Medicaid Contract Purchasing Specifications
Part 7 - Part 8 - Part
9 - Part 10
Part 11 - Part 12 - Part
13 - Part 14
Part 7
Relationships with Other State
and Local Agencies 1
Table of Contents
§701. In General
§702. Relationships with State and Local
Public Health Agencies
§703. Relationships with State Title
V Agency
§704. Relationships with State WIC Agency
§705. Relationships with State Medicaid
Agency
§706. Relationships with State and Local
Education and Part C Lead Agencies
§707. Relationships with State Child
Welfare Agency
§708. Relationships with State Developmental
Disabilities Agency
§709. Relationships with State Mental
Health and Substance Abuse Agency
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 relationships with other agencies
and programs is for your consideration.
K§701. In
General 2
Commentary: The state and local agencies referenced in this Part
will generally not be parties to a contract between a State SCHIP Agency
and an MCO. These agencies may, however, have formal legal relationships
with the State SCHIP Agency that bear on the provision of health care
services to SCHIP-eligible children. One option that a State SCHIP Agency
may wish to explore is to impose a duty on the MCOs with which it contracts
to cooperate with one or more of these other state and local agencies
in achieving common program goals. Of course, these state and local agencies
are under no legal duty to cooperate with contracting MCOs, and these
purchasing specifications do not impose such an obligation. See also SCHIP
and Its Meaning for Public Health, a report by the American Public Heath
Association, January 1999 (www.apha.org/ppp/schip/SCHIP.pdf).
This report summarizes issues relating to the integration of SCHIP with
public health and related services.
(a) Relationships with Other State and Local Agencies
— Contractor shall comply with the requirements of:
(1) §702 regarding relationships with State
and Local Public Health Agencies;
(2) §703 regarding relationships with the State
Title V Agency;
(3) §704 regarding relationships with the State
WIC Agency;
(4) §705 regarding relationships with the State
Medicaid Agency;
(5) §706 regarding relationships with State
and Local Education and Part C Lead Agencies;
(6) §707 regarding relationships with the State
Child Welfare Agency;
(7) §708 regarding relationships with the State
Developmental Disabilities Agency; and
(8) §709 regarding relationships with the State
Mental Health and Substance Abuse Agency. 3
(b) Exchange of Information with Other State and Local Agencies
(1) Liaison — Contractor shall designate individual(s)
to act as a liaison with the agencies enumerated in subsection (a) and
[drafter insert names of other public agencies or programs that provide
health or other services to enrolled children] for the purpose of responding
to requests for information enumerated in paragraph (2).
(2) Information to Requesting Agencies to Facilitate Qualification
for Public Benefits
(A) If an agency enumerated in paragraph (1) requests individual
medical information regarding an enrolled child, Contractor shall,
without charge to [drafter insert name of the requesting agency],
provide the requested information to the agency if the conditions
of subparagraph (B) are met.
(B) The conditions of this subparagraph are:
(i) [drafter insert name of the requesting agency] is authorized
by the family or caregiver of an enrolled child (or in the case
of an adolescent, the enrolled adolescent) to obtain individual
medical information concerning the enrolled child or adolescent;
and
(ii) the information requested is required in order for the child
to apply for assistance or benefits under a public program.
(3) Information to Requesting Agencies on Access to Covered Items and
Services — Contractor shall, upon request, provide information
to the agencies enumerated in paragraph (1) regarding:
(A) the scope of items and services covered under §102(a)
of Part 1 furnished by Contractor
to an enrolled child under [drafter insert name of purchasing document];
(B) the identity of providers participating in Contractor's provider's
network; and
(C) the manner in which the agency may on behalf of an enrolled child
request the furnishing of items or services covered under §102(a)
of Part 1 to the child, including
medical evaluations or assessments necessary to enable the child to
apply for benefits or assistance under a public program.
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K§702. Relationships
with State and Local Public Health Agencies
Commentary: The following illustrative language assumes that the
state agency administering the SCHIP program is not the state health department.
If this assumption is incorrect, the language is inapplicable.
(a) Reporting of Reportable Information — Contractor
shall, consistent with the confidentiality requirements of subsection
(c), promptly report to [drafter insert name of the appropriate state
public health agency], in the form and manner required by such agency
under [drafter insert reference to applicable state law], information
regarding the incidence of the following reportable conditions or diseases:
(1) sexually transmitted diseases;
(2) tuberculosis;
(3) vaccine-preventable illnesses;
(4) metabolic or genetic conditions; and
(5) [drafter insert other conditions specified under state law].
(b) Cooperation with Case Surveillance and Prevention Responsibilities
— Contractor shall, consistent with the confidentiality requirements
of subsection (c), make available upon request to [drafter insert name
of the appropriate state public health agency] individual medical information
regarding an enrolled child that is necessary to enable the agency to
carry out its responsibilities for surveillance and prevention of reportable
diseases or disabling conditions under [drafter insert reference to state
law].
(c) Confidentiality — In providing reportable information with
respect to an enrolled child under subsection (a), or individual medical
information with respect to an enrolled child under subsection (b), Contractor
shall comply with the requirements relating to confidentiality enumerated
in §1002 of Part 10.
(d) Implementation of Treatment Plan — 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:
(1) cover and furnish, or arrange for the furnishing of, the items
and services that are specified in the treatment plan and are:
(A) enumerated under §102(a) of
Part 1; and
(B) covered under §101A of Part
1A (relating to standards for medical necessity and coverage);
4
(2) ensure that the enrolled child's primary care provider has:
(A) fully implemented the treatment plan; or
(B) 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; and
(3) notify the agency that issued the treatment plan, in such form
and manner as the agency shall specify, of:
(A) Contractor's progress in implementing the treatment plan (or
alternate treatment undertaken by the enrolled child's primary care
provider); and
(B) the status of the enrolled child's disease.
