Medicaid Contract Purchasing Specifications

Part 1 - Part 2 - Part 3 - Part 4 - Part 5 - Part 6

Part 1

Items and Service

Title XXI gives states a number of options with respect to the health benefits coverage they offer under their State SCHIP Plan. Section 2103(a)(1) of the Social Security Act, 42 U.S.C. §1397cc(a)(1), requires that health benefits coverage under SCHIP be equivalent to the benefits coverage in a Ã¬benchmarkÃ® benefit package. One of the "benchmark" 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. §1397cc(b)(1). For illustrative purposes, the following benefits specifications are taken from this FEHBP-equivalent Ã¬benchmark.Ã® ¹

States have other benefits options under SCHIP. As of January 2002, all states had implemented their SCHIP plans (see www.hcfa.gov/init/chip-map.htm) through managed care or fee-for-service arrangements. Many policy and research organizations are tracking the implementation of SCHIP. For analyses of SCHIP implementation, see >(A) SCHIP Policy Studies Project Policy Brief #3: Managed Care Purchasing under SCHIP: A Nationwide Analysis of Freestanding SCHIP Contracts (December 2001), Policy Brief #1: State SCHIP Design and the Right to Coverage (March 2001), and Policy Brief #2: State Benefit Design Choices under SCHIP: Implications for Pediatric Health Care (May 2001), available on the website of GW's Center for Health Services Research and Policy, www.gwhealthpolicy.org/);

(B) Charting CHIP: Report of the Second National Survey of the Children's Health Insurance Program (July 2001), Progress and Innovations in Implementing CHIP: A Report of Four State Site Visits (June 2000), An Analysis of Policy Issues in SCHIP and Medicaid Implementation (July 2000), all available the National Academy for State Health Policy's website, www.nashp.org);

(C) Children's Health Insurance Program: State Implementation Approaches are Evolving (GAO/HEHS-99-65, May 1999), www.gao.gov;

(D) 2000 Annual Report of the State Children's Health Insurance Program ( National Governor's
Association and National Conference of State Legislatures, www.nga.org);

(E) S-CHIP Managed Care Contracting (December 2000); Making Child Health Coverage a Reality: Lessons from Case Studies of Medicaid and SCHIP Outreach and Enrollment Strategies (September 1999), all available on Kaiser Family Foundation's website, www.kff.org); and

(F) All Over the Map: A Progress Report on the State Children's Health Insurance Program (CHIP) (Children's Defense Fund, July 2000, www.childrensdefense.org).

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.

§101. In General

(a) Contractor shall, for each enrolled child (including an adolescent), cover and furnish, or arrange the furnishing of, the items and services enumerated in §102(a) in accordance with:

(1) §006(a)(1) of the Overview (relating to child health supervision guidelines);

(2) Part 1A (relating to coverage determination standards and procedures);

(3) Part 1B (relating to delivery of covered items and services); and

(4) Part 1C (relating to authorized cost sharing).

§102. Scope of Benefit (FEHBP Option)

(a) Covered Items and Services ² — The covered items and services are:

(1) Inpatient hospital benefits:

(A) room and board, including semiprivate accommodations, and intensive care units; private room when isolation is covered by law or determined medically necessary for contagion;

(B) operating, recovery and other treatment rooms;

(C ) drugs and medical supplies;

(D) x-ray, laboratory, and pathological services, and machine diagnostic tests;

(E) dressings, splints, plaster casts;

(F) anesthetics and anesthesia service;

(G) administration of blood and blood plasma, but not the blood itself;

(H) pre-admission testing recognized as part of the hospital admission procedures;

(I) hospitalization for dental work if necessary to safeguard the health of the enrolled child;

(J) chemotherapy and radiation therapy when supported by allogeneic or autologous bone marrow transplants or autologous stem cell support is only covered for specific diagnoses; and

(K) inhospital physician care.

(2) Surgical benefits:

(A) operative or cutting procedures, including treatment of fractures and dislocations, surgical sterilization, and normal pre- and post-operative care by the operating physician;

(B) diagnostic procedures such as endoscopies and biopsies;

(C) treatment of burns;

(D) surgical correction or congenital anomalies;

(E) extraction of reinfusion of bone marrow or blood stem cell as part of an allogeneic or autologous bone marrow transplant or autologous stem cell support procedure;

(F) surgical correction of amblyopia and strabismus;

(G) multiple surgical procedures;

(H) assistant surgeon if required by the complexity of the surgical procedure;

(I) anesthesia;

(J) organ/tissue transplants (3 sets of transplants and types of conditions); and

(K) oral and maxillofacial surgery limited to excision of tumors and cysts of the jaws, checks, lips, tongue, roof and floor of mouth when pathological examination is required:

(i) surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth;

(ii) excision of exostoses of jaws and hard palate;

(iii) external incision and drainage of cellulitis;

(iv) incision and surgical treatment of accessory sinuses, salivary glands or ducts;

(v) reduction of dislocations and excision of temporomandibular joints; and

(vi) removal of impacted teeth.

(3) Maternity benefits: 3

(A) room and board as described in paragraph (1);

(B) bassinet and nursery;

(C) outpatient care for delivery including care in freestanding ambulatory facilities, including birthing centers;

(D) obstetrical care for pregnancy (including related conditions) and resulting childbirth or miscarriage;

(E) services of a licensed or certified nurse midwife for pre- and post-partum care and delivery;

(F) anesthesia services, services of a nurse anesthetist, and surgical assistance as described in (2);

(G) contraceptive devices and drugs;

(H) diagnosis and treatment of infertility;

(I) prenatal testing; and

(J) voluntary sterilization.

(4) Mental conditions/substance abuse benefits: ⁴

(A) inpatient care;

(B) inpatient visits for mental conditions and substance abuse;

(C) outpatient care;

(D) professional care;

(E) therapy outpatient visits available up to 25 visits per person for individual or group therapy, up to two hours per day, including collateral visits with members of the patients immediate family, provided by a physician, qualified clinical psychologist, psychiatric nurse, or clinical social worker;

(F) day-night hospital services;

(G) pharmacotherapy; and

(H) substance abuse inpatient care limited to one treatment program (28-day maximum) per lifetime.

(5) Other medical benefits:

(A) outpatient facility care;

(B) diagnostic services, including x-ray, laboratory, and pathological services, and machine diagnostic tests;

(C) preventive services, including cervical cancer screening, tetanus-diphtheria (Td) booster, and immunization for influenza and pneumonia;

(D) radiation therapy, chemotherapy, and renal dialysis; physical, occupational and speech therapy; allergy tests, surveys, injections; hospital services in connection with dental procedures only when a nondental physical impairment exists;

(E) ambulance services associated with covered hospital inpatient care, when related to and within 72 hours after an accidental injury or medical emergency, or during covered home health care;

(F) dental care for accidental injury;

(G) durable medical equipment;

(H) home nursing care;

(I) miscellaneous services, including:

(i) allergy tests, surveys, and injections;

(ii) blood and blood plasma;

(iii) neurological testing per a clinical psychologist;

(iv) one set of eyeglasses or contact lenses, or one replacement to an existing prescription, required as a result of, and directly related to, a single instance of intra-ocular surgery, or a single ocular injury;

(v) ostomy and catheter supplies;

(vi) oxygen;

(vii) medical foods for children with inborn errors of amino acid metabolism;

(viii) prescription drugs;

(ix) home infusion therapy; and

(x) nonsurgical treatment for amblyopia and strabismus; and

(J) physical therapy up to 50 visits per person per calendar year, occupational and speech therapy up to 25 visits per person per calendar year.

(6) Additional benefits:

(A) preventive benefits;

(B) routine physical examination;

(C) cancer screening and immunization schedules;

(D) cervical cancer screening;

(E) immunizations for influenza and pneumonia once every calendar year, and TB booster once every ten calendar years;

(F) well-child care for children up to age 19 consistent with the guidelines enumerated in §006(a)(1), including:

(i) all healthy newborn inpatient physician visits, including routine screening (inpatient or outpatient); and

(ii) routine physical examination, laboratory tests, immunizations, and related office visits as recommended by [drafter insert selected guidelines in §006(a)(1)]; ⁵

(G) accidental injury;

(H) home health care; and

(I) home hospice care.

(7) Prescription drug benefits:

(A) purchase of 90-day supply of listed medications and supplies prescribed by provider:

(i) drugs, vitamins and minerals and nutritional supplements;

(ii) insulin;

(iii) needles and disposable syringes for the administration of covered medications;

(iv) intrauterine devices, Norplant, Depo-Provera, and oral contraceptives; and

(v) drugs to aid smoking cessation.

(8) Dental benefits: ⁶

(A) clinical oral evaluations;

(B) radiographs;

(C) tests and laboratory exams;

(D) palliative treatment;

(E) prophylaxis;

(F) topical application of fluoride limited to 2 per person per calendar year;

(G) topical application of fluoride not including prophylaxis;

(H) space maintainers;

(I) amalgam restorations;

(J) silicate restorations;

(K) filled or unfilled resin restorations;

(L) inlay restorations;

(M) extractions; and

(N) surgical extractions.

(b) Items and Services Excluded from Coverage — Contractor shall not have a duty to cover the following items or services:

(1) Room and board and inhospital physician care when the admission is one of the following:

(A) custodial care;

(B) convalescent care or a rest cure;

(C) domiciliary care provided because care in home is not available or is unsuitable;

(D) inpatient private duty nursing; or

(E) not medically necessary (for services which did not require the acute hospital inpatient (overnight) setting, but could have been provided in a physician's office, the outpatient department of a hospital, or some other setting, without adversely affecting the enrolled child's condition or the quality of medical care rendered.

