Medicaid Contract Purchasing SpecificationsMANAGED CARE FOR TITLE XXI (SCHIP) PEDIATRIC SERVICESA TECHNICAL ASSISTANCE DOCUMENTApril, 2002
IntroductionExecutive SummaryPart 1 - Part 1A - Part 1B - Part 1C - Part 2 -Part 3- Part 4 - Part 5 - Part 6 - Part 7 - Part 8 - Part 9 - Part 10 - Part 11 - Part 12 - Part 13 - Part 14
Overview§001 - §002 - §003
- §004 - §005 - §006
- §007 Funded with support from: Health Resources and Services Administration, US DHHS CONTENTS
Many states are implementing the State Children’s Health Insurance Program (SCHIP) under Title XXI of the Social Security Act by purchasing coverage for SCHIP-eligible children from managed care organizations (MCOs).1 These SCHIP Pediatric Purchasing Specifications were prepared by the George Washington University Medical Center, School of Public Health and Health Services’ Center for Health Services Research and Policy (CHSRP) in consultation with experts in child health policy. This technical assistance document should be viewed as a tool to assist SCHIP agencies and other public purchasers identify key issues as they prepare their purchasing agreements with MCOs. The contents of this document are optional and are not policy guidance of the Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC), or the Centers for Medicare and Medicaid Services (CMS). These specifications provide a broad menu of draft provisions for contracts, requests for proposals (RFPs), requests for information (RFIs), and general service agreements for the purchase of covered health benefits from MCOs on behalf of targeted low-income children and adolescents eligible under a state’s SCHIP plan. These purchasing specifications are for state SCHIP programs other than Medicaid. States that have opted to enroll SCHIP-eligible children in their Medicaid programs may wish to use the Medicaid Pediatric Purchasing Specifications also prepared by CHSRP (available at www.gwhealthpolicy.org/). Some of these illustrative provisions reflect federal law; some reflect professional guidelines; and some reflect the judgment of experts in maternal and child health. The key to these different bases is explained below. Origins of This Technical Assistance Project Since 1995, CHSRP has conducted an intensive examination of contracts between state Medicaid agencies and MCOs. Three editions of Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts have been published by CHSRP; the 4th edition includes a database of SCHIP managed care contracts in states with freestanding SCHIP programs and is only available online at www.gwhealthpolicy.org/ under “managed care contracts.â€� Negotiating the New Health System is a part of a broader managed care contract analytic studies and technical assistance project financed by numerous funders, including HRSA, CDC, the Substance Abuse and Mental Health Services Administration (SAMHSA), the David and Lucile Packard Foundation, and the Commonwealth Fund. Original funding for this project was supported by the Pew Charitable Trusts and the Annie E. Casey Foundation. The development of purchasing specifications under managed care constitutes one component under this project. The process for developing these specifications began with guidance from a HRSA working group. A parallel process relating to adolescent health and school health was conducted with CDC staff. CDC and HRSA agreed to incorporate these components into these pediatric specifications. Draft specifications were prepared and presented to various agencies, including HRSA, CDC, and CMS. The purchasing specifications were reviewed through a series of vetting meetings involving state Medicaid and public health officials, providers, MCO representatives, consumers, and other outside child health experts. The changes suggested at these vetting meetings have been incorporated into the purchasing specifications and have been reviewed by representatives from these meetings. Organization and Structure of This Technical Assistance DocumentThese purchasing specifications contain over 120 illustrative sections. These specifications also include over 70 alternative options, which take the form of footnotes. These specifications and alternative options are for the consideration of state purchasers that are interested in buying pediatric care for SCHIP-eligible children from MCOs on a risk basis. The suggested language is organized by issue so that a user with a particular interest can refer only to those portions of the document that are relevant. These specifications were developed to be consistent with the SCHIP statute as passed in the Balanced Budget Act of 1997 (BBA), P.L. 105-33, with final regulations promulgated by HHS on June 25, 2001. In addition, these specifications are consistent with the available interpretations of SCHIP as reflected in letters to state officials, as well as responses to questions about SCHIP, and are available at www.hcfa.gov. Specific provisions that correspond to the final regulations are footnoted. The specifications are divided into an Overview of Contractor’s Duties and 14 accompanying Parts that provide greater detail on specific subject areas. The logic of this format -- an Overview and various Parts -- is as follows. First, there is no uniform drafting format for SCHIP purchasing agreements; instead, each state has its own approach. In order to be useful to as many interested states as possible, illustrative specifications such as those in this document must be organized into segments of manageable size that are readily accessible to different potential users. Second, much of the federal policy and the science in this area has been