(e) Memorandum of Understanding with State or Local Health Agency
(1) In General — Contractor shall enter into a memorandum of
agreement with [drafter insert name of state or local public health
agency with jurisdiction over Contractor's service area] that is willing
to enter into such a memorandum, which shall have the same term as this
[drafter insert name of purchasing document], and which shall address
the matters enumerated in paragraph (2).
(2) Elements of Memorandum of Understanding — For illustrative
language, see Purchasing Specifications for Memorandum of Understanding
between MCOs and Public Health Agencies (forthcoming), www.gwhealthpolicy.org/.
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§102(a)
of Part 1 and enumerated in §102(b)
of Part 1; and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to children;
(B) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and payment for, items and services that:
(i) are not covered under §102(a)
of Part 1; and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to children;
(C) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for prompt identification
of enrolled children with special health care needs (as defined in
§1401(e)) or otherwise in need of medical
or remedial services;
(D) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for arrangements
for reciprocal referrals of enrolled children;
(E) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for exchange of
data and information relating to items and services furnished to enrolled
children; and
(F) The responsibility of Contractor and the responsibility of the
Agency for the designation of individuals responsible for coordinating
the implementation of the memorandum.
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K§704. Relationships with State
WIC Agency 5
(a) Cooperation with WIC — Contractor shall ensure that each provider
participating in Contractor's provider network cooperates with the [drafter
insert names of State and local agencies through which services are provided
to women, infants, and children under the WIC program under section 17
of the Child Nutrition Act of 1966, 42 U.S.C. §1786] in the implementation
of the WIC program with respect to enrolled children who are enrolled
in, or eligible for, the WIC program.
(b) Referral of Enrolled Children — Contractor shall comply the
requirements of §005(h) of
the Overview relating to referral of eligible or potentially eligible
enrolled children in WIC.
(c) Referral of Certain Disenrolled Children
(1) Duty to Refer — Contractor shall at the time
of disenrollment notify an enrolled child described in paragraph (2) (and
the child's family or caregiver) in writing of the availability of supplemental
food, nutrition education services from the [drafter insert name of local
WIC agency operating in area served by Contractor].
(2) Disenrolled Child — The duty described in
paragraph shall apply in the case of an enrolled child who has attained
age 1 but has not attained age 5, or who is pregnant, postpartum, or breastfeeding,
and whose enrollment is terminated due to ineligibility for [drafter insert
name of State SCHIP program].
(d) Nutritional Risk — Contractor shall ensure
that providers participating in Contractor's provider network respond
in a timely manner to a request from [drafter insert name of local WIC
agency] for the results of appropriate hematological tests, if any, performed
with respect to an enrolled child that are necessary for the determination
of whether the child is at nutritional risk (as defined in 7 C.F.R. §246.7(e))
for the purpose of establishing eligibility for WIC benefits.
(e) Memorandum of Understanding with State WIC Agency
— Contractor shall enter into a memorandum of understanding with
[drafter insert name of state WIC Agency] if the Agency is willing to
enter into such a memorandum, which shall:
(1) have the same term as [drafter insert name of purchasing document];
and
(2) which shall facilitate Contractor's performance of its duties under
subsection (c) with respect to the referral of enrolled children and disenrolled
children to local WIC agencies.
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K§705. Relationships with State
Medicaid Agency
Commentary: The following illustrative language assumes that the
state agency administering the SCHIP program is not the state Medicaid
agency. If this assumption is incorrect, the language is inapplicable.
(a) Memorandum of Understanding with State Medicaid Agency
(1) In General — Contractor shall enter into
a memorandum of understanding with [drafter insert name of State Medicaid
Agency] if the Agency is willing to enter into such a memorandum, which
shall have the same term as [drafter insert name of purchasing document],
and which shall address the matters enumerated in paragraph (2).
(2) Elements of Memorandum of Understanding Relating to Delivery
of Services — The memorandum of understanding described
in paragraph (1) shall enumerate the administrative and financial responsibilities
of the Agency under state law and of Contractor under [drafter insert
name of purchasing document] with respect to:
(A) an enrolled child who loses eligibility for coverage under [drafter
insert name of purchasing document] because the child has established
eligibility for benefits under the [drafter insert name of state Medicaid
program]; and
(B) a child entitled to benefits under [drafter insert name of state
Medicaid program] who is enrolled in a plan operated by Contractor
under a risk contract with [drafter insert name of state Medicaid
program] and who loses eligibility for Medicaid benefits and establishes
eligibility for coverage under [drafter insert name of state SCHIP
program].
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K§706. Relationships with State
and Local Education and Part C Lead Agencies
(a) Interagency Agreement — Contractor shall ensure that Contractor
and each provider participating in Contractor's provider network complies
with:
(1) [drafter insert the requirements, if any, applicable to Purchaser
under its interagency agreement with the State Education Agency under
Part B of the Individuals with Disabilities Education Act, 20 U.S.C.
§1412(a)(12), 34 C.F.R. §300.142(b) and (e), relating to furnishing
or paying for services]; and
(2) [drafter insert the requirements, if any, applicable to Purchaser
under its interagency agreement with the State Education Agency under
Part C of the Individuals with Disabilities Education Act, 20 U.S.C.
§1435(a)(10), relating to furnishing or paying for services].
(b) Memorandum of Understanding with State and Local Education Agency
or Part C Lead Agency
(1) In General — Contractor shall enter into a memorandum of
understanding with [drafter insert name of State Education Agency or
Part C Lead Agency] if the Agency is willing to enter into such a memorandum,
which shall have the same term as [drafter insert name of purchasing
document], and which shall address the matters enumerated in paragraph
(2).