(2) Surgical benefits:

(A) Cosmetic surgery unless required for congenital anomaly or to restore or correct a part of the body which had been altered as a result of accidental injury, disease, or surgery which occurred while enrolled under Contractor's plan;

(B) radial keratotomy; or

(C) services for or related to reversal of surgical sterilization.

(3) Maternity benefits:

(A) Assisted Reproductive Technology (ART) procedures, such as artificial insemination, in vitro fertilization, and embryo transfer, as well as items and supplies related to ART procedures, including sperm banking;

(B) reversal of voluntary sterilization; or

(C) contraceptive devices.

(4) Mental conditions/substance abuse benefits:

(A) marital, family, educational, or other counseling or training services;

(B) services rendered or billed by a school or halfway house or a member of its staff;

(C) psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present; or

(D) services and supplies that are not medically necessary.

(5) Other medical benefits:

(A) exercise and bathroom equipment;

(B) lifts, such as seat, chair or van lifts;

(C) air conditioners, humidifiers, dehumidifiers, and purifiers;

(D) shoes or related corrective devices;

(E) wigs;

(F) implanted bone conduction hearing aids;

(G) computer story boards or lights talkers for communication-impaired individuals;

(H) maintenance or palliative physical, occupational, or speech therapy for a chronic disease or condition; or

(I) home nursing care when requested by, or for the convenience of, the patient or the patient's family or if it consists of bathing, feeding, exercising, homemaking, moving the patient, giving medication, or acting as a companion or sitter.

(6) Drug benefits:

(A) medical supplies such as dressings and antiseptics;

(B) drugs and supplies for cosmetic purposes; or

(C) medication that does not require a prescription.

(7) Dental benefits:

(A) any dental procedures involving orthodontic care, dental implants, periodontal disease, or preparing the mouth for the fitting or the continued use of dentures, except as specifically described.

Part 1A

Coverage Determination Standards and Procedures ⁸

§101A. Coverage Determination Standards
§102A. Coverage Determination Procedures
§103A. Prior Authorization
§104A. Self-Referral for Certain Services without Prior Authorization
§105A. Prior Purchaser Approval

Commentary: §101A speaks to standards for coverage determination, which is a decision by 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 Ã¬coverage determination.Ã® 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.

Section 2102(b)(3)(E) of the Social Security Act, 42 U.S.C. §1397bb(b)(3)(E), requires that State SCHIP plans describe procedures used to ensure the coordination of SCHIP benefits packages with other public and private programs. Section 2105(c)(6) of the Act, U.S.C.§1397ee(c)(6) and 42 C.F.R. §300 et seq. prohibits the payment of federal SCHIP matching funds with respect to expenditures for items or services that are covered (or should be covered) by private or federal third party payors. This Part does not contain language relating to coordination of benefits that would address this issue. For illustrative language based upon the Medicaid program's policies and procedures with respect to third party liability, see §105A of Part 1A of Medicaid Pediatric Purchasing Specifications, (GW Center for Health Services Research and Policy, September 1999, www.gwhealthpolicy.org/).

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 on coverage determination standards and procedures is for your consideration.

§101A. Coverage Determination Standards — In making a coverage determination (as defined in subsection (e)) with respect to an enrolled child (including a child with special health care needs and an adolescent), Contractor (and where coverage determinations are delegated to providers participating in Contractor's provider network, such providers) shall comply with the following requirements:

(a) Standard of Coverage — In making coverage determinations (as defined in subsection (e)), Contractor shall apply the following standards:

^L(1) As required under §2103(f)(1) of the Social Security Act, 42 U.S.C. §1397cc(f)(1), Contractor shall not impose any preexisting condition exclusion for items or services covered under covered under §102(a) of Part 1; ⁹

^L(2) Coverage limitations imposed by Contractor shall comply with the Newborns' and Mothers' Health Protection Act of 1996, §2704 of the Public Health Service Act, 42 U.S.C. §300gg-4, and 29 U.S.C. §1185a, 63 Fed. Reg. 57545 (October 27, 1998);

^L(3) Coverage limitations imposed by Contractor shall comply with the Mental Health Parity Act, §2705 of the Public Health Service Act, 42 U.S.C. §300gg-5, and 29 U.S.C. §1185a; ¹⁰

^L(4) Coverage limitations imposed by Contractor must not discriminate against an enrolled child based upon a child's disability in violation of the Americans with Disabilities Act, 42 U.S.C. §12101 et seq. and 28 C.F.R. §35.130; and

^K(5) As required by §805(a)(1) of Part 8, coverage limitations imposed by Contractor shall be consistent with the child health supervision guidelines reflecting generally accepted principles of professional pediatric practice enumerated in §006(a)(1) of the Overview.

^K(b) Evidence to be Considered in Making Coverage Determinations — In making a coverage determination (as defined in subsection (e)), Contractor shall take into account the following evidence and information:

(1) Recommendation of the provider treating the enrolled child for whom the coverage determination must be made;

(2) Clinical evidence of the health status and needs of the enrolled child for whom the coverage determination must be made;

(3) Evidence and information that is provided by the enrolled child or by the enrolled child's family or caregiver;

(4) Opinions of medical, dental and other health care practitioners who are experienced in the treatment of children with mental or physical illnesses or conditions similar to that of the enrolled child with respect to which a coverage determination is being made;

(5) Professional standards of medical, dental and other health care practice related to the care of children, as reflected in:

(A) scientific literature published in peer-reviewed journals;

(B) the results of clinical trials relevant to pediatric care;

(C) government-sponsored studies;

(D) professional consensus statements; and

(E) other sources of valid and reliable evidence regarding the pediatric standard of care;

(6) Opinions of, and evidence supplied by, qualified individuals who are involved in the care of the enrolled child and who are affiliated with [drafter insert names of publicly-supported agencies, programs, or providers delivering health services to children residing in Contractor's service area]; and

(7) Provisions of an Individualized Education Program (IEP) (as defined in §1401(n)) or an Individualized Family Services Plan (IFSP) (as defined in §1401(o)). ¹¹

^K(c) Prohibited Grounds for Denial or Exclusion of Services — Contractor shall not deny or reduce coverage in part or in whole of an item or service covered under §102(a) with respect to an enrolled child because:

(1) the item or service is required to treat a condition rather than an illness or injury;

(2) the item or service will not result in the restoration or achievement of normal functioning;

(3) the item or service which is sought is experimental, unless the Contractor demonstrates to [drafter insert name of appropriate state agency] that the item or service is:

(A) available only through a clinical trial, or

(B) not a generally accepted practice or procedure among pediatric specialists;

(4) the item or service is identified in a plan of care developed by [drafter insert name of state child welfare agency, state Title V agency or grantee, or other state or local agency];

(5) the item or service is a related service in an Individualized Education Program (IEP) (as defined in §1401(n)) or an early intervention service in an Individualized Family Services Plan (IFSP) (as defined in §1401(o)) that would otherwise be covered under [drafter insert reference to state's SCHIP plan]; ¹²

(6) the item or service is provided in a school setting that would otherwise be covered under [drafter insert reference to state's SCHIP plan]; or

(7) the item or service is required because of a failure of the family or caregiver of the enrolled child to ensure that the child has complied with a recommendation or prescription of the child's treating provider. ¹³

^K(d) Special Rule for Coverage of Treatment for Reportable Diseases — In the case of an enrolled child (including an adolescent) with respect to whom [drafter insert name of state or local public health agency] has issued an order for the treatment of a reportable disease, Contractor shall comply with the treatment order by furnishing items and services covered under §102(a) of Part 1 and specified under the order until:

(1) the course of treatment is completed; or

(2) the enrolled child is medically evaluated, the treatment order is reviewed by a provider participating in Contractor's provider network who is qualified to treat the reportable disease with respect to which the treatment order applies, and, based on such evaluation and review, the child's primary care provider initiates an alternative course of treatment.

Commentary: Under traditional commercial insurance principles, coverage is limited to treatments that Ã¬restore normal functioningÃ® following Ã¬illness or injuryÃ®. See Negotiating the New Health System (2nd Ed., 1998), Vol. 1, p. 18. The following illustrative language does not reflect these principles, instead it is consistent with the broader approach to coverage underlying the Medicaid EPSDT benefit. Of course, states under SCHIP are not required to offer the EPSDT benefit if they implement a free-standing SCHIP program. In such cases, an interested state purchaser may wish to modify the following language which is intended to address items and services needed by enrolled children with chronic conditions, disabilities, or delays that cannot be prevented, corrected, or ameliorated.

(e) Coverage Determination Defined — A determination by Contractor (or by the provider or other entity to whom Contractor has delegated such determination) as to whether, in the case of an enrolled child, an item or service enumerated under §102(a) of Part 1 is necessary:

(A) to prevent, correct, or ameliorate a condition, disability, illness or injury;

(B) to prevent, correct, or ameliorate a developmental disability or delay; or

(C) to maintain functioning.

^K§102A. Coverage Determination Procedures¹⁴ — In making coverage determinations (as defined in §101A(e), with respect to an enrolled child, Contractor shall comply with the following requirements:

(a) Determination in Writing — A determination regarding coverage shall be in writing and shall state the factual basis for the determination.

(b) Timely Determination — Contractor shall make a coverage determination within
[ ] days of a request for such a determination unless within such time Contractor notifies the enrolled child or the provider requesting such determination that additional information is required. In no event shall Contractor make a coverage determination in more than [ ] days of the request for such determination.