evolving and will continue to do so. The format of this technical assistance document allows new developments on any particular issue to be incorporated into the relevant Part without redrafting the remainder of the document. Finally, contracts or agreements between purchasers and MCOs tend to cover a wide range of substantive issues. This format is designed to facilitate the drafting and negotiation of these documents by enabling the parties to refer to those provisions for which they need technical assistance. In short, the Overview and the individual Parts are portable; that is, they can be broken out separately or integrated into other purchasing documents as the circumstances require at the option of the purchaser. These purchasing specifications are designed for numerous users including: agencies that want to construct a new purchasing document; agencies that have a purchasing document in use but wish to modify it; public health agencies, other state and local agencies, and constituency groups that want to provide technical assistance to the purchasing agency; and MCOs. Consumers and health care providers also should find this document useful in helping them identify key issues in managed care contracting. Not all users can be expected to be interested in every issue addressed in these specifications. To facilitate the use of this document, CHSRP developed User Guides that identify the specific provisions that are relevant to certain users. The following User Guides appear at the end of this document: State Title V Agencies, Adolescents, School Health, and Community Health Centers. The illustrative language in this document is drafted to minimize ambiguity and maximize clarity. The more clearly an MCO understands what is expected of it by the purchaser, and the more clearly a purchaser understands what the MCO is obligating itself to provide, the more likely it is that any agreement between the two parties will be carried out to the mutual satisfaction of each and will be likely to benefit the children enrolled with the MCO. Format and Optional Nature of This Technical Assistance DocumentEach Part contains three elements: suggested language for purchasing agreements, alternative options to such language, and compliance measures that Purchasers may wish to use in evaluating the performance of MCOs and their compliance with particular duties. Consider for example §101A(c) of Part 1A. This section offers language as to the grounds on which MCOs might be prohibited from denying coverage to a SCHIP-eligible child. There are seven suggested categories of prohibited grounds for denial. One ground, denial on the basis that the item or service is experimental, permits an MCO to deny coverage only if the MCO demonstrates to the purchaser that the item or service in question is available only through a clinical trial or is not a generally accepted practice or procedure among pediatric specialists (see §101A(c)(3)). Many insurers use significantly different standards in administering their private products. One option available to an interested state purchaser is not to include such language. This option is contained in the alternative option suggested in footnote 5. Another option would be to include the language in §101A(c)(3) but to modify the definition of “experimentalâ€� so as to narrow (or broaden) the class of items and services which could be subject to denial on this ground. Yet another option available to the purchaser is to include in the purchasing agreement this language (as modified) along with one or more of the remaining seven categories. Whatever policy the state purchaser chooses, it should be interested in determining the extent to which the MCO is in compliance with the purchaser’s policy. At the end of Part 1A, a suggested compliance measure appears in boldface for the Purchaser to use in making this determination. Procedural time frames are generally not included in these specifications. Instead, a bracket ([ ]) serves as a placeholder for the state purchaser to insert a selected time frame. How to Use This Technical Assistance DocumentAs mentioned above, the contents of this document are optional. Some of the specifications are based on federal law, some are based on formal guidelines, and some are based on the best judgment of maternal and child health experts. To assist the user in identifying the basis (or bases) for each specification, this document uses the following symbols: • An “Lâ€� means the provision is based in whole or in part on federal SCHIP law, as articulated in the SCHIP statute, regulation, or other written CMS policy, such as Letters to State Health Officials. For example, §901(b)(1) of Part 9 of these specifications requires Contractor to meet the data requirements in §2107(b)(1) of the Social Security Act. • A “Gâ€� means the provision is based in whole or in part on formal guidelines issued by, or under the auspices of, a government agency, a professional society, or a formally convened deliberative body. • A “Kâ€� means the provision is based in whole or in part on the best judgment and opinions of persons knowledgeable in the maternal and child health care practice, delivery, and management. This symbol is used to signify specifications that do not reflect a formal legal policy or that are not part of a formal guideline but that are recommended as an option because they reflect good practice in the opinion of experts. These provisions do not represent CMS policy, nor the position of the SCHIP program. For example, §005(f) of the Overview would require Contractor to allow an enrolled child to receive certain public health services from any licensed provider, whether or not the provider participates in Contractor’s provider network. There is no express requirement to this effect under Title XXI. However, illustrative language is included in these specifications for this provision, and for others that are not expressly required under the statute, in order to assist interested Purchasers that have particular concerns in regard to the accessibility of health care services to low-income children. The drafting format used in these specifications is as follows:
Every state purchaser has its own drafting format. The particular format used in these specifications is NOT intended as a substitute for each state’s own format. Instead, it is intended simply to divide each suggested provision into the smallest practicable policy elements. This division and subdivision format is designed to enable a user to identify quickly the policy choices contained in each provision and to identify which, if any, of the elements the user wishes to adopt. This format also serves as a detailed checklist for those users who wish to compare portions of their current purchasing documents with the relevant portions of these specifications. For example, assume a state purchaser uses the following language relating to data:
If this purchaser were to find that potential contractors are seeking greater specificity in order to better evaluate the potential administrative burden that they would be undertaking, the purchaser could use Part 9 of these specifications. Part 9 identifies eight different types of data that a purchaser may wish to collect, as well as the provisions relating to issues that cut across all types of data, including confidentiality, public access, ownership, and purchaser access. Finally, the table of contents will also lead interested purchasers to specifications on MCO information systems and remedies for noncompliance with any duties a purchaser may wish to impose. These different elements are integrated into a comprehensive statement of Contractor’s duties relating to data in §901 (“In Generalâ€�) of Part 9. Assume the purchaser wishes to implement process indicator #1 relating to data on immunizations set forth in American Academy of Pediatrics, SCHIP Evaluation Tool (October 1998, www.aap.org/research/evaltool.htm). The specifications at §902(b), footnote3, suggest the following language:
The purchaser could then adapt this specification to its own format:
Issues Not Addressed in This Technical Assistance DocumentThese purchasing specifications do not contain all the provisions that are commonly found in contracts or purchasing agreements between state agencies and MCOs. For example, this document does not include provisions on capitation rates, insolvency, financial audits, reinsurance, duration of the agreement, termination procedures, or subcontractual relationships. For suggested language on these and other general provisions, see: • Wendy L. Krasner, “Government Contracts in Managed Care,� in Critical
Steps in Managed Care Contracting: A Looseleaf Guide, National Health
Lawyers Association, 1995; and Related CHSRP ActivitiesIn addition to these SCHIP Purchasing Specifications, CHSRP has developed with support from HRSA Medicaid Pediatric Purchasing Specifications for state Medicaid programs (www.gwhealthpolicy.org/). The format of the Medicaid Pediatric Purchasing Specifications parallels that of the SCHIP specifications in this document, but there are significant policy differences that reflect differences in the underlying statutory authorities. For example, the Medicaid Pediatric Purchasing Specifications contain a far more extensive set of covered benefits than are found in the SCHIP specifications. This is because the federal Medicaid statute contains a more comprehensive minimum benefits package than does the SCHIP statute. CHSRP has also developed a number of purchasing specifications
which are listed in Table
1 below. The dated specifications are posted on CHSRP's website,
www.gwhealthpolicy.org/. All other listed specifications are
under development. Table 1. Purchasing
Specifications
Executive SummaryPart 1 - Part 1A - Part 1B - Part 1C - Part 2 - Part 3 - Part 4 - Part 5 - Part 6 - Part 7 - Part 8 - Part 9 - Part 10 - Part 11 - Part 12 - Part 13 - Part 14 Overview of Contractor’s DutiesThe SCHIP Pediatric Purchasing Specifications are divided into an Overview of Contractor’s Duties and 14 accompanying Parts that provide greater detail on specific subject areas. The Overview sets forth the basic duties owed by Contractor and providers to comply with the requirements in the various Parts. Part 1: Items and Services This Part enumerates the benefit package for an enrolled child. Title XXI gives states a number of options with respect to the health benefits coverage they offer under their State SCHIP Plan. Title XXI requires that health benefits coverage under SCHIP be equivalent to the benefits coverage in a “benchmarkâ€� benefit package. One of the “benchmarkâ€� packages is the Standard Blue Cross and Blue Shield Preferred Provider Option Service Plan under the Federal Employees’ Health Benefits Program (FEHBP), §2103(b)(1) of the Social Security Act, 42 U.S.C. §1397aa(b)(1). This Part contains the FEHBP-equivalent “benchmark,â€� including the covered and non-covered benefits. Part 1A: Coverage Determination Standards and Procedures This Part sets forth coverage determination standards and procedures to be followed by MCOs as well as permissible prior authorization and self-referral procedures. §101A speaks to standards for coverage determination, which is a decision by the Contractor as to whether to furnish (or pay for) an item or service that is covered under the purchasing agreement (in Part 1) with respect to an individual child. Subsection (e) defines “coverage determination.