(2) Elements of Memorandum of Understanding
(A) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and the payment for, items and services that:
(i) are covered under §102(a)
of Part 1 with respect to enrolled
children under IEPs (as defined in §1401(n))
or under IFSPs (as defined in §1401(o));
and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to children under IEPs
or IFSPs;
(B) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and the payment for, items and services that:
(i) are not covered under §102(a)
of Part 1 and enumerated in §102(b)
with respect to enrolled children under IEPs (as defined in §1401(n))
or under IFSPs (as defined in §1401(o));
and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to children with IEPs or
IFSPs;
(C) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for payment for
treatment of a member of the family of an enrolled child under an
IEP or and IFSP, or a caregiver of the child, who is not enrolled
under [drafter insert name of purchasing agreement], but who requires
treatment in order to effectively treat a condition or developmental
disability or delay of the child;
(D) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the identification
of enrolled children who may require an IEP or an IFSP;
(E) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for arrangements
for reciprocal referrals of enrolled children with IEPs or IFSPs;
(F) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the exchange
of data and information relating to items and services furnished to
enrolled children with IEPs and IFSPs; and
(G) The responsibility of Contractor and the responsibility of the
Agency for the designation of individuals responsible for coordinating
the implementation of the memorandum.
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K§707. Relationships with State
Child Welfare Agency
(a) Memorandum of Understanding with State Child Welfare Agency
(1) In General — Contractor shall enter into a memorandum of
understanding with [drafter insert name of State Child Welfare Agency]
if the Agency is willing to enter into such a memorandum, which shall
have the same term as [drafter insert name of purchasing document],
and which shall address the matters enumerated in paragraph (2).
(2) Elements of Memorandum of Understanding Relating to Delivery of
Services — The memorandum of understanding described in paragraph
(1) shall enumerate the administrative and financial responsibilities
of the Agency under state law and of Contractor under [drafter insert
name of purchasing document] with respect to:
(A) consistent with Part
2, the initial assessment of, and furnishing of items and services
covered under §102(a) of Part
1 to, a newly enrolled child under the jurisdiction of the Agency;
(B) consistent with Part
2, the furnishing of or the referral for, items and services required
by an enrolled child under the jurisdiction of the Agency that are
not covered under §102(a) of Part
1 and enumerated in §102(b)
of Part 1;
(C) consistent with §906 of Part
9, the collection and reporting of encounter data regarding the
furnishing of items and services covered under §102(a)
of Part 1 to enrolled children under
the jurisdiction of the Agency; and
(D) consistent with §§204
and 205 of Part
2, the continuity of the furnishing of needed items and services
upon the disenrollment of a child under the jurisdiction of the Agency;
and
(E) [drafter insert other issues identified by State Child Welfare
Agency].
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K§708. Relationships with State
Developmental Disabilities Agency
(a) Referral of Disenrolled Children — In the case of an enrolled
child with a disability whose enrollment is terminated due to ineligibility
for [drafter insert name of State SCHIP program], Contractor shall at
the time of disenrollment notify the child and the child's family or caregiver
in writing of the availability of health care services and care coordination
services from:
(1) [drafter insert name of state developmental disabilities agency];
or
(2) providers subcontracting with or funded by [drafter insert name
of State Developmental Disabilities Agency].
(b) Memorandum of Understanding with State Developmental Disability Agency
(1) In General — Contractor shall enter into a memorandum of
understanding with [drafter insert name of State Developmental Disabilities
Agency ] if the Agency is willing to enter into such a memorandum, which
shall have the same term as [drafter insert name of purchasing document],
and which shall address the matters enumerated in paragraph (2).
(2) Elements of Memorandum of Understanding
(A) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and the payment for, items and services that:
(i) are covered under §102(a) of
Part 1; and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to enrolled children;
(B) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and the payment for, items and services that:
(i) are not covered under §102(a)
of Part 1 and enumerated in §102(b);
and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to enrolled children;
(C) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for payment for
treatment of a member of the family of an enrolled child with special
health care needs (as defined in §1401(e)),
or a caregiver of the child, who is not enrolled under [drafter insert
name of purchasing agreement], but who requires treatment in order
to effectively treat a condition or developmental disability or delay
of the child;
(D) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the identification
of enrolled children with special health care needs;
(E) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the arrangements
for reciprocal referrals of enrolled children with special health
care needs;
(F) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the exchange
of data and information relating to items and services furnished to
enrolled children who receive such services from the Agency; and
(G) The responsibility of Contractor and the responsibility of the
Agency for the designation of individuals responsible for coordinating
the implementation of the memorandum.
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K§709. Relationships with State
Mental Health and Substance Abuse Agency
(a) Referral of Disenrolled Children — In the case of an enrolled
child with special health care needs (as defined in §1401(e))
whose enrollment is terminated due to ineligibility, Contractor shall
at the time of disenrollment notify the child and the child's family or
caregiver in writing of the availability of health care services and care
coordination from:
(1) [drafter insert name of State Mental Health and Substance Abuse
Agency]; or
(2) providers subcontracting with or funded by [drafter insert name
of State Mental Health and Substance Abuse Agency].
(b) Memorandum of Understanding with State Mental Health and Substance
Abuse Agency
(1) In General — Contractor shall enter into a memorandum of
understanding with [drafter insert name of State Mental Health and Substance
Abuse Agency ] if the Agency is willing to enter into such a memorandum,
which shall have the same term as [drafter insert name of purchasing
document], and which shall address the matters enumerated in paragraph
(2).
(2) Elements of Memorandum of Understanding
(A) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and the payment for, items and services that:
(i) are covered under §102(a)
of Part 1 with respect to enrolled
children with special health care needs (as defined in §1401(e));
and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to children with special
health care needs;
(B) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the furnishing
of, and the payment for, items and services that:
(i) are not covered under §102(a)
of Part 1 and enumerated in 102(b)
of Part 1 with respect to enrolled
children with special health care needs; and
(ii) the Agency routinely furnishes (or arranges through grantees
or subcontractors for the furnishing of) to children with special
health care needs;
(C) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for payment for
treatment of a member of the family of an enrolled child with special
health care needs, or a caregiver of the child, who is not enrolled
under [drafter insert name of purchasing agreement], but who requires
treatment in order to effectively treat a condition or developmental
disability or delay of the child;
(D) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the identification
of enrolled children with special health care needs;
(E) The responsibility of Contractor and the responsibility of the
Agency (or the Agency's grantees or subcontractors) for the arrangements
for reciprocal referrals of enrolled children with special health
care needs;
(F) The responsibility of Contractor and the responsibility of the
Agency for the exchange of data and information relating to items
and services furnished to enrolled children with special health care
needs; and
(G) The responsibility of Contractor and the responsibility of the
Agency for the designation of individuals responsible for coordinating
the implementation of the memorandum.