(c) Notice of Determination — Contractor shall provide written copies of a determination regarding coverage within [ ] days of such determination to:

(1) the enrolled child's family or caregiver (or in the case of an enrolled adolescent, the adolescent);

(2) the enrolled child's primary care provider and pediatric specialist (if any); and

(3) subject to the requirements of §1002 of Part 10 relating to confidentiality protections, [drafter insert name of publicly-supported agency, program, or provider delivering health services to children residing in Contractor's service area] that referred the enrolled child for the item or service at issue.

(d) Notice of Denial or Reduction — In the case of a determination involving the denial or reduction of an item or service covered under §102(a) of Part 1 , Contractor shall within [ ] days of such determination inform the enrolled child's family or caregiver orally and in writing that:

(1) the enrolled child may invoke the grievance procedure maintained by the Contractor under §009 of the Overview and Part 10; and

(2) the enrolled child's rights and remedies under such procedure.

(e) Personnel Qualified to Make Coverage Determinations — Contractor shall ensure that determinations regarding the coverage of items and services enumerated in §102(a) of Part 1, including determinations of coverage of items and services for which prior authorization is required, be conducted by:

(1) personnel with training in pediatric health care and qualified through licensure, accreditation, education, experience, and other means, to make coverage determinations regarding the provision of physical, dental or mental health services to an enrolled child;

(2) in the case of an enrolled adolescent, an individual described in paragraph (1) with experience in treating adolescents;

(3) in the case of an enrolled child with an Individualized Education Program (IEP) (as defined in §1401(n)) or an Individualized Family Services Plan (IFSP) (as defined in §1401(o)), an individual described in paragraph (1) or (2) with expertise in IEPs or IFSPs; and

(3) in the case of an enrolled child who is a racial or ethnic minority, an individual described in paragraph (1), (2) or (3) who is culturally competent (as defined in §1401(h)).

(f) Language-Appropriate Determinations — In the case of an enrolled child whose family or caregiver speaks a language other than English that is spoken by more than [ ] enrollees, the written coverage determination described in subsection (c), and the information regarding appeal rights described in subsection (d), shall be in such language.

^K§103A. Prior Authorization ¹³

(a) In General

(1) Items and Services Subject to Prior Authorization — Contractor shall comply with the requirements of subsection (b) if Contractor requires authorization for the furnishing of a covered item or service enumerated in subsection (c) prior to the furnishing of, or payment for, such item or service to an enrolled child (including an adolescent).

(2) Items and Services Excluded from Prior Authorization — Contractor shall not require prior authorization for the furnishing of a covered item or service enumerated in subsection (d) and §104A (relating to self-referrals).

(b) Prior Authorization Procedures — Contractor shall comply with the requirements of paragraphs (1) through (4) relating to prior authorization for the covered items and services enumerated in subsection (c).

(1) Notification of Providers ¹⁶ — Contractor shall notify in writing all providers participating in Contractor's provider network, as well as other providers that furnish covered items or services under §102(a) of Part 1 to enrolled children at Contractor's request, regarding:

(A) the items and services for which prior authorization must be obtained that are enumerated in subsection (c);

(B) the manner in which requests for prior authorizations must be made;

(C) the information and documentation that must accompany a request for prior authorization;

(D) to whom the request for prior authorization must be given;

(E) the identity of the individual responsible for communicating Contractor's determination regarding a request for prior authorization to the affected enrolled child.

(2) Availability of Forms — In a case in which Contractor requires prior authorization requests to be submitted on particular forms, Contractor shall ensure that all providers participating in Contractor's provider network have a sufficient quantity of such forms at all times.

(3) Toll-Free Number

(A) Establishment and Operation — Contractor shall establish and operate on a [ ]Ã±hour, [ ]Ã±day per week basis, a toll-free telephone number through which an enrolled child, the child's family or caregiver, or the child's treating provider may request prior authorization for an item or service enumerated in subsection (c).

(B) Staffing

(i) Sufficient Number — Contractor shall ensure that the toll-free telephone number described in subparagraph (A) shall be staffed at all times of operation by a number of individuals meeting the qualifications described in clause (ii) that is sufficient to ensure that the waiting times for callers seeking to request prior authorization does not exceed [ ] minutes.

(ii) Qualifications — Contractor shall ensure that the individuals receiving requests for prior authorization on the toll-free telephone number under subparagraph (A) are qualified by medical or related training, and authorized by Contractor, to approve requests for prior authorization by or on behalf of enrolled children.

(4) Standards for Timeliness — Contractor shall render a coverage determination:

(A) in the case of requests, prior authorization for items or services involving an enrolled child in foster care or other out-of-home placement (including a child with special health care needs in such circumstances), within [ ] hours of receipt a request for prior authorization; and

(B) in all other cases, within [ ] hours of receipt of a request for prior authorization unless within that time ontractor notifies the enrolled child or provider that additional information is required, but in no event later than [ ] days of receipt of a request.

(c) Items and Services Subject to Prior Authorization — [drafter insert list of covered items and services that require prior authorization].

(d) Items and Services Excluded from Prior Authorization — Contractor shall not require prior authorization of the following items and services:

(1) emergency services (as defined in §1401(k)) and post-stabilization care services (as defined in §1401(s)) not subject to pre-approval under 42 C.F.R. §422.100(b)(iv);

(2) urgent care (as defined in §1401(z));

(3) immunization services covered under §102(a) of Part 1;

(4) prenatal care covered under §102(a) of Part 1 ;

(5) items and services related to diagnosis and treatment of a sexually transmitted disease to the extent covered under §102(a) of Part 1 ;

(6) items and services related to the diagnosis and treatment of tuberculosis to the extent covered under §102(a) of Part 1;

(7) items and services provided under an Individualized Education Program (IEP) (as defined in §1401(n)) or early intervention item or service in an Individualized Family Services Plan (IFSP) (as defined in §1401(o));

(8) a physical examination of an enrolled child upon entry into the [drafter insert reference to state's foster care system];

(9) items and services related to treatment for childhood lead poisoning to the extent covered under §102(a) of Part 1;

(10) items and services related to prevention of HIV infection to the extent covered under §102(a) of Part 1;

(11) treatment services ordered with respect to an enrolled child by [drafter insert reference to state/local courts with jurisdiction];

(12) an examination to determine whether a child has been subject to physical or sexual abuse; and

(13) items and services related to the treatment of ongoing chronic condition that has been diagnosed by a pediatric specialist (as defined in §1401(r)) participating in Contractor's provider network. ¹⁷

^K§104A. Self-Referral for Certain Services without Prior Authorization — Contractor shall permit self-referral by an enrolled adolescent or a family or caregiver on behalf of any child to a provider participating in Contractor's provider network for the following services:

(a) consistent with §005(f):

(1) family planning services and supplies to the extent covered under §102(a) of Part 1;

(2) items and services related to diagnosis and treatment of a sexually transmitted disease to the extent covered under §102(a) of Part 1; and

(b) items and services relating to dental and oral health to the extent covered under §102(a) of Part 1.

^K§105A. Prior Purchaser Approval

Prior to the first enrollment of an eligible child after the effective date of [drafter insert name of purchasing document], Contractor shall obtain the approval of Purchaser that Contractor's coverage determination standards and procedures and prior authorization requirements comply with the requirements of this Part.

Compliance measure: Contractor shall make available to Purchaser all protocols, provider manuals, memoranda, and other materials used by Contractor to make coverage determinations or to instruct providers on coverage, coverage determination standards and procedures, and prior authorization procedures under [drafter insert name of purchasing document].

Part 1B

Delivery of Covered Items and Services

§101B. In General
§102B. Delivery of Preventive Services to Adolescents
§103B. Delivery of Dental Services
§104B. Delivery of Immunizations
§105B. Delivery of STD Services
§106B. Delivery of HIV Services
§107B. Delivery of TB Services
§108B. Delivery of Childhood Lead Poisoning Services
§109B. Delivery of Diabetes Services

Commentary: This Part is 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 with respect to specific illnesses or conditions. The service delivery provisions of applicable specifications developed by CHSRP are cross-referenced in this Part.

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 on delivery of covered items and services is for your consideration.

§101B. In General

(a) Preventive Services for Adolescents — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §102B relating to the delivery of preventive services to enrolled adolescents to the extent such items or services are covered under §102(a) of Part 1.

(b) Dental Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §103B relating to the delivery of dental care services to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

(c) Immunizations — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §104B relating to the delivery of immunizations to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

(d) STD Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §105B relating to the delivery of STD services to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

(e) HIV Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §106B relating to the delivery of HIV services to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

(f) TB Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §107B relating to the delivery of TB services to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

(g) Childhood Lead Poisoning Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §108B relating to the delivery of childhood lead poisoning services to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

(h) Diabetes Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §109B relating to the delivery of diabetes services to enrolled children to the extent such items or services are covered under §102(a) of Part 1.

