free-of-charge, except for an administrative fee. The administrative fee is set at eight (8) dollars and Medicaid only pays the fee for Medicaid eligible children. The remaining VFC-eligible children had their administration fee covered by the State. All fees are currently paid by Medicaid's fiscal agent, Electronic Data Systems (EDS). All immunizations must be reported to the Division of Public Health Immunization Registry, where they are tracked and subsequently passed electronically to EDS for processing and payment of the administration fee.
Under the Diamond State Health Plan, the cost of vaccines covered by the VFC Program are not reimbursable to providers since they are supplied for free. Providers must follow the ACIP schedule for immunizations. That schedule is provided in the EPSDT Standards package. MCOs may determine whether to pay providers a specific administration fee for vaccines administered under the VFC Program. However, if the MCO does choose to pay an administration fee, it must be paid at the same level as the Medicaid rates paid to providers for all children not eligible for the Diamond State Health Plan. MCO primary care providers must enroll in the VFC Program to receive free vaccines and to be eligible for any administration fee.
The Division of Public Health Immunization Registry will track all immunizations, send delinquent notices for missed immunizations, and will be able to report data on all children vaccinated. MCOs must assure all childhood immunizations are obtained and should report immunization levels as required under the DHSSHP data and reporting requirements. MCOs must coordinate and link with Division of Public Health Immunization Registry in order to track immunizations provided to their covered population. Each provider who provides immunizations will be given a turn-around document (TAD) that will allow all immunizations to be recorded and provided to physicians and others to keep and use for the next immunization.
The Vaccine for Children Program is not available for children covered under Title XXI. The cost of the vaccine and the administration will be factored into the MCOs rate and the MCOs will pay the provider a negotiated rate for the vaccine and administration. Reporting is the same for both programs." Delaware RFP, pages II.38-II.40.
FL
"35. Good Faith Effort with CHDs. The plan shall make a good faith effort to execute memoranda of agreement with the local county health departments to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, DCF foster care emergency shelter medical screenings, school-based services pursuant to Section 409.9122(2)(a)3., and services related to Healthy Start prenatal and postnatal screenings..." Florida Contract, page 70.
"Exhibit M
Model Memorandum of Agreement...
1. This agreement is entered
into between the State of Florida, Department of Health...County Health
Department, hereinafter
referred to as the 'CHD' and the...HMO hereinafter referred to as the 'HMO',
for the purpose of improving services to patients through coordinated,
cooperative health care interactions between the HMO and the CHD...
4. The HMO agrees to:
A. Reimburse without prior
authorization, medical screenings for foster care children and emergency
shelter care children.
B. ...reimburse without
prior authorization, the CHD for school-based urgent care services; and
the diagnosis and treatment of sexually transmitted disease and other communicable
diseases, such as tuberculosis and human immunodeficiency
syndrome. This shall include the clinical, medical and laboratory services
provided by the CHD to an
HMO patient.
C. Offer the Healthy Start
prenatal screen to each member who is pregnant...
D. Refer all pregnant women
meeting Healthy Start high risk screening criteria to the local CHD for
Healthy Start care coordination...
E. Offer the Healthy Start
postnatal (infant) screen to each woman for her newborn...
F. Refer all infants meeting
Healthy Start high risk screening criteria to the local CHD for Healthy
Start Care coordination...
G. Refer all pregnant women,
postpartum women (up to six months after delivery), breastfeeding women
(up to one year
after delivery), infants and children up to the age of five to the Special
Supplemental Nutrition Program for Women, Infants and Children (WIC) available
through the local CHD.
H. Reimburse without prior
authorization services for a member's immunizations.
I. Reimburse without prior
authorization for family planning services and related pharmaceuticals.
5. The CHD agrees to:
A. Attempt to contact the
HMO before providing health care services to their members.
B. Provide the plan with
a copy of the member immunization record at the time that the immunization
is provided to the plan member...
E. Refer HMO patients back
to the HMO for ongoing primary care following provision of services covered
in this agreement..." Florida Contact, pages 107-108.
FLMH
"4. Care Coordination...
(2) Describe your organization's
proposed plan linkages to supports needed by the members, including the
department... the Social Security Administration, Office of Disability
Determination, Family Service Planning Teams and other family support programs,
Case Review Committees... etc." Florida Mental Health Contract, pages 97-98.
HI
"33.300 Department of Health
(DOH) Services...
Vaccines for Children (VFC)...
As long as the VFC program
is federally funded, the MQD will not reimburse the health plans for any
privately acquired vaccines which can be obtained by the Hawaii VFC program.
If the VFC program ceases to be funded by the federal government, the health
plans will assume financial responsibility for providing the required immunizations
and the DHS will adjust the capitation rate accordingly...The fee for the
administration of the vaccine is included in the capitated rate.