Compliance measure: Contractor shall make available to Purchaser
on request copies of memoranda of understanding executed with the various
state and local agencies under this Part.
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Part 8
Quality Measurement and Improvement
Table of Contents
§801. In General
§802. Quality Measurement and Improvement
Program
§803. Clinical Studies
§804. Drug Formulary Assessment
§805. Utilization Review
§806. Confidentiality
§807. Data Collection and Reporting
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 quality measurement and improvement
is for your consideration.
K§801. In General 6
(a) Internal Quality Assurance — Contractor7
shall establish and maintain an internal quality measurement and improvement
program that complies with the following:
(1) Program Elements — Contractor shall comply with the requirements
of §802;
(2) Clinical Studies — Contractor shall conduct clinical studies
in accordance with §803; and
(3) Drug Formulary Assessment — Contractor shall conduct the
assessment required under §804.
(b) Utilization Review — Contractor shall comply with the requirements
of §805.
(c) Reporting — Contractor shall comply with the requirements
of §807 relating to reporting of quality data.
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K§802. Quality Measurement and
Improvement Program
(a) In General — Contractor shall establish and maintain an internal
quality measurement and improvement program to:
(1) monitor and evaluate the quality and appropriateness of items and
services covered under §102(a) of Part
1 furnished to enrolled children under [drafter insert name of purchasing
document]; and
(2) identify and correct instances and patterns of inappropriate reduction
or denial of items and services covered under §102(a)
of Part 1 for enrolled children under
[drafter insert name of purchasing document].
(b) Elements — The program described in subsection (a) shall contain
the following elements:
(1) Standards — Contractor shall develop and apply the following
standards:
(A) standards for measuring the quality, continuity, and appropriateness
of items and services covered under §102(a)
of Part 1 furnished to enrolled children;
(B) standards for access by enrolled children to items and services
covered under §102(a) of Part
1 that are consistent with Part 6;
(C) standards for access by enrolled children with special health
care needs (as defined in §1401(e)) to items
and services covered under §102(a)
of Part 1;
(D) standards for access by enrolled children whose family or caregivers
do not use English as a primary language that are consistent with
§506 of Part
5; and
(E) standards for access by enrolled children to items and services
covered under §102(a) of Part
1 furnished in a culturally competent manner that are consistent
with §501(d) of Part
5.
(2) Compliance Review — Contractor shall review its compliance
(and the compliance of providers through which Contractor furnishes
items and services covered under §102(a)
of Part 1 to enrolled children) with:
(A) the requirements of §§101A
— 103A of Part
1A relating to coverage determination standards, coverage determination
procedures, and prior authorization;
(B) the requirement of §004(d)
of the Overview for professional competence applicable to each provider
participating in Contractor's provider network; and
(C) the requirement of §006(a)(1)
of the Overview relating to the use of child health supervision guidelines
reflecting generally accepted principles of professional pediatric
practice.
(3) Satisfaction Surveys
(A) Duty to Survey — Contractor shall conduct, or arrange for
the conduct of, a survey at least once every [ ] months to assess
the satisfaction of enrolled children (and the children's families
or caregivers) and providers participating in Contractor's provider
network with respect to the accessibility and quality of items and
services covered under §102(a)
of Part 1.
(B) Prior Purchaser Approval — Contractor shall conduct the
survey described in subparagraph (A) with an instrument that Purchaser
has approved in advance of the administration of the survey.
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K§803. Clinical Studies 8
(a) Clinical Studies — Contractor shall conduct on an [ ] basis
the following studies to assess the clinical quality of the items and
services covered under §102(a) of
Part 1 furnished to enrolled children:
(1) the provision of appropriate immunization services covered under
§102(a) of Part
1 to enrolled children whose immunization status is not current;
(2) the provision of mental and developmental evaluations to the extent
covered under §102(a) of Part
1 to enrolled children under age 3; 9
(3) the provision of preventive dental services covered under §102(a)
of Part 1;
(4) the clinical management of enrolled children with elevated blood
lead levels identified through assessments to the extent covered under
§102(a) of Part
1;
(5) the clinical management of enrolled children diagnosed with tuberculosis
to the extent covered under §102(a)
of Part 1;
(6) the provision of case management services to the extent covered
under §102(a) of Part
1 to enrolled children with special health care needs (as defined
in §1401(e)); and
(7) the provision of family planning services to the extent covered
under §102(a) of Part
1 to enrolled adolescents (as defined in §1401(a)).
10
(b) Consultation — In conducting the clinical studies required
under subsection (a), Contractor shall consult with [drafter insert names
of experts in pediatric care and appropriate state agencies].
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K§804. Drug Formulary Assessment
(a) Assessment — In the event that Contractor uses a drug formulary
in furnishing items and services covered under §102(a)
of Part 1, Contractor shall perform on
a [ ] basis an assessment of the sufficiency of the formulary for enrolled
children which identifies:
(1) each drug in the formulary and its therapeutic equivalent;
(2) the process for substitution of a therapeutic equivalent; and
(3) the effect of the substitution of a therapeutic equivalent upon
the quality of clinical care furnished to enrolled children.
(b) Consultation — In conducting the assessment described in subsection
(a), Contractor shall consult with [drafter insert names of experts in
pediatric care and appropriate state agencies].
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K§805. Utilization Review
(a) Compliance with Coverage Requirements — Contractor shall ensure
that the utilization review policies and procedures in use by Contractor:
(1) comply with the requirements of §§101A
— 103A of Part
1A relating to coverage determination standards, coverage determination
procedures, and prior authorization; and
(2) are consistent with the child health supervision guidelines reflecting
generally accepted principles of professional pediatric practice enumerated
in §006(a)(1) of the Overview.