â€� Subsection (a) lists the standards that the Contractor is to apply in making such determinations. Subsection (b) lists the types of evidence the Contractor must consider in making such determinations. Subsection (c) lists the reasons for which a Contractor may not make a coverage determination that results in the denial of a covered item or service to an individual child. Finally, subsection (d) sets forth a special rule for coverage determinations in the case of enrolled children with reportable diseases. The process by which coverage determinations are to be made is set forth in §102A. Part 1B: Delivery of Covered Items and Services The provisions in this Part address ways in which providers may deliver items and services to enrolled children. This Part was designed to enable Purchasers to specify, at their option, criteria and guidelines for the delivery of health care services to specific populations of children, or for specific illnesses or conditions. Part 1C: Authorized Cost-Sharing This Part sets forth Contractor's duties with respect to authorized cost-sharing under Title XXI. Section 2103(e) of the Social Security Act gives states discretion to impose cost-sharing on eligible children for certain services up to certain limits. The language in this Part corresponds to the benefit package enumerated in Part 1 and sets forth the types of benefits for which cost-sharing is specified under the FEHBP-equivalent "benchmark" package. However, the language does not specify the cost-sharing amounts, and interested purchasers may consult with the FEHBP for additional information at www.opm.gov/insure. Part 2: Enrollment and Disenrollment Procedures This Part sets forth Contractor’s possible duties related to enrollment and disenrollment procedures. Specifically, §201 clarifies that children born to women who are enrolled with a contractor shall be treated as temporarily enrolled with the contractor and shall remain enrolled until the newborn is determined ineligible for SCHIP by the State SCHIP Agency or disenrolled by the family or caregiver. The other sections in this Part concern the possible duties related to children receiving treatment at the time of enrollment, and at the time of disenrollment. In addition, possible grounds for disenrollment of an enrolled child are enumerated. Part 3: Information for New and Potential Enrolled Children This Part enumerates the possible information to be given to enrolled children prior to enrollment, and once enrolled. The contents of and requirements of an enrollee handbook are spelled out. The Part also specifies what information should be included in health education materials for enrolled children and in a pamphlet for enrolled adolescents. In addition, the Part would require Contractor to issue an enrollment card with Contractor’s name and 24-hour toll-free phone number to the family of each enrolled child. Part 4: Provider Selection and Assignment This Part sets forth an option for the process for selection and assignment of primary care providers and dental care providers by enrolled children. It also provides for an option that allows a child with special health care needs to have a choice between a primary care provider or a pediatric specialist to serve as the primary care provider. This Part also allows for periodic re-selection of providers by enrolled children. It specifies that an enrolled child may disenroll for cause if inaccurate provider information is given or if Contractor fails to comply with the requirement to find an appropriate provider. In addition, this Part requires Contractor to issue an updated enrollment card with provider information to the family of each enrolled child. Part 5: Provider Network This Part sets forth optional specifications for participation in Contractor’s provider network, including requirements specific to primary care providers, pediatric specialists, and dental care providers. Measures of sufficiency and the role of the provider are enumerated in§§502-504. This Part also contains participation and reimbursement provisions relating to specific types of providers, such as school-based providers and traditional providers. §509and §510 address access and reimbursement provisions relating to out-of-network providers. In addition, this Part sets forth requirements applicable to participating providers under federal fraud and abuse laws. Part 6: Access Standards This Part sets forth possible access standards for an initial assessment of an enrolled child, along with travel time and service waiting time standards. The initial assessment is an encounter between the enrolled child and the child’s primary care provider. §602 addresses (1) the number of providers to which an enrolled child may have access, (2) the types of providers available to enrolled children in an urban service area, and (3) a specified travel time to each type of provider within the urban area. §603 addresses maximum service waiting times for emergency and urgent medical conditions and for other illnesses or conditions. Part 7: Relationships with Other State and Local Agencies This Part sets forth optional specifications to coordinate Contractor’s relationship with eight specific public agencies, including state Title V agencies and state Child Welfare agencies. This Part is divided into sections that address the issues and administrative mechanisms specific to each agency. Each section contains a provision relating