skip over navigation

Medicaid Contract Purchasing Specifications

HIV Infection, AIDS, and HIV-Related Conditions

Table of Contents

Introduction and Overview

Part 1 HIV/AIDS Benefits
Part 2 Service Delivery and Health Care Quality Improvement and Measurement
Part 3 Reimbursement for HIV/AIDS Services (Reserved)

Introduction and Overview

These sample managed care purchasing specifications address issues in the primary and secondary prevention and medical management of HIV, AIDS and HIV-related conditions (hereinafter termed "HIV/AIDS"). The specifications are intended for use in Purchasing Agreements that either for a preset fee (i.e., a premium) or under an administrative services only (ASO) agreement for the delivery of comprehensive health care through a network of participating providers. These specifications have been developed for use by both public sector Purchasers (e.g., state Medicaid programs) and private-sector entities (e.g., employers and employer purchasing coalitions).

The specifications were drafted by attorneys at the George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy (CHSRP), (formerly Center for Health Policy Research) with guidance from experts in the field of HIV prevention and management. They were reviewed by consumers, health care providers, policy makers, managed care officials, and state Medicaid agencies. The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) provided expertise, direction and financial support for their development.

These sample specifications are illustrative. They are designed to function as one of the many tools that Purchasers employ to develop and oversee managed care systems for their members. The specifications may be used either in their entirety or on an item-by-item basis, depending on the range of issues a Purchaser wishes to address. The individual specifications in this document may be added to appropriate sections in a Purchasing Agreement. Alternatively a Purchaser may wish to use the specifications to develop an Appendix or Attachment relating specifically to the prevention and medical management of HIV/AIDS.

Because of variations in Purchasers' financing options, policy preferences and legal duties, there is no single correct method for covering and delivering care, particularly in the case of a condition as complex as HIV/AIDS. However, it is possible to identify the critical decision points that Purchasers may face and to suggest approaches to each. The specifications offer illustrative options for addressing key issues in coverage, access, delivery and quality of care. It is anticipated that Purchasers will tailor them to the laws of the state(s) in which the contract is in operation. (Purchasers should consult with the public health agency in a state to ensure consistency with state laws regarding reporting, confidentiality, and other matters addressed in state public health statutes and regulations.) In the case of Medicaid Purchasers, the specifications have been drafted to be consistent with federal legal requirements pertaining to managed care purchasing. Medicare and other public and commercial Purchasers may wish to consult these specifications for their approach to particular issues in the care and delivery of services and benefits for persons with HIV/AIDS, although it is recognized that most forms of coverage offer a narrower range of benefits than Medicaid, which in great part was designed as a means of financing care for persons with serious and chronic illness..

A Purchaser may elect to remain silent with respect to a particular matter for which illustrative language has been prepared. In such a case, rules of contract construction would mean that the Purchaser would effectively elect to defer resolution of the particular issue to Contractor discretion.

These specifications do not currently address payment methodologies for HIV/AIDS services. However, Purchasers may wish to consult the HIV Capitation Risk Adjustment Conference Report of the Henry J. Kaiser Family Foundation, which is available through the Foundation's worldwide website address.1 A second resource is the 1998 National Academy for State Health Policy report on the range of financing strategies (risk-adjusted payment rates, separate payment ("carve out") for HIV pharmacy costs, mandated reinsurance, risk corridors and risk pools) currently being tested in six Medicaid managed care programs.2 Medicaid Purchasers may also wish to evaluate the experiences of other states (Maryland, Colorado, Oregon, Utah and New York State, all of which have adopted specialized capitation rates either specifically for HIV/AIDS or for enrollees with disabilities.) These public-sector efforts to test appropriate HIV/AIDS payment mechanisms may also be informative to private sector Purchasers.

The specifications are accompanied by Commentaries to aid in reading and interpretation. The commentaries reference clinical practice guidelines cited in the text and provide background explanations. In light of the importance of Medicaid to financing the care and management of persons with HIV/AIDS, the commentaries provide references to federal Medicaid law. In addition, the commentaries reference current relevant treatment guidelines. These specifications will be modified as needed as new guidelines emerge; in addition, the website addresses for the guidelines that are identified in the commentaries will also carry new guidelines as they emerge. Of particular significance will be new guidelines from the U.S. Public Health Service on HIV testing of pregnant women.3

In several places throughout the document, readers will see blank spaces (____) accompanied by a footnote. These spaces identify places where purchasers may wish to develop performance standards, particularly with respect to service timelines and other attributes of managed care service delivery systems. The Commentary accompanying the blank spaces provides recommendations from persons knowledgeable about HIV prevention and care.