VFC vaccines are available to authorized health practitioners and clinics which have been enrolled with the Department of Health Hawaii Immunization Program. Providers must enroll, complete appropriate forms to qualify to receive VFC vaccine, and meet all other requirements for VFC participation. Vaccine orders are filed directly with the Hawaii Immunization Program. Vaccines are distributed to the providers via a contractor to the Hawaii Immunization Program.
If the DOH health centers are requested to provide pediatric immunizations for QUEST members enrolled with health plans, the members may be returned to the health plans or pediatricians. If the DOH health center receives authorization from the health plan to provide the immunization, the Quest plan shall be financially responsible for the administration of the immunization." Hawaii RFP, page 35.
IL
"(C) Certified Local Health
Department Services
(1) The Contractor shall
work in good faith to assist the Department to achieve its objective of
supporting Certified Local Health Departments. To this end, the Contractor
shall execute one of the following documents with each Certified Local
Health Department serving a jurisdiction in which Beneficiaries reside:
(A) the Contractor shall
subcontract with Certified Local Health Departments to provide, at a minimum,
the services listed in this Section (c)(2); or
(B) the Contractor shall
enter into linkage agreements with Certified Local Health Departments.
Such linkage agreements shall conform to the model Certified Local Health
Department Linkage Agreement in Attachment VI of this Contract
or the terms of such alternate model linkage agreements as the Department
may establish. Any variation in terms
from the model agreements is subject to the mutual agreement of the Contractor
and the Certified Local Health Department
and prior approval by the Department." Illinois HMO Contract, pages 25-26.
IA
"4.7 Coordination and Continuation
of Care
The HMO shall ensure that
the Enrollee's care is coordinated and continuous, including at a minimum
the following: ...
- Linkages with state and
local public health officials to foster continuity of services, prevent
cost shifting to other publicly funded programs and make reasonable efforts
to assure collaboration with official entities responsible for essential
core public health function." Iowa Contract, pages 26-27.
KS
"D. LOCAL HEALTH DEPARTMENTS
The Kansas Department of
Health and Environment provides funding to Local Health Departments for
the provision of health
care services to low income individuals. The HMO shall make a reasonable
effort to subcontract with any local health care provider receiving funds
from Titles V and X of the Social Security Act. Close cooperation with
these entities is strongly encouraged.
The HMO will coordinate all cases of Sexually Transmitted Diseases (STD) and tuberculosis with the Local Health Departments to ensure prevention and the spread of disease. The HMO shall cooperate with the treatment plan developed by the Local Health Department. SRS requires the HMO to provide written documentation of cooperation on STDs and tuberculosis between the HMO and any local health departments within the counties they have proposed serving prior to contract signature." Kansas General Service, page 10.
KY
"7.6.1 Required Services
The Partnership shall maintain
a Provider Services function that is responsible for the following services
and tasks: ...
* Encouraging and coordinating
the enrollment of primary care providers in the Department for Public Health
and the Department for Medicaid Services Vaccines for Children Program.
This program offers certain vaccines free of charge to Medicaid members
under the age of 21 years." Kentucky RFA, page 41.
"The Partnership shall use
public health departments in its Program to:
(a) Provide at least the
direct access services as established in 907 KAR 1:705, Sections 7(5)(a)(b)(e)(f)
and (g).
(b) Collaborate in assessment
of the health and health care needs of the Member populations and Partnership
region.
(c) Collaborate in the development
and implementation of Member and Partnership Region health promotion programs.
(d) Serve on The Partnership's
governing body and Quality and Access Recipient Advisory Committee." Kentucky
RFA, page 50.
"In addition, Partnerships shall establish formal collaborative relationships with public health departments for development and implementation of the Member education program." Kentucky RFA, page 57.
MD
"Chapter 65 Maryland Medicaid
Managed Care Program: Managed Care Organizations...
.02 Conditions for Participation...
E. An MCO shall enter a
memorandum of understanding with each local health department (LHD) in
its service area addressing
the method by which the MCO and the LHD will collaborate and communicate
on matters of mutual interest and
concern, including but not limited to the responsibility of the LHD for
contact tracing for sexually transmitted d iseases and directly observed
therapy for tuberculosis." Maryland COMAR 10.09.65.02.
"10.09.66.03.
.03 Access Standards: Outreach...
C. Adults.
(1) An MCO shall, before
referring the enrollee to the local health department, make, documented
attempts to schedule follow-up appointments in accordance with the enrollee's
treatment plan by attempting a variety of contact methods, which may include:
(a) Written correspondence;
(b) Telephone contact; and
(c) Face-to-face contact.
(2) If the enrollee, due
to impaired cognitive ability or psychosocial problems such as homelessness
or other conditions, can be expected to have difficulty understanding the
importance of treatment instructions or difficulty navigating the
health care system, the MCO shall, after exhausting its best efforts to
contact and bring into care the enrollee in accordance with §C(l)
of this regulation, make, or ensure that the enrollee's provider makes,
a written referral to the local health department for its assistance within
10 business days of whichever first occurs:
(a) The third consecutive
missed appointment; or
(b) The MCO or the enrollee's
provider identifies the enrollee's repeated noncompliance with a regimen
of care." Maryland COMAR 10.09.66.03.