11
(b) Detection of Under-Utilization — Contractor shall ensure that
the utilization review policies and procedures in use by Contractor:
(1) effectively detect and correct instances and patterns of under-utilization
of covered items and services by enrolled children; and
(2) provide for the periodic review of utilization patterns among enrolled
children by pediatric specialists (as defined in §1401(r)).
(c) Personnel Qualified to Make Review Determinations — Contractor
shall ensure that the personnel making utilization review or coverage
determinations on the part of Contractor are appropriately qualified in
accordance with §102A(e) of Part
1A.
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K§806. Confidentiality
The requirements of §1002 of Part
10 relating to confidentiality protections shall apply to Contractor's
compliance with the quality measurement and improvement requirements under
this Part.
K§807. Data Collection and Reporting
Contractor shall ensure that Contractor and each provider participating
in Contractor's provider network comply with the requirements of Part
9 relating to data collection and reporting.
Compliance measure: Contractor shall make available to Purchaser
on request:
(1) copies of all standards for quality and access in use
in Contractor's quality measurement and improvement program;
(2) copies of the protocols and procedures used by Contractor
in carrying out clinical studies;
(3) copies of the protocols and procedures used by Contractor
in conducting drug formulary assessments;
(4) copies of the protocols and practice guidelines used
by Contractor in carrying out utilization review;
(5) the names and qualifications of the personnel conducting
utilization review for Contractor; and
(6) copies of satisfaction surveys of enrolled children and
participating providers.
[Back to Top]
Part 9
Data Collection and Reporting
As discussed in the introduction to these Medicaid Pediatric Purchasing
Specifications, CHSRP is also developing purchasing specifications relating
to data and information collection and reporting and a number of public
health issues. 12 Upon completion of these purchasing
specifications, the relevant sections relating to data requirements will
be incorporated into this Part.
For additional information on SCHIP data reporting, see Framework
and User's Guide for State Evaluation of the Children's Health Insurance
Program (National Academy for State Health Policy, August 1999,www.nashp.org).
Table of Contents
§901. In General
§902. Public Health Data
§903. Access Data
§904. Quality Data
§905. Aggregate Utilization Data
§906. Encounter Data
§907. Complaint and Grievance Data
§908. Expenditure and Claims Data
§909. Data Relating to Practitioners
§910. Confidentiality of Data
§911. Public Access to Data
§912. Ownership of Data
§913. Information System
§914. Purchaser Access to Data
§915. Remedies for Noncompliance
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 data collection and reporting requirements
is for your consideration.
K§901. In General
(a) Information Systems — Contractor shall maintain an information
system that meets the requirements of §913.
(b) Data
(1) SCHIP Program Data — Contractor shall collect and report
to Purchaser, in such form and manner as Purchaser specifies, data necessary
to enable Purchaser to meet the reporting requirements imposed by the
Secretary of Health and Human Services under §2107(b)(1) of the
Social Security Act, 42 U.S.C. §1397gg(b)(1) and 42 CFR §457.700
et seq. 13
(2) Access Data — Contractor shall comply with the requirements
of §903 relating to collection and reporting
of data relating to access to covered items and services by enrolled
children.
(3) Quality Data — Contractor shall comply with the requirements
of §904 relating to collection and reporting
of data relating to the quality of covered items and services provided
to enrolled children.
(4) Utilization Data — Contractor shall comply with the requirements
of §905 relating to collection and reporting
of data relating to the utilization of covered items and services by
enrolled children.
(5) Encounter Data — Contractor shall comply with the requirements
of §906 relating to collection and reporting
of data relating to encounter data.
(6) Complaint and Grievance Data — Contractor shall comply with
the requirements of §907 relating to collection
and reporting of data relating to complaints and grievances by or on
behalf of enrolled children.
(7) Expenditure and Claims Data — Contractor shall comply with
the requirements of §908 relating to collection
and reporting of data relating to Contractor's expenditures for covered
items and services and claims submitted to Contractor by providers furnishing
such services.
(8) Data Relating to Practitioners — Contractor shall comply
with the requirements of §909 relating to collection
and reporting of data relating to practitioners.
(c) Public Health Data
(1) Access to Data — Contractor shall ensure that Contractor
and each provider participating in Contractor's provider network provides
upon request to [drafter insert name of state or local public health
agency with responsibility for surveillance, prevention, and control
activities in the area served by Contractor] access (including
on-line access where applicable) to:
(A) any public health data enumerated in subsection (b); and
(B) any written or electronic records, medical charts, data files,
or other documentation relating to data under subparagraph (A).
(2) Collection and Reporting — Contractor shall comply with the
requirements of §902 relating to collection
and reporting of data relating to public health.
(d) Data Disclosure — In disclosing data under this Part to Purchaser
or [drafter insert name of public health agency identified in subsection
(c)], Contractor shall comply with:
(1) §1002 of Part 10
(relating to confidentiality protections); and
(2) 42 C.F.R. Part 2 (relating to
the information regarding mental illness and addiction disorders).
(e) Responsible Individual — Contractor shall designate an individual
with the responsibility and authority for responding to requests for data
under this Part and shall inform Purchaser and [drafter insert name of
public health agency identified in subsection (c)] of the name and work
phone number of the individual and any successor to such individual.
(f) Purchaser Access to Data — Contractor shall comply with the
requirements of §914 relating to access to data
by Purchaser.
(g) Responsibility of Participating Providers — Contractor shall,
through the written agreement under §501(b)
of Part 5, require each provider participating
in Contractor's provider network to agree to submit accurate and complete
data necessary to satisfy the duties of Contractor under this Part.
(h) Data Defined — As used in this Part and in [drafter insert
name of purchasing document], data includes information.
[Back to Top]
K§902. Public Health Data
(a) In General — Contractor shall comply, and shall ensure that
each provider participating in Contractor's provider network complies,
with the reporting requirements of §702 of Part
7 relating to reportable conditions or diseases.