§102B. Delivery of Preventive Services to Adolescents ¹⁸

^K(a) Screening — Contractor shall ensure that, in performing a comprehensive health history to the extent covered under §102(a) with respect to an enrolled adolescent, each provider participating in Contractor's provider network shall:

^G(1) follow the Guidelines for Adolescent Preventive Services enumerated in §006(a)(1)(B) of the Overview; and

^K(2) (to the extent not otherwise provided in such Guidelines) determine:

(A) immunization status (consistent with guidelines enumerated in §104B);

(B) pregnancy status and risk of unintended pregnancy;

(C) the presence or risk of infection with a sexually transmitted disease (STD) (consistent with guidelines enumerated in §105B);

(D) the presence or risk of infection with the Human Immunodeficiency Virus (HIV) (consistent with guidelines enumerated in §106B);

(E) use of alcohol, tobacco, or other drugs;

(F) the presence or risk of physical or sexual abuse;

(G) the presence or risk of depression or related conditions;

(H) the risk of suicide;

(I) the risk of intentional and unintentional injuries;

(J) diet and the presence or risk of eating disorders; and

(K) performance at school (including involvement in community service activities).

^K(b) Counseling — Contractor shall ensure that, in furnishing counseling services covered under §102(a) of Part 1 to an enrolled adolescent, each provider participating in Contractor's provider network shall:

^G(1) follow the Guidelines for Adolescent Preventive Services enumerated in §006(a)(1)(B) of the Overview;

^K(2) (to the extent not otherwise provided in such Guidelines) counsel the adolescent with respect to:

(A) physical growth and development;

(B) psychosocial and psychosexual development;

(C) diet and physical activity;

(D) injury prevention;

(E) use of tobacco, alcohol, or other drugs;

(F) reducing the risk of infection with a sexually transmitted disease (STD);

(G) reducing the risk of infection with the Human Immunodeficiency Virus (HIV); and

(H) reducing the risk of unintended pregnancy; and

^K(3) in the case of an adolescent for whom English is not a primary language, ensure that arrangements are made for carrying out paragraphs (1) and (2) through a health care professional who is fluent in the adolescent's primary language and who is qualified to carry out paragraphs (1) and (2).

^K(c) Confidentiality — Contractor shall ensure that, in furnishing screening services, counseling services, family planning services and supplies, and other items and services covered under §102(a) of Part 1 to an enrolled adolescent, each provider participating in Contractor's provider network shall comply with the requirements of §1002(b) of Part 10 relating to confidentiality protections.

§103B. Dental Services ¹⁹

See §103(b), §104(b), §105(b), and §106(b) of Purchasing Specifications for Pediatric Dental and Oral Health Services, March 2000, www.gwhealthpolicy.org/.

§104B. Immunizations

See §003(b) and (c) of Purchasing Specifications for Immunizations, May 1998, www.gwhealthpolicy.org/.

§105B. STD Services

See §103(c), §104(c), §105(b), and §106(b) of Purchasing Specifications for Sexually Transmitted Disease Services, November 1999, www.gwhealthpolicy.org/.

§106B. HIV Services

See §204 of Purchasing Specifications for Services for HIV and HIV-related conditions, August 1999, www.gwhealthpolicy.org/.

§107B. TB Services

See §103(b), §104(b), §105(b) and (d), §106(b), and §107(b) of Purchasing Specifications for Tuberculosis Services, August 1999, www.gwhealthpolicy.org/.

§108B. Childhood Lead Poisoning Services

^K(a) In General — Contractor shall furnish, or arrange for the furnishing of, items and services described in subsections (b) and (c) to an enrolled child in accordance with the guidelines enumerated in subsection (d).

^K(b) Screening — In performing the assessment of blood lead levels, Contractor shall conduct screening blood lead level (BLL) tests (capillary or venous sample) to determine the presence of elevated blood lead level (EBLL) (as defined in subsection (e)) in an enrolled child at each of the following ages:

(1) twelve (12) months;

(2) twenty-four (24) months;

(3) in the case of an enrolled child between the ages of thirty-six (36) and seventy-two (72) months who has not previously received such a test, at the child's first encounter with a provider participating in Contractor's provider network; and

(4) at such other times as are required under [drafter insert any additional standards set forth in State's SCHIP Plan].

^K(c) Clinical Management — In the case of an enrolled child with respect to whom a screening under subsection (b) indicates an EBLL (as defined in subsection (e)), Contractor shall:

(1) conduct a diagnostic blood lead level (BLL) test (venous sample) to confirm an EBLL; and

(2) in the case of an enrolled child with a confirmed EBLL, furnish clinical management of the EBLL in accordance with the guidelines described in subsection (d), to the extent that the recommended diagnostic and treatment items and services are otherwise covered under §102(a) of Part 1.

^K(d) Guidelines — The guidelines enumerated in this subsection are Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials (Centers for Disease Control and Prevention, 1997), www.cdc.gov/.nceh/programs/lead/guide/1997/guide97.htm.

^K(e) Elevated Blood Lead Level (EBLL) Defined — Elevated blood lead level is a concentration of lead in whole blood (capillary or venous sample) that is equal to or greater than micrograms per deciliter.

§109B. Diabetes Services

See §103(b), §104(b), §105(b), and §106(b) of Purchasing Specifications for Diabetes Services, July 2000, www.gwhealthpolicy.org/.

Part 1C

Authorized Cost-Sharing

Title XXI gives states a number of options with respect to the health benefits coverage they offer under their State SCHIP Plans. Section 2103(e) of the Social Security Act, 42 U.S.C. §1397cc(e) and 42 CFR § 457.500 et seq., gives states discretion to impose cost-sharing on eligible children for certain services up to certain limits. States participating in SCHIP are not required to include cost-sharing in their plans. If they choose not to, none of the illustrative language in this Part would be necessary. However, if a state elects to impose cost-sharing requirements on one or more groups of children for one or more types of services, the illustrative language below is for the purchaser's consideration.

The following cost-sharing specifications are taken from the Federal Employees Health Benefits Program Standard Blue Cross/Blue Shield Preferred Provider Option Service Benefit Plan (in effect as of 1998) and correspond to the benefits package enumerated in §102(a) of Part 1. As discussed in the commentary in Part 1, this benefit package is one of several options a state has, and is set forth here for illustrative purposes only.

For an analysis of the status of SCHIP plans, see Pernice, C., et al., Charting CHIP: Report of the Second National Survey of the Children's Health Insurance Program (July 2001) and Riley, T. and Pernice, C. How Are States Implementing Children's Health Insurance Plans?: An Analysis and Summary of State Plans Submitted to the Health Care Financing Administration, 2nd Edition (September 1998) National Academy for State Health Policy, (www.nashp.org).

A CHSRP review of the literature on cost-sharing in the case of lower income families suggests that cost-sharing requirements Ã¬both deter entry into health coverage systems and use of even necessary health care.Ã® See Rosenbaum et al., CHIP, Health Insurance Premiums, and Cost-Sharing: Lessons from the Literature (GW Center for Health Services Research and Policy, 1998, www.gwhealthpolicy.org/). For additional information on SCHIP cost-sharing policy issues, see Pernice, C., Cost Sharing in CHIP Programs: A Snapshot of Current Practice, (National Academy for State Health Policy, January 2000, www.nashp.org), Rosenbaum, S., et al., An Analysis of Implementation Issues Relating to CHIP Cost-Sharing Provisions for Certain Targeted Low-Income Children (GW Center for Health Services Research and Policy, June 1999, available at www.hcfa.gov/init/children.htm).

In 1999, Congress passed legislation to require a federal evaluation of SCHIP; one of the areas to be studied is an assessment of the effect of cost-sharing on utilization, enrollment, and coverage retention.

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 on cost-sharing is for your consideration.

^L§101C. In General ²⁰

(a) Imposition of Cost-Sharing Only If Expressly Authorized — Contractor shall ensure that no cost-sharing amount (as defined in subsection (f)) is imposed by any provider furnishing covered items or services to an enrolled child at the request or authorization of Contractor (whether or not the provider is participating in Contractor's provider network) unless the cost-sharing amount is expressly authorized to be imposed on such enrolled child under this Part.

(b) Exclusion of Well-Baby or Well-Child Care from Cost-Sharing — Contractor shall ensure that no cost-sharing amount (as defined in subsection (f)) is imposed on an enrolled child with respect to well-baby care or well-child care, including age-appropriate immunizations, as defined in paragraph (1).

(1) Well-Baby or Well-Child Care is:

(A) all healthy newborn inpatient physician visits, including routine screening (inpatient or outpatient);

(B) routine physical examinations, laboratory tests, immunizations, and related office visits, as recommended in the American Academy of Pediatrics Guidelines for Health Supervision III under §006(a)(1)(C) of the Overview, or as described in Bright Futures Guidelines under §006(a)(1)(A) of the Overview; and

(C) routine preventive and diagnostic dental services (i.e., oral examinations, prophylaxis, and topical fluoride applications, sealants, and x-rays), as described in the AAPD Reference Manual under §006(a)(1)(D) of the Overview.

(c) Maximum Allowable Cost-Sharing for Certain Enrolled Children²¹ — With respect to items and services other than those enumerated in subsection (b)(1), Contractor may impose cost-sharing to the extent authorized in paragraphs (1) and (2), and shall provide cost-sharing information to the families and caregivers of enrolled children as required under paragraph (3).