"10.09.67.20...
C. An MCO shall provide
referrals for services not covered by Medicaid, but which are furnished
at little or no cost to recipients, including appropriate referrals to:
...
(5) Maternal and Child Health
Services located at local health departments." Maryland COMAR 10.09.67.20.
MA
"Section 2.12 Behavioral
Health Program Services...
C. BH Program Provider Network
Development, Administration and Management...
3. Relationships with State
Agencies
a. The Contractor shall
enter into written agreements with certain Massachusetts state agencies
to implement mechanisms to address the behavioral health needs of Enrollees
who receive services from, or eligible to receive services from these agencies,
and to coordinate and link BH Program Services with these state agencies
according to the
time frames established below:
1) Within 30 days of receiving
a copy of such written agreement from the Division: ...
b) Department of Public
Health's Bureau of Substance Abuse." Massachusetts Contract, pages 68-72.
"Section 2.12 Behavioral
Health Program Services...
J. BH Dual Diagnosis
The Contractor shall:
1. Develop a list of a continuum
of services to meet the needs of Enrollees with a BH Program BH Dual Diagnosis.
The Contractor shall: ...
b. Consult and collaborate
with DPH/BSAS in building the continuum of care, developing education programs
for clinicians, and developing credentialing and re-credentialing requirements
for substance abuse clinicians.
c. In conjunction with the Division, work with designated staff from. DPH/BSAS to encourage the development of appropriate residential programming at a range of intensities and types which meet the needs of Enrollees with a BH Dual Diagnosis upon their discharge from BH Program Inpatient Services levels of care, and which complement BH Program Outpatient Services." Massachusetts Contract, pages 68-86.
MABH
"2.06.07 Agreements with
State Agencies
The Contractor shall: ...
b. Develop and submit to
the Division for prior review and approval within the first six months
of the Contract, a plan to ensure that its Network Management staff communicate
on an ongoing basis, and no less than monthly, with DSS designated staff,
DPH/BSAS designated staff, DMH area directors and other appropriate state
agencies' designated staff to address Enrollees' service planning,
admissions, discharge plans, utilization, and coordination of DMH Continuing
Care Services." Massachusetts MH/SAP Contract, Appendix B, page 22.
MI
"II-I Special Coverage Provision...
9. Well Child Care/Early
and Periodic Screening, diagnosis & Treatment (EPSDT) Program...
If a child is found to have
elevated blood lead levels in accordance with standards disseminated by
DCH, a referral should
be made to the local health department for follow-up services that may
include an epidemiological investigation to determine the source of blood
lead poisoning..." Michigan Contract, pages 22, 28.
"II-M CONTRACTOR ORGANIZATIONAL
STRUCTURE, ADMINISTRATIVE SERVICES, FINANCIAL REQUIREMENTS AND PROVIDER
NETWORKS...
6. Provider Network in the
CHCP...
(c) Public and Community
Providers and Organizations
Contractor must work closely
with local public and private community-based organizations and providers
to address prevalent
healthcare conditions and issues. Such agencies and organizations include
local health departments." Michigan
Contract, pages 32, 35, 37.
"APPENDIX A
Model Agreement Between
HEALTHPLAN and Local Health Department (LHDs)...
(4) Areas of Coordination
and Collaboration
Under the contract with
the Department of community Health, Qualified Health Plans are responsible
and accountable for
providing or arranging health services specified with the contract. As
identified in the accompanying matrix, certain health care services may
be more efficiently and effectively delivered through coordination and
collaboration with LHDs. The matrix describes opportunities for coordination
and collaboration for the following services:
(a) Communicable Diseases...
(b) Chronic Diseases...
(c) Family Planning...
(d) Prenatal and Postnatal
care
(e) Maternal and Infant
Support Services
(f) Laboratory
(g) Lead (Pb)
(h) Well Child Care (EPSDT)."
Michigan Contract, Appendix A.
MN
"Section 6.8. Vaccines for Children. The HEALTH PLAN agrees to participate in the Vaccines for Children (VFC) immunization program, pursuant to 42 U.S.C., Section 1396s. The HEALTH PLAN will collaborate as reasonably requested with public health agencies to ensure childhood immunizations to all enrolled families with children,pursuant to Minnesota Statutes, Section 256L.12, Subdivision 10." Minnesota Contract, page 64.
"Section 6.24.4. Public Health Goals. The HEALTH PLAN shall engage in the following public health activities,toward the achievement of public health goals.
A. For the Metro Area:
1) Response to Violence...
2) Immunization...
3) Tobacco Use Prevention
and Control...