(b) Immunizations 14
See §009 of Purchasing Specifications
for Immunizations, May 1998, www.gwhealthypolicy.org.
(c) Pediatric HIV
See §205 of Purchasing Specifications
for HIV Infection, AIDS, and HIV-related Conditions, August 1999, www.gwhealthpolicy.org/.
(d) STDs 15
See §204 of Purchasing Specifications
for Services for Sexually Transmitted Diseases, November 1999, www.gwhealthpolicy.org/.
(e) TB
See §205 of Purchasing Specifications
for Tuberculosis, August 1999, www.gwhealthpolicy.org/.
(f) Childhood Lead Poisoning
See §009 of Purchasing Specifications
for Prevention of Lead Poisoning, November 1998, www.gwhealthpolicy.org/.
[Back to Top]
K§903. Access Data
(a) In General — Contractor shall collect and report, in such
form and manner as Purchaser specifies, the data necessary to enable Purchaser
to determine whether enrolled children have access to items and services
covered under §102(a) of Part
1. 16
(b) Provider Network-Related Data — Contractor shall collect and
report, in such form and manner as Purchaser specifies, the data necessary
to enable Purchaser to determine Contractor's compliance with the requirements
of §502 (relating to primary care
providers) and §503 (relating to pediatric
specialists) of Part 5.
(c) Access Standards — Contractor shall collect and report, in
such form and manner as Purchaser specifies, the data necessary to enable
Purchaser to determine Contractor's compliance with the requirements of:
(1) §602 of Part
6 (relating to travel time);
(2) §603 of Part
6 (relating to service waiting times); and
(3) §604 of Part
6 (relating to services for enrolled adolescents).
[Back to Top]
§904. Quality Data
K(a) HEDIS — Contractor shall report to Purchaser
all outcomes of care measurements included in [drafter insert name of
most current version of the Health Employer Data Information Set (HEDIS)]
at such time as Purchaser specifies.
K(b) Results of Clinical Studies — Contractor
shall report the results of all clinical studies conducted under §803
to Purchaser in such form and manner as Purchaser specifies.
K(c) Results of Drug Formulary Assessments —
Contractor shall report the results of drug formulary assessments conducted
under §804 of Part 8 to Purchaser
in such form and manner as Purchaser specifies.
L(d) Substandard Providers
(1) Quality — Consistent with the Health Care Quality Improvement
Act of 1986, 42 U.S.C. §11133, Contractor shall report to the Board
of Medical Examiners any professional review action taken by Contractor
or provider participating in Contractor's provider network relating
to the clinical privileges of a physician or other health care practitioner.
(2) Fraud and Abuse — Consistent with §1128E of the Social
Security Act, 42 U.S.C. §1320a-7e, Contractor shall report to the
National Health Care Fraud and Abuse Data Collection Program established
by the Secretary of HHS any final adverse action taken against a health
care provider, supplier, or practitioner.
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K§905. Aggregate Utilization
Data
(a) In General — Contractor shall collect and report, on a [ ]
basis, in such form and manner as Purchaser specifies, the data relating
to aggregate utilization of items and services covered under §102(a)
of Part 1 by enrolled children required
under §805 of Part 8 using
the minimum data elements and format specified by Purchaser for the purpose
of:
(1) detecting underutilization of covered items or services by enrolled
children;
(2) ensuring the actuarial soundness of the capitation rates under
[drafter insert name of purchasing document];
(3) validating the encounter data collected and reported under §906;
and
(4) [drafter insert other purposes]. 19
[Back to Top]
K§906. Encounter Data
(a) In General — Contractor shall collect and report, on a [ ]
basis, in such form and manner as Purchaser specifies, encounter data
relating to utilization of each item or service covered under §102(a)
of Part 1 by each enrolled child using
the minimum data elements and format specified by Purchaser for the purpose
of:
(1) detecting underutilization of covered items or services by enrolled
children as required under §805(b) of Part
8;
(2) measuring compliance with the coverage requirements under §§101A-103A
of Part 1A as required under §805(a)
of Part 8;
(3) establishing or adjusting the capitation rates under [drafter insert
name of purchasing document] to take into account the health status
of enrolled children;
(4) assessing the quality of the items and services furnished to enrolled
children by Contractor under [drafter insert name of purchasing document];
and
(5) [drafter insert other purposes].
(b) Identification of Treating Provider — Contractor shall collect
and report to Purchaser, in such form and manner as Purchaser specifies,
the encounter data necessary to enable Purchaser to identify the provider
who furnishes an item or service covered under §102(a)
of Part 1 to an enrolled child.
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K§907. Complaint and Grievance
Data
(a) Complaint Data — Contractor shall submit to Purchaser, on
a [ ] basis, in such form and manner as Purchaser specifies, a log of
complaints received by Contractor under §1006
of Part 10 that contains, with respect to each complaint:
(1) the name of the party filing the complaint;
(2) the date on which the complaint was filed;
(3) the nature of the complaint;
(4) the date on which the complaint was resolved;
(5) the name and title of the individual resolving the complaint; and
(6) the resolution of the complaint.
(b) Grievance Data — Contractor shall submit to Purchaser, on
a [ ] basis, in such form and manner as Purchaser specifies, a log of
grievances received by Contractor under §1005
of Part 10 that contains, with respect to each grievance:
21
(1) the name of the party filing the grievance;
(2) the date on which the grievance was filed;
(3) the nature of the grievance;
(4) the date on which the grievance was resolved;
(5) the name and title of the individual resolving the grievance;
and
(6) the resolution of the grievance.
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K§908. Expenditure and Claims
Data
(a) Expenditures — Contractor shall collect and report to Purchaser,
on a [ ] basis, in such form and manner as Purchaser specifies, data on
expenditures made by Contractor under [drafter insert name of purchasing
document] for items and services furnished to enrolled children under
§102(a) of
Part 1 (other than expenditure data collected and reported under §901(b)(7)).