(1) Enrolled Children with Incomes At or Below 150 Percent of the Federal Poverty Level ²² — In the case of an enrolled child with a family income at or below 150 percent of the federal poverty level, ²³ Contractor shall ensure that the cost-sharing amounts (as defined in subsection (f)) imposed by Contractor or by any provider under [drafter name of purchasing document] do not exceed the following:

(A) $1.00 with respect to an item or service valued at amount of $15.00 or less;

(B) $2.00 with respect to an item or service valued at an amount between $15.01 and $40.00;

(C) $3.00 with respect to an item or service valued at an amount between $40.01 and $80.00; and

(D) $5.00 with respect to an item or service valued at an amount over $80.00. ²⁴

(2) Enrolled Children with Incomes Above 150 Percent of the Federal Poverty Level — In the case of an enrolled child with a family income above 150 percent of the federal poverty level, Contractor ²⁵ shall ensure that the cost-sharing amounts (as defined in subsection (f)) imposed by Contractor or by any provider under [drafter name of purchasing document] do not exceed:

(A) [drafter insert the amounts specified in the State's Child Health Plan with respect to individual items and services]; and

(B) in total annual aggregate, 5 percent of the total income of the child's family or caregiver during the calendar year. ²⁶

(3) Duty to Provide Cost-Sharing Information — Upon request by an enrolled child or the family or caregiver of an enrolled child described in paragraph (2), ²⁷ Contractor shall make available within [ ], without charge, using the tracking capability required under paragraph (4), a summary of each cost-sharing amount incurred by the enrolled child during the calendar year in which the request is made, including the date on which each cost-sharing amount was imposed. ²⁸

(4) Tracking Capability — Contractor shall comply with the requirement §913(c)(7) of Part 9 relating to the capability of Contractor's information system to record the imposition of each cost-sharing amount on each enrolled child. ²⁹

(d) Prohibition on Balance Billing — Contractor shall ensure that no provider furnishing covered items or services to an enrolled child at the request or authorization of Contractor (whether or not the provider is participating in Contractor's provider network) bills or imposes any charge upon an enrolled child, or upon the child's family or caregiver, for an item or service covered under §102(a) of Part 1 other than a cost-sharing amount authorized under subsection (c) and §102C.

(e) Prohibition on Denial or Withholding of Care ³⁰

(1) Contractor shall ensure that no provider participating in Contractor's provider network withholds, delays, or reduces an item or service covered under §102(a) of Part 1 if an enrolled child or the child's family or caregiver fails to pay part or all of a deductible, coinsurance, or copayment or other charge imposed by provider in connection with such item or service.

(2) Paragraph (1) shall not be construed to extinguish the liability of the family or caregiver of an enrolled child for the payment of any cost-sharing amount properly imposed under subsection (c) and §102C.

(f) Cost-sharing Amount Defined — A cost-sharing amount is the amount of any premium, enrollment fee, deductible, coinsurance, or copayment requirement or similar charge.

§102C. Authorized Cost-Sharing

Commentary: Under §2103(e)(3)(A) of the Social Security Act, 42 U.S.C. §1397cc(e)(3)(A), and 42 C.F.R. §457.540, a State SCHIP program may impose enrollment fees, premiums, or similar charges on children with family income at or below 150 percent of the federal poverty level ($21,945 for a family of 3 in 2001), subject to two separate limitations. The maximum monthly charge may not exceed the amounts a state may impose under Medicaid for a family of the same size and income. In addition, in the case of cost-sharing other than premiums, the maximum amount may not exceed the Ã¬nominalÃ® amounts permitted under federal Medicaid regulations.

Under §2103(e)(3)(B) of the Social Security Act, 42 U.S.C. §1397cc(e)(3)(B), and 42 C.F.R. §457.560, a State SCHIP program may not impose premiums, deductibles, cost-sharing or similar charges higher than the cumulative cost sharing maximum. The total annual aggregate cost-sharing with respect to all eligible children in a family may not exceed 5 percent of the family's income for the year.

The following language in §102C incorporates the limitations set forth in §101C(c)(1) and (c)(2) into the FEHBP-equivalent Ã¬benchmarkÃ® benefits package to bring that package into conformity with the statutory limitations on cost-sharing. See CMS's Responses to Questions about SCHIP (http://www.hcfa.gov/init/qa/q%26a7%2D29.pdf: Question 2a (September 11, 1997).

§102C(b) sets forth the types of benefits for which cost-sharing is specified under the FEHBP-equivalent Ã¬benchmarkÃ® package, but it does not specify these cost-sharing amounts. Interested purchasers may find these amounts in the Blue Cross and Blue Shield Service Benefit Plan authorized by the Federal Employees Health Benefits Program (http://www.opm.gov/insure). These amounts are not specified here because many are high in relation to the family income of SCHIP-eligible children. The FEHBP benefit package was designed for federal employees, not for families with incomes below percent of the federal poverty level whose children may qualify for SCHIP. Purchasers may wish to consider the potential effects of such cost-sharing on access by such children to needed services.

(a) Cost-Sharing Authorized ³¹ — Contractor may impose the cost-sharing amounts described in subsection (b) with respect to an enrolled child only to the extent authorized under §101C(c).

(b) Cost-Sharing Amounts — The cost-sharing amounts described in this subsection are, with respect to:

(1) Inpatient hospital benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b):

(A) Participating hospital admissions require a [$ ] per admission deductible;

(B) Non-participating hospital admissions require a [$ ] per admission deductible;

(C) In-hospital physician care requires a [$ ] calendar year deductible; and

(i) for PPO/Preferred physicians, [ %] of the Preferred Provider Allowance (PPA); ³²

(ii) for participating physicians, [ %] of the Participating Provider Allowance (PAR); and ³³

(iii) for non-participating physicians, the difference between Contractor's payment and the physician's actual charge.

(2) Surgical benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b):

(A) In-hospital physician care requires a [$ ] calendar year deductible, and

(i) for PPO/Preferred physicians, [ ] of the PPA;

(ii) for participating physicians, [ %] of the PAR; and

(iii) for non-participating physicians, the difference between Contractor's payment and the physician's actual charge.

(3) Maternity benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b):

(A) Participating hospital admissions require a [$ ] per admission deductible;

(B) Non-participating hospital admissions require a [$ ] per admission deductible;

(C) Professional care billed by a physician or nurse midwife requires a [$ ] calendar year deductible, and

(i) for participating physicians/nurse midwives, [ ] of the PAR; and

(ii) for non-participating and PPO/preferred physicians/nurse midwives, the difference between Contractor's payment and the physician's actual charge.

(4) Mental conditions/substance abuse benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b):

(A) for PPO/preferred hospitals, hospital care requires a [$ ] per day copayment;

(B) for participating hospitals, hospital care requires a [$ ] per day copayment;

(C) for non-participating hospitals, hospital care requires a [$ ] per day copayment;

(D) Inpatient admissions require a [$ ] calendar year deductible;

(E) Outpatient facility care requires a [$ ] calendar year deductible; and

(i) [$ ] for PPO/preferred facilities;

(ii) [$ ] for participating facilities;

(iii) [$ ] for non-participating facilities; and

(F) Professional care requires a [$ ] calendar year deductible, and
[% ] of the allowable charges.

(5) Other medical benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b):

(A) Outpatient care requires a [$ ] calendar year deductible; and

(i) [$ ] for PPO/preferred facilities;

(ii) [$ ] for participating facilities; and

(iii) [$ ] for non-participating facilities.

(6) Prescription drug benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b):

(A) Prescription drug benefits from PPO/preferred retail pharmacies require a [$ ] deductible, and [ %] of the PPA;

(B) Prescription drug benefits from non-preferred retail pharmacies require a [$ ] deductible, and [ ] of the billed charge; and

(C) Prescription drug benefits by mail require a [$ ] copayment.

(7) Dental benefits, to the extent not excluded from cost-sharing as well-baby or well-child care under §101C(b), require [ ].

Part 2

Enrollment and Disenrollment Procedures

§201. Enrollment In General
§202. Duties Related to Children Receiving Treatment at the Time of Enrollment
§203. Disenrollment In General
§204. Duties Related to Children Receiving Treatment at the Time of Disenrollment
§205. Duties Related to Children Not Receiving Treatment at Time of Involuntary Disenrollment

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 on enrollment and disenrollment procedures is for your consideration

^K§201. Enrollment In General

(a) Children Receiving Treatment at the Time of Enrollment — Contractor shall comply with the requirements of §202.

(b) Newborns — A child born to a woman who is enrolled with Contractor and who is eligible for [drafter insert name of State's SCHIP program] shall be screened by Purchaser and temporarily enrolled under [drafter insert name of purchasing document] from the time of birth until:

(1) Purchaser has notified Contractor that the child is ineligible for [drafter insert name of State's SCHIP program]; or

(2) the child has been disenrolled by child's family or caregiver.

^K§202. Duties Related to Children Receiving Treatment at the Time of Enrollment

Commentary: The following illustrative language addresses the Contractor's duties related to children receiving treatment at the time of enrollment. The duties will have implications both for the children and for other state agencies with program responsibilities for those children. The provisions set forth policy options Purchasers may want to consider in addressing the on-going treatment needs of an enrolled child as he/she enters into a managed care plan. For example, the Contractor may continue to furnish the items and services under the original treatment plan, or may undertake an alternate treatment based on a medical evaluation by a network provider. Purchasers may wish to consider adjusting their premium payments to reflect additional costs if the Contractor implements the original treatment plan.

(a) Children with Certain Reportable Diseases — In the case of an enrolled child with respect to whom [drafter insert name of state or local public health agency or agencies with jurisdiction] has issued a treatment plan with respect to [drafter insert names of relevant reportable diseases] under [drafter insert reference to applicable state law], Contractor shall, upon the child's enrollment: ³⁴

(1) cover and furnish, or arrange for the furnishing of, the items and services that are specified in the treatment plan (whether or not such items and services are covered under §102(a) of Part 1) until:

(A) the enrolled child's primary care provider has:

(i) fully implemented the treatment plan; or

(ii) on the basis of a medical evaluation, undertaken an alternate treatment for the disease that is set forth in writing in the enrolled child's medical record;

(2) notify the agency that issued the treatment plan, in such form and manner as the agency shall specify under [drafter insert reference to memorandum of agreement implementing §702(d) of Part 7], of Contractor's progress in implementing the treatment plan (or alternate course of treatment undertaken by the enrolled child's primary care provider) and the status of the enrolled child's disease.