B. For the Non-Metro Area,
up to three goals per county or group of counties, including any of the
following:
1) Response to Violence.
2) Immunization.
3) Tobacco Use Prevention
and Control.
4) Improved Birth Goals...
5) Unintended Injury...
6) Dental. The HEALTH PLAN
shall promote oral health.
7) C&TC Support.." Minnesota
Contract, pages 73-74.
MO
"2.1.5 Services shall include...
z. Services provided by
local health agencies (may be provided by the health plan or through an
arrangement between the
local health agency and the health plan)." Missouri RFP, page 19.
"k. Local Health Agencies: While the State will not require inclusion of local health agencies in health plan's networks, the state agency encourages health plans to contract with local health agencies." Missouri RFP, pages 27-28.
"Public Health Programs, Mandated Plan Reimbursements: The Department of Health and Local Health Agencies administer certain public health programs which are critical to the protection of the public's health and, therefore, must be made available to MC+ members." Missouri RFP, page 58.
"Medicaid Managed Care Provider
Coordination with Local Health Agencies (LHA) and Missouri Department of
Health (DOH)
Immunizations
Lead Screening, Diagnosis
and Treatment...
STD Screening, Diagnosis
and Treatment
TB Screening, Diagnosis
and Treatment
HIV Screening and Diagnosis...
Family Planning.
LHA/DOH Must Be Reimbursed If they Provide Service." Missouri RFP, Attachment Five.
NE
"13.7 PCP Qualifications
and Responsibilities: Under the contractual responsibilities of the plan,
the plan shall ensure that the PCP: ...
(13) Communicate with agencies
such as, but not limited to, local public health agencies for the purpose
of participating in immunization registries and programs, e.g., Vaccine
for Children, communications regarding management of infectious or notifiable
diseases, cases involving children with lead poisoning." Nebraska Contract,
page 81.
"13.24 Public Health Initiatives: The plan shall work cooperatively with the public health agencies to share appropriate service data, participate in other similar preventative and data collection initiatives that may be promoted by the Department and public health agencies, and comply with all noticeable requirements and 'good practices'." Nebraska Contract, page 86.
"13.42 HEALTH CHECK (EPSDT):
The plan shall develop a program to ensure the delivery of HEALTH CHECK
(i.e., Early and Periodic Screening, Diagnosis and Treatment or EPSDT services).
(a) HEALTH CHECK (EPSDT)
Screening: ...
(d) The PCP/plan shall take
a proactive approach to ensure clients obtain HEALTH CHECK (EPSDT) screening
services and medically necessary diagnosis and treatment services. A proactive
approach includes: ...
(4) Provision of demographic
information to public health agencies when HEALTH CHECK (EPSDT) screening
identifies children
with elevated blood lead levels (EBLL); and
(5) Referrals to public
health agencies for environmental assessments and caregiver education services
for children with lead poisoning...
(f) Throughout the contract
term, the plan shall participate in the NHC Quality Assurance Plan's ongoing
maternal and child health-related activities, including those supporting
the HHS regulations and licensure's grant under maternal and child health
programs and activities. Cooperate with the Department's Title V, Maternal
Child Health Program (MCHP), to include: ...
(7) Cooperating with public
health agencies who have identified children with abnormal lead levels.
The plan will provide lead screening and blood lead testing according to
the Center for Disease Control (CDC) and Health Care Financing Administration
(HCFA) requirements; provide information to PCPs regarding the provision
of blood lead screening and testing; provide information regarding coverage
of environmental investigation; encourage collaboration and communication
with public health lead prevention programs; and utilize and reimburse
laboratories under contract with public health lead prevention programs
to perform blood level testing. The plans shall not require a PCP/plan
approval to receive reimbursement for specimens sent to the laboratories
by public health agencies; and
(8) Coordinating with public
health immunization clinics regarding immunization reporting." Nebraska
Contract, pages 90-91.
NEBH
"11.11.3 MH/SA Provider Qualifications
and Responsibilities: Pursuant to the PHP's contractual responsibilities,
the PHP shall ensure that the MH/SA provider complies with the following:
...
(b) Signing a contract with
the PHP as a MH/SA provider which explains the provider's responsibilities
and compliance with the following NHC requirements: ...
(13) Communicating with
agencies including, but not limited to, local public health agencies..."
Nebraska Behavioral Health Contract, pages 54, 56.
"11.28 Public Health Initiatives: The PHP shall work cooperatively with the public health agencies to share appropriate service data, participate in other similar preventative and data collection initiatives that may be promoted by the Department and public health agencies, and comply with all notifiable requirements and 'good practices'." Nebraska Behavioral Health Contract, page 59.