to the possible elements of a memorandum of understanding between Contractor and the particular agency. Part 8: Quality Measurement and Improvement This Part sets forth optional specifications for Contractor’s quality measurement and improvement program regarding the delivery of covered items and services to enrolled children. The optional provisions address the specific program elements, along with criteria for clinical studies, drug formulary assessments, and utilization review. §805 addresses utilization review criteria, including Contractor’s compliance with the coverage determination standards and procedures required by this agreement and the detection of under-utilization of items and services by enrolled children. Part 9: Data Collection and Reporting This Part sets forth possible requirements for an information system to be maintained by Contractor, and specifies nine different types of data that a purchaser may wish to collect, including encounter and quality data. In addition, this Part addresses provisions relating to cross-cutting issues, including confidentiality, public access, ownership, and purchaser access. Part 10: Enrolled Child Safeguards This Part enumerates optional protections for enrolled children relating to communications with providers, confidentiality, and liability for payment. This Part also sets forth optional specifications for Contractor’s grievance and complaint procedures. Part 11: Publicly Purchased Vaccine Programs This Part sets forth optional specifications for participation of network providers in publicly purchased vaccine programs. This Part also reiterates CMS’s guidance regarding coverage of immunizations under Title XXI and the Vaccines for Children (VFC) program. Part 12: Remedies for Noncompliance This Part sets forth specific optional remedies for Purchaser to apply if Contractor does not comply, or otherwise fails to perform, a requirement of the agreement. Such remedies include withholding of capitation payments, suspension of enrollment, notification of right to disenroll, liquidated damages, civil money penalties and termination. In addition to these remedies, the Part enumerates remedies for different types of non-compliance. For example, §1202(a)(1) imposes a civil money penalty for each instance in which Purchaser determines that Contractor has substantially failed to provide medically necessary items and services required under this agreement. This Part also affords Contractor the right to a hearing prior to the imposition the civil money penalties specified. Part 13: Other Applicable Federal and State Requirements This Part specifies the application of federal requirements under §2107(e) of the Social Security Act to Contractor and network providers. Many of these requirements are also applied in various Parts of this agreement. These federal or state requirements are incorporated by reference into the agreement to provide protections to enrolled children. For example, §1301(b) enumerates 5 different non-discrimination statutes in federal law. Purchasers may wish to use this Part as a checklist for statutory references in developing SCHIP managed care purchasing documents. Part 14: Definitions This Part sets forth definitions used throughout the document and provides statutory references as necessary. Overview of Contractor’s Duties§001 - 002 - 003
- 004 - 005 - 006
- 007 If, as a purchaser you are interested in purchasing pediatric care for SCHIP-eligible children from managed care organizations on a risk basis, the following language is for your consideration. K§001. Purpose and Applicability
§002. Services
K§003. Enrollment and Disenrollment of Enrolled Children
Commentary: The following illustrative language is relevant only in a state that operates a vaccine purchase program other than the federal Vaccines for Children (VFC) program.
K§005. Access to Care
§006. Delivery of Covered Items and Services
Commentary: In its responses to questions on SCHIP dated July 29, 1998, CMS “strongly encouragesâ€� states to adopt the benefits and periodicity schedules that are recommended in Bright Futures (§006(a)(1)(A)), the AAP Guidelines (§006(a)(1)(C)), and the AAPD Reference Manual (§006(a)(1)(D)), in designing well-baby and well-child coverage under SCHIP. Routine physical examinations as recommended in both Bright Futures and in AAP Guidelines will be considered well-baby and well-child care services for cost sharing purposes under 42 CFR § 457.520.
K§007. Quality Measurement and Improvement Contractor shall comply with the requirements of Part 8. K§008. Data Collection and Reporting Contractor shall comply with the requirements of Part 9. K§009. Enrolled Child Safeguards
K§010. Enforcement
K§011. Other Applicable Federal and State Requirements Contractor shall comply with the requirements of Part 13. K§012. Effect of Participation
K§013. Relationships with Other State and Local Agencies Contractor shall comply with the requirements of Part 7. K§014. Definitions ( Applicable to Overview and All Parts) Commentary: Note that states are required to report SCHIP enrollment data for children under age 19 in four age categories: under 1, 1-5, 6-12, and 13-18. Letter to State Health Officials from Center for Medicaid and State Operations, CMS, December 4, 1998, www.hcfa.gov/init/cheval.htm. CMS has under consideration standardization of data collection according to these four categories. Purchasers and Contractors should address CMS’s efforts in their data collection requirements, and note that this definition of adolescent crosses two of the four age categories.
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