(b) Children Receiving Treatment for Other Conditions — In the case of a child (including an adolescent) who is not described in subsection (a) and who at the time of enrollment is under treatment for any physical or mental illness, condition, or disability, Contractor shall continue to furnish to the child items and services covered under §102(a) of Part 1 which are being furnished as part of the child's treatment unless:

(1) a provider participating in Contractor's provider network who has assumed responsibility for care of the enrolled child has, on the basis of a medical evaluation of the child, determined in accordance with §§101A and 102A in Part 1A that an item or service is no longer medically necessary; and

(2) Purchaser concurs in the providers determination under paragraph (1) (which is sought from Purchaser by the child or the child's family or caregiver).

^K§203. Disenrollment In General

Commentary: The following illustrative language assumes that in states in which a child's eligibility for SCHIP depends upon the payment of a monthly premium, the premium must be paid directly to the state rather than to the MCO. However, if the premium must be paid to the MCO directly, failure to pay the premium would be a permissible ground for disenrollment of the child by the MCO.

(a) Permissible Grounds for Disenrollment at Request of Contractor — Contractor may request that Purchaser disenroll an enrolled child eligible under [drafter insert name of State's SCHIP program] only if:

(1) Purchaser has notified Contractor that the child is no longer eligible for [drafter insert name of State's SCHIP program]; and

(2) the enrolled child has elected to disenroll for cause under subsection (b).

(b) Enrolled Child's Right to Disenroll for Cause ³⁵ — Upon request by an enrolled child (or a request by the child's family or caregiver with respect to the child), Contractor agrees that Purchaser has the authority and responsibility to disenroll the child under the circumstances enumerated in:

(1) §401(d) (relating to inaccurate provider information); or

(2) §401(e) (relating to no appropriate provider).

(c) Disenrollment Due to Loss of Eligibility ³⁶ — Contractor agrees that if an enrolled child is no longer eligible for [drafter insert name of State's SCHIP program]:

(1) Purchaser has the authority and responsibility to terminate the enrollment of the child under [drafter insert name of purchasing document]; and

(2) in the event of disenrollment, Contractor shall comply with the requirements of §204(b).

(d) Disenrollment Without Cause — Contractor agrees that Purchaser has the authority and responsibililty to disenroll an enrolled child (including an adolescent) without cause under the circumstances enumerated in:

(1) §1201(a)(3)(A) of Part 12 (relating to Contractor noncompliance); and

(2) §1201(b) of Part 12 (relating to termination of [drafter insert name of purchasing document]).

^K§204. Duties Related to Children Receiving Treatment at the Time of Disenrollment

Commentary: The following illustrative language addresses situations in which children are receiving acute care services at the time of disenrollment for a time-limited course of treatment. It is not intended to impose a duty on Contractors to continue the provision of services to disenrolled children with chronic care needs. Purchasers considering this language may also wish to consider adjusting their premium payments to reflect additional costs which Contractors may incur in complying with these duties.

(a) Children Receiving Treatment at the Time of Voluntary Disenrollment — In the case of an enrolled child (including an adolescent) who, at the time of disenrollment for any reason other than the loss of eligibility for [drafter insert name of state's SCHIP program], is under treatment for a particular diagnosis or condition, Contractor shall: ³⁷

(1) continue to cover and furnish, or arrange for the furnishing of, the acute care items or services in connection with such treatment until the earlier of the date on which:

(A) the child is enrolled in a successor managed care plan;

(B) Contractor has received notice from Purchaser that a fee-for-service provider has assumed responsibility for the treatment of the child; or

(C) the child's treatment has been completed;

(2) arrange at Contractor's expense for the transfer of the child's medical records to the successor managed care plan or provider assuming responsibility for care of the child within [ ] days of request by:

(A) the child's family or caregiver; or

(B) the successor managed care plan or provider; and

(3) ensure that providers participating in Contractor's provider network who were furnishing care to the child at the time of disenrollment are:

(A) notified of the child's disenrollment within [ ] days of the disenrollment; and

(B) available for review of the child's treatment with the successor managed care plan or provider assuming responsibility.

(b) Children Receiving Treatment at the Time of Involuntary Disenrollment — In the case of an enrolled child who is involuntarily disenrolled from Contractor under [drafter insert name of purchasing document] because of the loss of eligibility for [drafter insert name of state's SCHIP program] and who, at the time of involuntary disenrollment, is under treatment, Contractor shall:

(1) ensure completion of the treatment; ³⁸ and

(2) arrange (at Contractor's expense) for the transfer of the child's medical records to the successor managed care plan or provider assuming responsibility for care of the child within [ ] days of request by the child's family or caregiver or successor managed care plan or provider.

^K§205. Duty Related to Children Not Receiving Treatment at Time of Involuntary Disenrollment

(a) Basic Duty — In the case of an enrolled child who is involuntarily disenrolled from Contractor under [drafter insert name of purchasing document] because of the loss of eligibility for [drafter insert name of state's SCHIP program] and who, at the time of involuntary disenrollment, is not under treatment, Contractor shall arrange at Contractor's expense for the transfer of the child's medical records to the successor managed care plan or provider assuming responsibility for care of the child within [ ] days of request by:

(1) the child's family or caregiver; or

(2) the successor managed care plan or provider.

Compliance measure: Contractor shall make available to Purchaser upon request:

(1) copies of all information furnished to network providers regarding responsibilities with respect to the treatment of newly enrolled and disenrolled children; and
(2) the names of children for whom records have been transferred following disenrollment, as well as the name of the successor managed care plan or provider receiving such records.

Part 3

Information for New and Potential Enrolled Children

§301. Information to Potential Enrolled Children
§302. Information to New Enrolled Children
§303. Information to Enrolled Adolescents
§304. Provider Directory
§305. Enrollment Card

^K§301. Information to Potential Enrolled Children

(a) In General — Contractor shall provide to a potential enrolled child (including an adolescent) on whose behalf information is requested the following written information:

(1) Items and Services — A description of:

(A) all items and services covered under §102(a) of Part 1; and

(B) all items and services excluded from coverage under §102(b) of Part 1; ³⁹

(2) Items and Services Subject to Prior Authorization — An enumeration of:

(A) each covered item and service for which prior authorization is required under §103A(c) of Part 1A; and

(B) each covered item and service for which prior authorization is not required under §103A(d) of Part 1A;

(3) Provider Directory — The manner in which an enrolled child (or the child's family or caregiver) may obtain, without charge, a copy of Contractor's provider directory described in §304.

(4) Provider Selection — Procedures for selecting a primary care provider (including the right to designate a pediatric specialist as a primary care provider) and a dental care provider under Part 4;

(5) Access to Specialists — Procedures for obtaining direct access to pediatric specialists under §503 of Part 5;

(6) Self-Referrals — Information on self-referral rights for certain services under §104A of Part 1A;

(7) Complaints and Grievances — A description of Contractor's complaint and grievance process under §1005 and 1006 of Part 10;

(8) Physician Incentive Plans — A description of any physician incentive plans applicable to providers participating in Contractor's provider network that directly or indirectly affect a provider's compensation with respect to the treatment of an enrolled child; and

(9) Enrollee Rights and Responsibilities — A description of:

(i) enrollee rights not otherwise described in paragraphs (1) - (8); and

(ii) enrollee responsibilities under managed care, including the circumstances under which an enrolled child may obtain covered services through Contractor's provider network or outside of Contractor's provider network.

(b) Prior Purchaser Approval — Prior to distributing any information described in subsection (a) to any potential enrolled child, Contractor shall obtain the written approval of such information from Purchaser.

^K§302. Information to New Enrolled Children

(a) Comprehensive Information

(1) At Time of Enrollment — Within [ ] days of being notified by Purchaser of a child's enrollment, Contractor shall mail a written enrollee handbook ⁴⁰ which complies with subsections (b) and (c) to the family or caregiver of the enrolled child (including an adolescent); and

(2) On Request — Contractor shall upon request by the enrolled child (including an adolescent) or the child's family or caregiver:

(A) make the written enrollee handbook available at its administrative offices; and

(B) make the health education information described in subsection (f) available at the practice sites of primary care providers participating in Contractor's provider network.

(b) Understandability — Contractor shall ensure that the enrollee handbook required under subsection (a) and the health education information required under subsection (f) are written:

(1) in a manner and format which may be easily understood by an enrolled child's (or potential enrolled child's) family or caregiver;

(2) at the [ ]th grade level; and

(3) in each language which is spoken as a primary language by at least [ ] of Contractor's enrollees.