NM
"2.C.10.c Shared Responsibility
between MCO and Public health Offices:
The CONTRACTOR shall coordinate
with the public health offices regarding the following services:
(A) Sexually transmitted
disease services including screening, diagnosis, treatment, follow-up and
contact investigations;
(B) HIV prevention counseling,
testing, and early intervention:
(C) Tuberculosis screening,
diagnosis, and treatment;
(D) Disease outbreak prevention
and management including reporting according to state law requirements,
responding to
epidemiology requests for information, and coordination with epidemiology
investigations and studies:
(E) Referral and coordination
to ensure maximum participation in the supplemental food program for Women,
Infants, and children
(WIC);
(F) Health education services
for individuals and families with a particular focus on injury prevention
including car seat use, domestic violence, substance use and lifestyle
issues including tobacco use, exercise, nutrition, substance use;
(G) Development and support
for family support programs such as home visiting programs for families
of newborns and
other at-risk families and parenting education; and
(H) Participation and support
for local health councils to create healthier and safer communities with
a focus on coordination of efforts such as DWI councils, maternal and child
health councils, tobacco coalitions, safety counsel, safe kids and others."
New Mexico Contract, pages 30-31.
NY
"10. BENEFIT PACKAGE, COVERED
AND NON-COVERED SERVICES...
10.18 Coordination with
Local Public Health Agencies
The Contractor will coordinate
its public health-related activities with the Local Public Health Agency...
Coordination mechanisms
and operational protocols for addressing public health issues will be negotiated
with the Local
Public Health and Social Services Departments and be customized to reflect
County public health priorities.
Negotiations must result
in agreements regarding required health plan activities related to public
health. The outcome of negotiations may take the form of an informal agreement
among the parties which may include memos; a separate memorandum of understanding
signed by the Local Public Health Agency, LDSS , and the Contractor; or
an appendix to the contract between the LDSS and the Contractor...
10.19 Public Health Services
a) Tuberculosis Screening,
Diagnosis and Treatment; Directly Observed Therapy(TB\DOT): ...
ii) ...State and local departments
of health also will be available to offer technical assistance to the Contractor
in establishing TB policies and procedures.
iii)...The Local Public
Health Agency will: 1) make reasonable efforts to verify with the Enrollee's
PCP that he/she has not already provided TB care and treatment, and 2)
provide documentation of services rendered along with the claim..
vi) The Contractor shall
provide the Local Public Health Agency with access to health care practitioners
on a twenty-four (24) hour a day, seven (7) day a week basis who can authorize
inpatient hospital admissions.
b) Immunizations...
ii)...When an Enrollee presents
a membership card with a PCP's name, the Local Public Health Agency shall
call the PCP...
10.27 Coordination of Services
The Contractor shall coordinate
care for Enrollees with: ...
i) local governmental units
responsible for public health...
Coordination may involve
contracts or linkage agreements (if entities are willing to enter into
such agreement), or other mechanisms to ensure coordinated care for Enrollees."
New York Contract, pages 10-1-10-16.
ND
"ATTACHMENT D: HMO/HEALTH
TRACKS POLICIES AND PROCEDURES
1. Background...
The Contractor will coordinate
Health Tracks screenings with the local public health units. The Department
will pay the public health units directly for screening services." North
Dakota Contract, attachment D, page 1.
OK
"2.5.6 Immunizations...
In the case of outbreaks
of vaccine-preventable diseases, Health Plans shall cooperate with OSDH."
Oklahoma RFP, page
29.
PA
"F. IN-PLAN SERVICES...
5. Special Needs Population
Staffing
The HMO will be required
to develop, train, and maintain a 'special' dedicated unit with in its
organizational structure to deal with issues relating to MA members with
special needs.These staff members will be responsible to assist recipients
in accessing services and benefits of the HMO and to act as liaisons with
various government offices, providers, public entities, county entities
which shall include but not limited to: ...
* Public Health Entities."
Pennsylvania RFP, pages 37-48.
RI
"2.07.04.02 Lead Services
The Department of Health
provides a variety of services within its Lead Program, including case
management, home assessments,
environmental interventions, and consultation to providers. Contractor
agrees to have written policies and procedures to provide lead screening
education, and any medically necessary lead reduction therapies and agrees
to work cooperatively with the Department of Health Lead Program or Lead
Centers to coordinate delivery of these services with those provided through
Contractor..." Rhode Island RFP, page 31.
"2.08.08 Department Of Health
Laboratory
The Rhode Island Department
of Health operates a reference laboratory and relies on this laboratory
to monitor the incidence
of lead poisoning and contagious diseases throughout the State. To assist
in this monitoring process, Contractor
agrees to submit to the Department of Health laboratory all specimens for
HIV testing and myocobacteria (TB)
analysis. All blood lead screening test samples, including venipuncture
samples, should be submitted to RIDH lab
for analysis. All non-screening blood lead samples shall be considered
diagnostic lead testing and may be sent to
any lab licensed by the DOH to perform blood lead analysis. Contractor
also agrees to submit specimens from suspected
cases of measles, mumps, rubella, and pertussis when required by the State
to facilitate investigations of
outbreaks. Contractor shall negotiate fees directly with the Department
of Health laboratory." Rhode Island RFP,
page 37.