These specifications are part of a series of sample purchasing specifications that will be released during 1998 and 1999 and posted at CHPR's website address. 4 The term "reserved" in this document indicates policy areas that will be addressed in future specifications and that will be linked for use in conjunction with these specifications. Specifications will be hyperlinked to numerous related government and private agency website addresses.

Endnotes

  1. Diane J. Aschman, HIV Capitation Risk Adjustment Conference Report (1997, The Henry J. Kaiser Family Foundation, Menlo Park, CA); Tony Dreyfus, Richard Kronick, Carol Tobias, Using Payment to Promote Better Medicaid Managed Care for People with AIDS (1997, The Henry J. Kaiser Family Foundation, Menlo Park, CA). http://www.kff.org; Richard Kronick and Tony Dreyfus, The Challenge of Risk-Adjustment for People with Disabilities: Health-Based Payment for Medicaid Programs (1997, Center for Health Care Strategies, Inc. Princeton, NJ); Changing Environments for AIDS/HIV Service Delivery and Financing, Health Care Financing Review 19:3 (Spring, 1998); Tony Dreyfus, Richard Kronick, Carol Tobias, Using Payment to Promote Medicaid Managed Care for People with AIDS (National Academy for State Health Policy, Portland, ME., July, 1997); DHHS/OIG, Medicaid Managed Care and HIV/AIDS (DHHS, OEI-05-97-00210, April, 1998).
  2. J. Rawlings-Sekunda and Neva Kaye, Emerging Practices and Policy in Medicaid Managed Care for People with HIV/AIDS: Case Studies of Six Programs (1998, The National Academy for State Health Policy, Portland, ME: http://www.nashp.org). This study reports on current Medicaid managed care programs for people with HIV/AIDS in Massachusetts; New Jersey; Orange County, California; Texas; San Francisco; and Tennessee.
  3. The CDC convened an expert consultant meeting in April 1999 to solicit input on incorporating recommendations made by the Institute of Medicine (IOM) in its book, Reducing the Odds: Preventing Perinatal HIV Transmission in the United States. 1998. The IOM recommended universal HIV testing, with patient notification, as a routine component of prenatal care. "Routine notification" is defined by the IOM to mean that HIV tests would be included in the standard battery of prenatal tests and that women would be informed that an HIV test is being conducted and of their right to refuse it. In July, 1999, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists endorsed the IOM's recommendations. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Human Immunodeficiency virus screening (RE 9916); Joint statement of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Pediatrics 1999;104(1):128. CDC is expected to issue revised guidelines on HIV testing of pregnant women in 1999. The executive summary of the IOM report is available at http://www.nap.edu
  4. As of July, 1999, CHSRP's web site ( http://www.gwu.edu/~chsrp) contained sample purchasing specifications for immunization and prevention of vaccine-preventable diseases and childhood lead poisoning. Specifications addressing the following topics were under final review or in the process of development; access to health care; behavioral health (mental health and addiction disorder); cultural competence; comprehensive children's health services (Medicaid; Children's Health Insurance Program (CHIP); specialized children's health services (Medicaid dental and oral health; children with special health care needs; children's behavioral health; children in the child welfare system); data reporting and information; diabetes; health services for the homeless; HIV, AIDS and HIV-related conditions; memoranda of understanding between managed care organizations and state and local health agencies; pharmaceutical services; reproductive health (family planning and perinatal services); sexually transmitted diseases; tuberculosis. Development of sample specifications was supported by the Centers for Disease Control and Prevention (CDC); the Health Resources and Services Administration (HRSA); the National Committee on Vital and Health Statistics the Substance Abuse and Mental Health Administration (SAMHSA); The Commonwealth Fund ; Glaxo-Wellcome; and the David and Lucile Packard Foundation, Center for the Future of Children.