(1) Items and Services — A description of:

(A) items and services covered under §102(a) of Part 1; and

(B) all items and services excluded from coverage under §102(b) of Part 1;

(2) Cost-Sharing — A description of:

(A) the cost-sharing requirements authorized under Part 1C and the items and services to which such cost-sharing requirements apply;

(B) the exclusion of Well-Baby and Well-Child care from cost-sharing under §101C(b) of Part 1C;

(C) the maximum amount of cost-sharing allowed to be imposed by a provider on an enrolled child under §101C(c) of Part 1C;

(D) the prohibition on balance billing of an enrolled child by a provider under §101C(d) of Part 1C; and

(E) the prohibition on the denial or withholding of care from an enrolled child by a provider under §101C(e) of Part 1C; ⁴¹

(3) Coverage Determination Standards and Procedures — An explanation of Contractor's coverage determination standards and procedures under §§101A and 102A of Part 1A;

(4) Emergency Services — A description of emergency services (as defined in §1401(k)) covered under [drafter insert name of purchasing document], and the procedures that an enrolled child and the child's family or caregiver should follow in the event of an emergency (including a 24-hour toll-free telephone number);

(5) Items and Services Subject to Prior Authorization — An enumeration of:

(A) each covered item and service for which prior authorization is required under §103A(c)of Part 1A;

(B) each covered item and service for which prior authorization is not required under §103A(d) of Part 1A; and

(C) the procedure (including the 24-hour toll-free telephone number) by which an enrolled child and the child's family or caregiver may request prior authorization as required under §103A(b)(3);

(6) Provider Directory — The manner in which an enrolled child (and the child's family or caregiver) may obtain, without charge, a copy of Contractor's provider directory described in §304.

(7) Provider Selection — Procedures for selecting a primary care provider (including the right to designate a pediatric specialist as a primary care provider) and dental care provider under Part 4;

(8) Access to Specialists — Procedures for obtaining direct access to pediatric specialists under §503 of Part 5;

(9) Self-Referrals — Information on self-referral rights for certain services under §104A of Part 1A;

(10) Transportation — A description of transportation services covered under §102(a) of Part 1 and the procedures that an enrolled child and the child's family or caregiver should follow in obtaining such services;

(11) Service Waiting Times — Information on the requirements of §603 of Part 6 relating to waiting times for items and services with respect to emergency medical conditions, urgent medical conditions, and all other illnesses or conditions;

(12) Interpreters — A description of professional interpreter services available under §506(b)(2) of Part 5 with respect to clinical encounters and the manner in which the enrolled child and the child's family or caregiver may obtain such services;

(13) Disenrollment — A description of the circumstances under which an enrolled child may disenroll under Part 2;

(14) Complaints and Grievances — A description of Contractor's grievance and appeals process under §§1005 and 1006 of Part 10;

(15) Confidentiality — A description of the confidentiality protections for an enrolled child under §1002 of Part 10;

(16) Liability Protections — A description of the liability protections for an enrolled child and the enrolled child's family or caregiver under §1003 of Part 10;

(17) Physician Incentive Plans — A description of any physician incentive plans applicable to providers participating in Contractor's provider network that directly or indirectly affect a provider's compensation with respect to the treatment of an enrolled child; and

(18) Enrollee Rights and Responsibilities — A description of:

(i) enrollee rights not otherwise enumerated in paragraphs (1) - (17) that are set forth in [drafter insert reference to patient protections provisions in state managed care law]; and

(ii) enrollee responsibilities under managed care, including the circumstances under which an enrolled child may obtain covered services through Contractor's provider network or outside of Contractor's provider network.

(d) Periodic Update — Contractor shall ensure at least [ ] that the contents of the enrollee handbook enumerated in subsection (c) are current.

(e) Prior Purchaser Approval — Prior to distributing any enrollee handbook (or periodic update thereof) to any enrolled child, Contractor shall obtain the written approval of such handbook (or periodic update thereof) from Purchaser.

(f) Health Education Information ⁴² — Consistent with subsection (a)(2)(B), Contractor shall ensure that health education information is made available at the practice sites of primary care providers participating in Contractor's provider network to an enrolled child (including an adolescent) and to the child's family or caregiver with respect to the following priority illnesses or conditions:

(1) SIDS — Information on Sudden Infant Death Syndrome and Other Sudden and Unexpected Infant Death and strategies for reducing the risk of infant death;

(2) HIV/AIDS — Information on the risk factors associated with the transmission of Human Immunodeficiency Virus, reducing the risk of transmission, including perinatal transmission, the availability of HIV testing and prevention services, and treatments for HIV and Acquired Immune Deficiency Syndrome;

(3) Injury Prevention — Information on the types of injuries that most frequently affect children and adolescents, the risk factors associated with such injuries, and strategies for reducing the risk of injuries; and

(4) [drafter insert reference to other illnesses and conditions that represent priority to State public health department].

^K§303. Information to Enrolled Adolescents ⁴³

(a) Enrolled Adolescent Pamphlet — Contractor shall provide to each enrolled adolescent and to each enrolled child on the child's 11th ⁴⁴ birthday a pamphlet that meets the understandability requirements of §302(b) that includes the following information:

(1) Confidentiality — a description of the confidentiality protections for an enrolled adolescent under §1002(b) of Part 10;

(2) Adolescent Health Providers — the identity, location, qualifications, and availability of each provider participating in Contractor's provider network with an expertise in the care of adolescents;

(3) Self-Referrals — a description of an enrolled adolescent's right to self-refer for certain services under §104A of Part 1A;

(4) Emergency Services

(A) a description of emergency services (as defined in §1401(k)) covered under [drafter insert name of purchasing document]; and

(B) the procedures that an enrolled adolescent should follow in the event of an emergency (including a 24-hour toll-free telephone number);

(5) Treatment for Abuse — a description of the services available to abused enrolled adolescents, including the right to examination for physical or sexual abuse without prior authorization under §103A(d)(12); and

(6) Minor Consent Laws — a description (furnished to Contractor by Purchaser) of the State's minor consent laws.

^K§304. Provider Directory

(a) In General — Contractor shall, upon request, make available to each potential or new enrolled child (and the child's family or caregiver) without charge, on a [ ] basis, an accurate written list of all providers (as defined in §014 of the Overview) participating in Contractor's provider network under Part 5 that specifies:

(1) Identity

(A) the name, mailing address and telephone number (including the 24-hour emergency telephone number) of each provider; and

(B) in the case of a physician or other health professional who practices at a location that is a federally qualified health center, or rural health clinic, the information described in subparagraph (A) and the name of the center or clinic (or the name by which it is known in the community) at which the physician or professional practices;

(2) Location

(A) the location of each practice site of each provider; and

(B) the bus or subway routes through Contractor's service area;

(3) Qualifications

(A) specialty and board certification of each provider; and

(B) languages other than English in which the provider is fluent;

(4) Availability ⁴⁵

(A) the hours that each provider is actually available at the provider's practice site; and

(B) accommodations made by each provider for an enrolled child with special health care needs in accordance with §505 of Part 5.

^K§305. Enrollment Card

(a) Enrolled Child — Within [ ] days of being notified by Purchaser of a child's enrollment, Contractor shall issue to the child and the child's family or caregiver an enrollment card that contains Contractor's name and a 24-hour toll-free telephone number for use in the event of an emergency. ⁴⁶

Compliance measure: Contractor shall make available to Purchaser on request all handbooks, pamphlets, provider lists and other written information given to potential and newly enrolled children and the child's family or caregiver.

Part 4

Provider Selection and Assignment

§401. Selection of Primary Care Provider
§402. Pediatric Specialists as Primary Care Providers for Children with Special Health Care Needs
§403. Assignment of Non-Selecting Enrolled Children and Reassignment
§404. Selection of, or Assignment to, Dental Care Provider
§405. Information on Primary Care Providers, Pediatric Specialists, and Dental Care Providers

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 on provider selection and assignment is for your consideration.

^K§401. Selection of Primary Care Provider

Commentary: There are two basic approaches to beneficiary choice of primary care provider in managed care arrangements. The more common is to offer the beneficiary a choice between two or more MCOs and, once enrolled in an MCO, a choice among primary care providers. This approach is reflected in §401(b). The other approach, reflected in §401(a), is to offer the beneficiary a choice among primary care providers and, once that selection has been made, to assign the beneficiary to an MCO based on its affiliation with the provider.

(a) Duty to Allow Selection Prior to Enrollment — Contractor shall permit the family or caregiver of a child (including an adolescent) who is eligible to enroll under [drafter insert name of purchasing document] to select a primary care provider (as defined in §1401(t)) from among the primary care providers participating in Contractor's provider network and shall honor the selection unless a condition under subsection (f) applies.

(b) Duty to Allow Selection on or after Enrollment — Contractor shall permit the family or caregiver of a child (including an adolescent) who has enrolled under [drafter insert name of purchasing document] to select a primary care provider (as defined in §1401(t)) from among the primary care providers participating in Contractor's provider network and shall honor the selection unless a condition under subsection (f) applies.

(1) In General — Contractor shall permit the family or caregiver of an enrolled child (including an adolescent) to select a primary care provider for the child no less frequently than once every [ ] months after the most recent date of enrollment and shall honor the selection unless a condition under subsection (f) applies.

(2) Special Rule for Foster Care Children — In the case of a child in foster care or other out-of-home placement, Contractor shall comply with the duty described in paragraph (1) and allow the child (or the foster family or [drafter insert name of child welfare agency on behalf of the child]) to select a primary care provider whenever there is a change in the child's foster residence or other out-of-home placement.

(d) Inaccurate Provider Information — If Contractor fails to comply with the requirements of §§301(a)(3) and 302(c)(6) of Part 3 relating to accurate, current information regarding participation of providers in Contractor's provider network, and if the family or caregiver of an enrolled child, or if an enrolled adolescent, relies upon such information when enrolling with the Contractor, Contractor shall:

(1) in the case of an enrolled child, permit the child's family or
caregiver to disenroll the child for cause; and

(2) in the case of an enrolled adolescent, permit the adolescent to disenroll for cause.