SC
"4.7.8.2 Control and Prevention
of Communicable Diseases
DHEC is the state public
health agency responsible for promoting and protecting the public's health
and has the primary
responsibility for the control and prevention of communicable diseases
such as TB, STD, HIV infection and vaccine
preventable diseases. DHEC provides a range of primary and secondary prevention
services through its local health
clinics to provide and/or coordinate communicable disease control services.
Due to the specialized knowledge and expertise required to treat TB cases and prevent its spread, all TB cases at risk for noncompliance with treatment or primary drug resistance are reported to DHEC for treatment. As a result, 95% of TB cases in South Carolina are treated in DHEC clinics.
TB suspects and cases must be referred to DHEC by the Contractor and/or its network provider for clinical management and treatment and directly observed therapy. This care will be coordinated with the Contractor's PCP." South Carolina Contract, page 22.
"Immunizations
Until recently, DHEC has
traditionally provided the majority of immunizations to the citizens of
South Carolina...
To assure 'no missed opportunities'
to immunize, a policy that has been effective in making SC immunization
rates the highest
in the nation, Medicaid MCOs are encouraged to develop cooperative arrangements
with DHEC.
Arrangements may include:
sharing data, sharing immunization histories, promoting medical homes,
making referrals, and
billing the MCO for administration costs." South Carolina Contract, Appendix
B, page 2.
TX
6.12 TUBERCULOSIS (TB)
6.12.1 Education, Screening,
Diagnosis and Treatment...HMO must consult with the local TB control program
to ensure that
all services and treatments provided by HMO are in compliance with the
guidelines recommended by the American
Thoracic Society (ATS), the Centers for Disease Control and Prevention
(CDC), and TDH policies and standards.
6.12.2 Reporting and Referral. HMO must implement policies and procedures requiring providers to report all confirmed or suspected cases of TB to the local TB control program within one working day of identification of a suspected case...
6.12.4 Coordination and Cooperation
with the Local TB Control Program. HMO must coordinate with the local TB
control program to ensure that all Members with confirmed or suspected
TB have a contact investigation and receive Directly
Observed Therapy (DOT). HMO must require, through contract provisions,
that providers report any Member who
is non-compliant, drug resistant, or who is or may be posing a public health
threat to TDH or the local TB control program. HMO must cooperate with
the local TB control program in enforcing the control measures and quarantine
procedures contained in Chapter 81 of the Texas Health and Safety Code.
6.12.4.1 HMO must have a
mechanism for coordinating a post-discharge plan for follow-up DOT with
the local TB program.
6.12.4.2 HMO must coordinate
with the TDH South Texas Hospital and Texas Center for Infectious Disease
for voluntary and court-ordered admission, discharge plans, treatment objectives
and projected length of stay for Members with multi-drug resistant TB.
6.12.4.3 HMO may contract
with the local TB control programs to perform any of the capitated services
required in Article 6.12." Texas Contract, pages 47-48.
"6.15 SEXUALLY TRANSMITTED
DISEASES (STDS) AND HUMAN IMMUNODEFICIENCY VIRUS (HIV)...
6.15.3 HMO must consult
with TDH regional public health authority to ensure that Members receiving
clinical care of STDs, including HIV, are managed according to a protocol
which has been approved by TDH." Texas Contract, page 51.
"7.16 COORDINATION WITH PUBLIC
HEALTH...
7.16.2 HMO must make a good
faith effort to enter into subcontracts with public health entities in
the service area... Public health subcontracts must include the following
areas:
7.16.2.1 The general relationship
between HMO and the Public Health entity. The subcontracts must specify
the scope and responsibilities of both parties, the methodology and agreements
regarding billing and reimbursements, reporting responsibilities...
7.16.2.2 Public Health Entity
responsibilities:
(1) Public health providers
must inform Members that confidential health care information will be provided
to the PCP.
(2) Public health providers
must refer Members back to PCP for any follow-up diagnostic, treatment,
or referral services.
(3) Public health providers
must educate Members about the importance of having a PCP and accessing
PCP services
during office hours rather
than seeking care from Emergency Departments, Public Health Clinics, or
other Primary Care Providers or Specialists.
(4) Public health entities
must identify a staff person to act as liaison to HMO to coordinate Member
needs, Member referral, Member and provider education, and the transfer
of confidential medical record information.
7.16.3 Non-Reimbursed Arrangements
with Public Health Entities.