(b) Claims — Contractor shall collect and report to Purchaser
on a [ ] basis, in such form and manner as Purchaser specifies, the following
data on claims in connection with items and services furnished to enrolled
children under §102(a) of Part
1:
(1) claims pended;
(2) claims denied;
(3) claims paid; and
(4) estimated claims incurred but not reported.
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K§909. Data Relating to Practitioners
(a) In General — Contractor shall collect and maintain the data
enumerated in subsection (b) with respect to each practitioner participating
in Contractor's provider network.
(b) Data Elements
(1) name;
(2) area of practice;
(3) provider number;
(4) address (including zip code) at which the practitioner offers
services;
(5) current practice site telephone numbers;
(6) office hours at each practice site;
(7) capacity to accept additional patients at each practice site;
(8) licensure status;
(9) hospital privileges;
(10) education and training;
(11) board certification and specialization;
(12) age, sex, and race or ethnicity; and
(13) languages in which the practitioner is fluent.
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K§910. Confidentiality of Data
Contractor shall comply with the requirements of §1002
of Part 10 relating to confidentiality protections
in the collection and reporting of data under this Part.
K§911. Public Access to Data
(a) Access to Reported Data and Information — Contractor agrees
that all data and information reported by Contractor to Purchaser or to
the Centers for Medicare and Medicaid Services under [drafter insert name
of purchasing document] is:
(1) subject to disclosure under the Freedom of Information Act, 5 U.S.C.
§552, and under [drafter insert reference to applicable state or
local freedom of information act]; and
(2) not a trade secret or commercial or financial information that
is privileged or confidential.
(b) Access to Survey Findings — Contractor agrees that all findings
from surveys of Contractor (or of health care facilities, laboratories,
agencies, clinics, or organizations participating in Contractor's provider
network) conducted by [drafter insert name of State licensure agency]
shall:
(1) be available to the public; and
(2) be made available to the public by [drafter insert name of State
licensure agency].
[Back to Top]
K§912. Ownership of Data
(a) Agreement — Contractor agrees that:
(1) any data collected or prepared by Contractor or by a provider participating
in Contractor's provider network in connection with [drafter insert
name of purchasing document] shall be the property of Purchaser and
the U.S. Department of Health and Human Services; and
(2) all data and information reported by Contractor to Purchaser or
to the Centers for Medicare and Medicaid Services under this [drafter
insert name of purchasing document] is:
(A) subject to disclosure under the Freedom of Information Act, 5
U.S.C. §552, and under [drafter insert reference to applicable
state or local freedom of information act]; and
(B) not a trade secret or commercial or financial information that
is privileged or confidential.
(b) Consideration — The agreement referred to in subsection (a)
is made by Contractor in consideration of the use of federal and state
SCHIP funds in collecting and preparing data under [drafter insert name
of purchasing document].
[Back to Top]
K§913. Information Systemn 22
Commentary: The following illustrative provision would require Contractor
to maintain an information systems meeting certain standards. The provision
would not limit the Contractor to one information system, nor would it
require that Contractor's other information systems meet any of the specified
standards.
(a) Basic Duty — Contractor shall maintain an information system
that meets the requirements of this section.
(b) Compliance Capability — The information system shall enable
Contractor to comply with the requirements of this Part relating to the
collection, reporting, and confidentiality of, and public and Purchaser
access to, data.
(c) Elements — The information system shall have the capacity
to:
(1) collect and maintain all data in electronic record;
(2) verify the accuracy of the data collected and reported;
(3) screen the data collected and reported for completeness;
(4) integrate data collected from enrolled children, from providers
participating in Contractor's provider network, and from Purchaser and
[if applicable, drafter insert name of Purchaser's enrollment broker];
(5) receive data from, and transmit data to [drafter insert reference
to Purchaser's SCHIP management information system];
(6) provide Purchaser with direct, on-line access to Contractor's data
under [drafter insert name of purchasing document] in such manner and
format as Purchaser specifies;
(7) record the imposition of each cost-sharing amount on each enrolled
child and, as required by §101C(c)(3)
of Part 1C,
make such information promptly available on request to the child's family
or caregiver; 22 and
(8) update data and upgrade software as necessary to comply with the
requirements of this Part.
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K§914. Purchaser Access to Data
(a) Basic Duty — Contractor shall ensure that Contractor and each
provider participating in Contractor's provider network provides upon
request to the entities enumerated under subsection (b) access (including
on-line access where applicable) to:
(1) the data enumerated in §901(b); and
(2) any written or electronic records, medical charts, data files,
or other documentation relating to data under paragraph (1).
(b) Accessibility of Data — Contractor agrees to provide the data
enumerated in subsection (a) upon request to the following:
(1) Purchaser;
(2) the Centers for Medicare and Medicaid Services, U.S. Department
of Health and Human Services;
(3) the Office of the Inspector General, U.S. Department of Health
and Human Services; and
(4) the General Accounting Office.
(c) Independent Audit — Contractor agrees that Purchaser has the
right to conduct (directly or by contract) an independent audit of any
data collected or reported by Contractor under this Part, and agrees to
cooperate with such audit.
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K§915. Remedies for Noncompliance
For illustrative language relating to remedies for noncompliance with
the requirements of this Part, see §1205 of Part
12.
Compliance measure: Contractor shall make available to Purchaser
on request copies of:
(1) Contractor's provider manual and any other directives,
guidelines, protocols, or forms relating to Contractor's information
system or data transmitted in writing or electronically by Contractor
to providers participating in Contractor's provider network;
(2) the subcontract or other written agreement between Contractor
and each provider participating in Contractor's provider network;
and
(3) Contractor's operations manual and any other directive,
guidelines, protocols, or forms, whether in written or electronic
format, relating to Contractor's information system, data, or Contractor's
duties under this Part.