(e) No Appropriate Provider — In the case of an enrolled child (including an adolescent) who has not (or on whose behalf the family or caregiver have not) been able to select a primary care provider because a condition under subsection (f) applies, Contractor shall:

(1) in the case of an enrolled child, permit the child's family or
caregiver to:

(A) select a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under §102(a) of Part 1 in at least the same amounts and on terms at least as favorable as apply to primary care providers participating in Contractor's provider network;

(B) disenroll the child for cause and enroll the child in another managed care plan that has entered into a purchasing agreement with Purchaser if the primary care provider:

(i) participates in the provider network of the managed care plan; and

(ii) has the capacity to continue to serve as the child's primary care provider; and

(2) in the case of an enrolled adolescent, permit the adolescent to:

(A) select a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under §102(a) of Part 1 in at least the same amounts and on terms at least as favorable as apply to primary care providers participating in Contractor's network;

(B) disenroll for cause and enroll in another managed care plan that has entered into a purchasing agreement with Purchaser if the primary care provider:

(i) participates in the provider network of the managed care plan; and

(ii) has the capacity to continue to serve as the adolescent's primary care provider. ⁴⁷

(f) Conditions —Contractor shall be required to honor the selection of a primary care provider under subsections (a), (b), (c), or of a dental care provider under §404 unless:

(1) the provider is no longer participating in Contractor's provider network; or

(2) the provider has timely notified Contractor as required under §502(c)(8) and §503(c)(4) of Part 5 that the provider is unable to accept any additional enrolled children as patients because the provider no longer has the capacity to accept any additional children as patients.

Compliance measure: Contractor shall make available to Purchaser on request:

(1) the number of enrolled children whose families or caregivers select a primary care provider over most recent [ ] month period; and
(2) the number of enrolled children who disenroll under this Part.

^K§402. Pediatric Specialists as Primary Care Providers for Children with Special Health Care Needs ⁴⁸

(a) Children with Special Health Care Needs — In the case of an enrolled child with special health care needs (as defined in §1401(e)), Contractor shall offer the family or caregiver of such enrolled child (or in the case of an adolescent, the adolescent), the option of designating as the child's primary care provider either:

(1) a primary care provider (as defined in §1401(t)) participating in Contractor's provider network who is willing and has the capacity to assume primary care provider responsibilities for the child; or

(2) a pediatric specialist (as defined in §1401(r)) participating in Contractor's provider network who is willing and has the capacity to assume primary care provider responsibilities under §502(c).

Compliance measure: Contractor shall make available to Purchaser on request a list (contained in the Contractor's member handbook under §302(c) or otherwise made available to enrolled children) of all pediatric specialists participating in the Contractor's provider network who have agreed to serve as primary care providers for children with special health care needs.

^K§403. Assignment of Non-Selecting Children and Reassignment

(a) In General — In the event that the family or caregiver of an enrolled child (including an adolescent) who is not described in subsection (c), (d), or (e) fails to indicate a choice of primary care provider within [ ] days of enrollment, Contractor shall assign the enrolled child to:

(1) a primary care provider participating in Contractor's provider network from whom the child has received care within the previous [ ] months; or

(2) in the case of a child to whom paragraph (1) does not apply, to a primary care provider participating in Contractor's provider network in accordance with the following criteria:

(A) the travel time (using public transportation) 49 between the child's place of residence and the provider's practice site; and

(B) any special health care needs of the enrolled child and the qualifications of the provider to serve such needs. 50

(b) Involuntary Reassignment of an Enrolled Child to a Primary Care Provider

(1) Grounds for Involuntary Reassignment — In the case of an enrolled child who selected a primary care provider under §401, or who has been assigned to a primary care provider under subsection (a), Contractor may reassign the child to another primary care provider only if:

(A) the child or the child's family or caregiver has requested reassignment to a different primary care provider;

(B) the child's primary care provider:

(i) reduces the number of enrolled children the provider accepts as patients; or

(ii) no longer participates in Contractor's provider network; or

(C) the child's current primary care provider certifies in the child's medical record that reassignment of the child to another primary care provider will not:

(i) compromise the treatment of the child's health care needs, including access to covered prescription drugs; or

(ii) disrupt the child's access to pediatric specialists.

(2) Notification — Contractor shall not involuntarily reassign an enrolled child under paragraph (1) unless Contractor has notified the child (and the child's family or caregiver) in writing at least [ ] weeks prior to the effective date of the reassignment of:

(A) the effective date of the child's reassignment to a different primary care provider; and

(B) the name, mailing address, phone number, practice site, practice hours, and the bus or subway line serving the practice site.

(1) Assignment — In the event that the family or caregiver of an enrolled child (including an adolescent) who is in a migratory or seasonal agricultural worker family (as defined in §1401(q) and (x)) does not select a primary care provider within [ ] days of enrollment, Contractor shall make its best efforts to assign such child to a provider participating in Contractor's provider network with experience in providing health care to such children and families or caregivers.

(2) Out-of-Network — If Contractor is unable to assign the child to a provider as required under paragraph (1), Contractor shall permit the family or caregiver of the child to select for the child a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under §102(a) of Part 1 in at least the same amounts and on terms at least as favorable as apply to a primary care provider participating in Contractor's provider network. 51

(d) Children in Homeless Families ⁵²

(1) Assignment — In the event that the family or caregiver of an enrolled child (including an adolescent) who is in a homeless family (as defined in §1401(m)) does not select a primary care provider within [ ] days of enrollment, Contractor shall make its best efforts to assign such child to a provider participating in Contractor's provider network with experience in providing health care to such children and families or caregivers.

(2) Out-of-Network Provider — If Contractor is unable to assign the child to a provider as required under paragraph (1), Contractor shall permit the family or caregiver of the child to select for the child a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under §102(a) of Part 1 in at least the same amounts and on terms at least as favorable as apply to a primary care provider participating in Contractor's provider network.

(e) Children in Foster Care ⁵³

(1) Assignment — In the event that a child in foster care or other out-of-home placement (or a foster care parent or [drafter insert name of child welfare agency on behalf of such child]) does not select a primary care provider within [ ] days of enrollment, Contractor shall make its best efforts to assign such child to a provider participating in Contractor's provider network with experience in providing health care to such children and families or caregivers.

(2) Out-of-Network Provider — If Contractor is unable to assign the child to a provider as required under paragraph (1), Contractor shall permit the family or caregiver of the child to select for the child a primary care provider who does not participate in Contractor's provider network and reimburse the provider for items and services covered under §102(a) of Part 1 in at least the same amounts and on terms at least as favorable as apply to a primary care provider participating in Contractor's provider network.

Compliance measure: Contractor shall make available to Purchaser on request:

(1) the procedures and criteria used to assign enrolled children whose families or caregivers do not select primary care providers on their behalf;
(2) the number of enrolled children who are assigned by Contractor to a primary care provider due to non-selection over the most recent [ ] month period;
(3) the names of the primary care providers to whom non-selecting children are assigned by Contractor and the number of children so assigned over the most recent [ ] month period; and
(4) the names of providers, with experience in providing health care to children in migratory and seasonal agricultural worker families, homeless children, and children in foster care or other out-of-home placements, participating in Contractor's provider network who are willing and have the capacity to assume primary care responsibilities for such children.

Medicaid Contract Purchasing Specifications

Part 1

Items and Service

§101. In General

§102. Scope of Benefit (FEHBP Option)

Part 1A

Coverage Determination Standards and Procedures ⁸

Table of Contents

§101A. Coverage Determination Standards
§102A. Coverage Determination Procedures
§103A. Prior Authorization
§104A. Self-Referral for Certain Services without Prior Authorization
§105A. Prior Purchaser Approval

Part 1B

Delivery of Covered Items and Services

Table of Contents

Part 1C

Authorized Cost-Sharing

Part 2

Enrollment and Disenrollment Procedures

Table of Contents

Part 3

Information for New and Potential Enrolled Children

Table of Contents

§301. Information to Potential Enrolled Children
§302. Information to New Enrolled Children
§303. Information to Enrolled Adolescents
§304. Provider Directory
§305. Enrollment Card

Part 4

Provider Selection and Assignment

Table of Contents

Medicaid Contract Purchasing Specifications

Part 1

Items and Service

§101. In General

§102. Scope of Benefit (FEHBP Option)

Part 1A

Coverage Determination Standards and Procedures 8

Table of Contents

§101A. Coverage Determination Standards §102A. Coverage Determination Procedures §103A. Prior Authorization §104A. Self-Referral for Certain Services without Prior Authorization §105A. Prior Purchaser Approval

Part 1B

Delivery of Covered Items and Services

Table of Contents

Part 1C

Authorized Cost-Sharing

Part 2

Enrollment and Disenrollment Procedures

Table of Contents

Part 3

Information for New and Potential Enrolled Children

Table of Contents

§301. Information to Potential Enrolled Children §302. Information to New Enrolled Children §303. Information to Enrolled Adolescents §304. Provider Directory §305. Enrollment Card

Part 4

Provider Selection and Assignment

Table of Contents

Coverage Determination Standards and Procedures ⁸

§101A. Coverage Determination Standards
§102A. Coverage Determination Procedures
§103A. Prior Authorization
§104A. Self-Referral for Certain Services without Prior Authorization
§105A. Prior Purchaser Approval

§301. Information to Potential Enrolled Children
§302. Information to New Enrolled Children
§303. Information to Enrolled Adolescents
§304. Provider Directory
§305. Enrollment Card