7.16.3.1 Coordination with
Public Health Entities. HMOs must make a good faith effort to enter into
a Memorandum of Understanding (MOU) with Public Health Entities in the
service area regarding the provision of services for essential public health
care services... MOUs must contain the roles and responsibilities of HMO
and the public health department for the following services:
(1) Public health reporting
requirements regarding communicable diseases and/or diseases which are
preventable by immunization as defined by state law;
(2) Notification of and
referral to the local Public Health Entity, as defined by state law, of
communicable disease outbreaks involving Members;
(3) Referral to the local
Public Health Entity for TB contact investigation and evaluation and preventive
treatment of persons whom the Member has come into contact;
(4) Referral to the local
Public Health Entity for STD/HIV contact investigation and evaluation and
preventive treatment of persons whom the Member has come into contact;
and,
(5) Referral for WIC services
and information sharing;
(6) Coordination and follow-up
of suspected or confirmed cases of childhood lead exposure.
7.16.3.2 Coordination with
Other TDH Programs. HMOs must make a good faith effort to enter into a
Memorandum of Understanding
(MOU) with other TDH programs regarding the provision of services for essential
public health care services. MOUs must delineate the roles and responsibilities
of HMO and the TDH programs for the following services:
(1) Use of the TDH laboratory
for THSteps newborn screens; lead testing; and hemoglobin/hematocrit tests;
(2) Availability of vaccines
through the Vaccines for Children Program;
(3) Reporting of immunizations
provided to the statewide ImmTrac Registry including parental consent to
share data;
(4) Referral for WIC services
and information sharing;
(5) Pregnant, Women and
Infant (PWI) Targeted Case Management;
(6) THSteps outreach, informing
and Medical Case Management;
(7) Participation in the
community-based coalitions with the Medicaid-funded case management programs
in MHMR, ECI,
TCB, and TDH...
(8) Referral to the TDH
Medical Transportation Program;
(9) Cooperation with activities
required of public health authorities to conduct the annual population
and community based needs assessment; and
(10) Coordination and follow-up
of suspected or confirmed cases of childhood lead exposure." Texas Contract,
pages 72-75.
UTMH
"B. Clarification of Covered
Services...
10. Mental health evaluations
and reevaluations requested by the Department of Workforce Services (DWS)
or the Department
of Health to determine disability, inability to work, or incapacity to
parent related to ongoing Medicaid eligibility are Covered Services if
the individual is Medicaid eligible, is receiving treatment from the CONTRACTOR,
and a face-to-face visit is necessary to complete the Medicaid eligibility
evaluation or reevaluation." Utah Mental Health Contract, page 6.
VA
"33. Medallion II Carved-Out
Services
(a) The Contractor is not
required to cover Medallion II carved-out services...
(b) The following services
are Medallion II carved-out services: ...
(5) Investigations by local
health departments to determine the source of lead contamination in the
home as part of the management and treatment of Medicaid and CMSIP-eligible
children who have been diagnosed with elevated blood lead levels..." Virginia
Contract, page 55.
WV
"3.6.2 . Local Health Departments
Local governmental departments
administer certain public health programs which are critical to the protection
of the public's health and, therefore, must be available to Medicaid managed
care enrollees. For those services defined as public health services under
State law, the MCP may choose either to provide these services itself or
to contract with local health departments...
The MCP must provide the following core services to Medicaid managed care members and must reimburse the local health departments as specified: ...
The MCP must work with the local health departments to coordinate the provision of the above services and to avoid duplication of services.
DHHR will provide financial incentives for the MCP to contract with local health departments to provide the core services listed above as well as other services including Right from the Start services." West Virginia RFA, pages 22-23.
WI
"III. FUNCTIONS AND DUTIES
OF THE HMO
In consideration of the
functions and duties of the Department contained in this Contract the HMO
shall: ...
B. PROVISION OF CONTRACT
SERVICES.
14. The HMO must operate
a program full immunization of Medicaid recipients...
The HMO, as a condition of their certification as a Medicaid provider, shall share enrollee immunization status with Local Health Departments and other non-profit HealthCheck providers upon request of those providers without the necessity of enrollee authorization. The Department is also requiring that Local Health Departments and other non-profit HealthCheck providers share that equivalent information with HMOs upon request. This provision is made to ensure proper coordination of immunization services and to prevent duplication of services." Wisconsin Contract, pages 5, 11-12.
"Y. QUALITY IMPROVEMENT (QI)...
5. Health Promotion and
Prevention Services
a. The HMO must identify
at-risk populations for preventive services and develop strategies for
reaching Medicaid members included in this population. Local health departments
and community-based health organizations can provide the
HMO with special access to vulnerable and low-income population groups,
as well as settings that reach at-risk individuals
in their communities, schools and homes. Public health resources can be
used to enhance the HMO's health promotion and preventive care programs...
13. Priority Areas
a. The HMO must develop
and ensure implementation of program initiatives to address the specific
clinical needs that have a higher prevalence in the Medicaid population...
The Department strongly advocates the development of collaborative relationships
among HMOs, Local Health Departments, community based behavioral health
treatment agencies
(both public and private), and other community health organizations to
achieve improved services in priority areas. Linkages across Medicaid managed
care and public health agencies are essential elements for the achievement
of the public health objectives for the year 2000, thereby potentially
reducing the quantity and intensity of services the HMO needs to provide."
Wisconsin Contract, pages 21, 25-30.
"SS. SUBCONTRACTS WITH LOCAL HEALTH DEPARTMENTS-The Department encourages the HMO to contract with local health departments for the provision of care to Medicaid recipients in order to assure continuity and culturally appropriate care and services. Local health departments can provide HealthCheck outreach and screening, immunizations, blood lead screening services, and services to targeted populations within the community for the prevention, investigation, and control of communicable diseases (e.g., tuberculosis, HIV/AIDS, sexually transmitted diseases, hepatitis and others).
The Department encourages HMOs to work closely with local health departments...
Local health departments have a wide variety of resources that could be coordinated with HMOs to produce more efficient and cost effective care for HMO enrollees. Examples of such resources are ongoing programs of medical services, materials on health education, prevention, and disease states, expertise on outreaching speck subpopulations, communication networks with varieties of medical providers, advocates, community-based health organizations, and social service agencies, and access to ongoing studies of and information about health status and disease trends and patterns.
TT. SUBCONTRACTS WITH COMMUNITY-BASED HEALTH ORGANIZATIONS - The Department encourages the HMO to contract with community-based health organizations for the provision of care to Medicaid recipients in order to assure continuity and culturally appropriate care and services. Community-based organizations can provide HealthCheck outreach and screening, immunizations, family-planning services, and other types of services.
The Department encourages HMOs to work closely with community-based health organizations...
Community-based health organizations may also provide services, such as WIC services, that HMOs are required by Federal law to coordinate with and refer to, as appropriate." Wisconsin Contract, page 41.
"LOCAL HEALTH DEPARTMENTS
AND COMMUNITY-BASED HEALTH ORGANIZATIONS
A RESOURCE FOR HMOs
Local Health Departments
Local Health Departments
(LHDs) throughout the state have an essential role in promoting the health
of citizens of Wisconsin. They have general and specific statutory authority
to prevent disease, promote health and protect the health of the citizens.
They work in collaboration with community-based organizations, medical
care facilities, and local community agencies to develop and coordinate
systems of care so that the public's health can be protected. Specific
statutory authority include the three public health core functions of assessment,
policy development and assurance: ...
Description of Public Health Services: LHDs' capacities may vary, however, LHDs are required to provide or assure five basic public health services. These include: communicable disease surveillance, prevention and control; health romotion; disease prevention; human health hazard control; and generalized public health nursing programs. The following specific services have been delineated with the hope of linking Medicaid Managed Care Plans with Local Health Departments. Linking primary care and public health is an essential strategy to strengthen the health of local communities and thus benefit the population of the state as a whole.
- LHDs have access to population
data that may be very useful to managed care organizations in determining
their services and quality studies.
- LHDs closely collaborate
their programs with key community agencies that serve the Medicaid population.
These include: WIC, Prenatal Care Coordination, School Health Services,
Birth to Three Programs, Family Planning, and Developmental Disabilities.
- LHDs promote and provide
health education programs on topics that include: Domestic Abuse/Violence
Prevention, Smoking
Cessation, Breast Feeding, Cardiovascular Risk Reduction, Prenatal/Postpartum
Education, Nutrition, and Self-Care
Skills.
- LHDs provide health-related
home/community inspections in areas that include Lead Poisoning, Asbestos,
Indoor Air Quality, Home Safety, and Drinking Water Safety.
- LHDs monitor communicable
disease incidence/prevalence, provide information to the public on prevention,
conduct epidemiologic investigations of outbreaks/unusual conditions.
Access to Special Populations
Wisconsin's LHDs perform
many public health services including the provision of direct services
to Medicaid recipients. Some local health departments provide Medicaid
reimbursed services for which HMOs may contract, such as:
- HealthCheck screening,
outreach and follow-up;
- Immunizations;
- Blood lead screening;
- Extended case management
of medical conditions such as asthma, diabetes, hypertension and children
with special health
care needs; and
- Home health and personal
care services...
Community Based Health Organizations
Throughout the state, the health care network includes many nonprofit community based health organizations including: private HealthCheck providers, family planning clinics, and WIC clinics. These organizations may provide some of the same Medicaid reimbursed services as LHDs and are an essential element o advance the health of community. They may also have the same access to special populations as LHDs.
Collaboration with Public and Community Based Health Organizations
HMOs should consider how
to utilize the local public health departments and community based health
organizations through:
- Identifying and utilizing
the resources they provide; and
- Where appropriate, contracting
with local health departments and other community health agencies for Medicaid-reimbursable
services." Wisconsin Contract, Addendum XX, pages 143-144.