Part 10
Enrolled Child Safeguards
Commentary: These purchasing specifications are designed to address
issues in SCHIP managed care contracting. Of course, there are many state
law issues that state purchasers may also wish to address. For example,
one state law remedy that is sometimes used to enforce contractual guarantees
under conventional insurance coverage and could have similar effect in
this context is the designation of enrolled children as third party beneficiaries
to the purchasing agreement. The legal doctrine of third party beneficiary
holds that individuals who are not party to a contract may, under certain
circumstances, enforce performance of duties in the contract on the part
of the parties to the contract. While varying from state to state, this
doctrine is reflected in both state court decisions and state laws, and
applies to both private and public contracts. See Calamari and Perillo,
Contracts 3rd Ed. 1987, §§17-4, 17-7.
Table of Contents
§1001. Protection of
Enrolled Child-Provider Communications
§1002. Confidentiality Protections
§1003. Protections for Enrolled Children
Against Liability for Payment
§1004. Protections for Enrolled Children
Against Discrimination
§1005. Grievance Procedure
§1006. Complaint Procedure
§1007. Written Policies on Enrolled
Child Rights
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 enrolled child safeguards is for
your consideration.
K§1001. Protection of Enrolled
Child-Provider Communications
(a) General Rule — Contractor shall not restrict any physician
or other health care professional (whether or not such provider participates
in Contractor's provider network), from advising an enrolled child about
the child's health status or medical care or treatment for the child's
condition or disease, regardless of whether items and services for such
care or treatment are covered under [drafter insert name of purchasing
document], if the professional is acting within the lawful scope of practice.
K§1002. Confidentiality Protections
24
(a) In General — Contractor shall comply with the requirements
of [drafter insert reference to any generally applicable state confidentiality
law].
(b) Adolescents — Contractor shall ensure that any information
relating to an enrolled adolescent in the possession of Contractor or
a provider participating in Contractor's provider network shall not be
disclosed, except information shall be disclosed if:
(1) disclosure is expressly required under [drafter insert reference
to any applicable state law];
(2) disclosure is required under subsection (c); or
(3) in the opinion of the treating provider, disclosure of the information
is necessary to avoid serious, imminent harm to the enrolled adolescent
or another individual. 25
(c) Public Health
(1) STDs
See §207 of Purchasing Specifications
for Services for Sexually Transmitted Diseases, November 1999, www.gwhealthpolicy.org/.
(2) HIV
See §208 of Purchasing Specifications
for HIV Infection, AIDS, and HIV-Related Conditions, August 1999, www.gwhealthpolicy.org/.
(3) TB
See §207 of Purchasing Specifications
for Tuberculosis, August 1999, www.gwhealthpolicy.org/.
[Back to Top]
§1003. Protections for Enrolled Children Against
Liability for Payment
K(a) General Rule — Contractor and each provider
through which Contractor furnishes or arranges for the furnishing of items
or services covered under §102(a)
of Part 1 to an enrolled child (whether
or not the provider participates in Contractor's provider network) may
not be held liable or be subject to collection efforts for:
(1) Contractor's debts in the event of insolvency;
(2) the cost of items and services covered under §102(a)
of Part 1 in the event that Contractor
fails to receive payment from Purchaser;
(3) the cost of items and services covered under §102(a)
of Part 1 if a provider participating
in Contractor's provider network fails to receive payments from Contractor;
or
(4) payments to a provider that furnishes items and services covered
under §102(a) of
Part 1 to an enrolled child under [drafter insert name of purchasing
document] in excess of the amount that would be owed by the enrolled
child if Contractor had furnished such items or services directly.
L(b) Cost-Sharing — Contractor shall comply
with the requirements of §101C of
Part 1C (relating to the imposition
of cost-sharing or similar charges on enrolled children under [drafter
insert name of purchasing document]).
[Back to Top]
K§1004. Protections
Against Discrimination
(a) In General — Contractor shall comply with the requirements
of §1301(b) of Part 13
relating to the protection of an enrolled child (and the child's family
or caregiver) against discrimination.
(b) Language — Contractor shall comply with the requirements of
§506(b) of Part
5 relating to the protection of enrolled children who do not speak
English.
K§1005. Grievance
Procedure 26
(a) In General
(1) Basic Duty — Contractor shall establish and maintain a grievance
procedure in compliance with the requirements of this section.
(2) Scope — The grievance procedure maintained by Contractor
under this section shall resolve disputes involving the notice under
§102A(d) of Part
1A of the denial or reduction of a covered item or service.
(b) Filing of Grievances
(1) Parties — Within [ ] days of notice under §102A(d)
of Part 1A of a determination involving
the denial or reduction of a covered item or service, any of the following
may invoke the grievance procedure under this section by filing with
Contractor a grievance in writing (by facsimile or otherwise):
(A) the family or caregiver of the enrolled child (or in the case
of an enrolled adolescent, the adolescent) adversely affected by the
determination;
(B) the primary care provider (and pediatric specialist, if any)
of the enrolled child adversely affected by the determination; or
(C) with the permission of the enrolled child affected by the determination
(or the family or caregiver of such child), [drafter insert name of
publicly-supported agency, program, or provider] that referred the
enrolled child for the item or service at issue.
(2) Relationship to Complaints — The parties enumerated in paragraph
(1) may file a grievance with Contractor under this section whether
or not any of the parties has filed a complaint under §1006.
(c) Facilitation of Grievance Procedures
(1) Information — Contractor shall provide on a timely basis
to the party filing a grievance under subsection (b) reasonable access
to, and copies of, all documents, records, and other data and information
(without regard to whether such documents, records, data or information
were considered or relied upon in making the adverse determination)
which, in judgment of the party, is needed to enable the party to:
(A) fully understand the basis for the determination;
(B) establish that the qualifications of the personnel responsible
for the determination are consistent the requirements of §102A(f)
of Part 1A; and
(C) effectively argue for an alternate determination.
(2) Interpreter Services — Contractor shall make available professional
interpreter services at any stage in the grievance procedure under this
section upon request of the enrolled child's family or caregiver.
(d) Resolution of Grievances
(1) Timeframe
(A) Contractor shall resolve grievances filed under this section
not later than [ ] days after the date of receipt of the grievance,
except in cases described in subparagraph (B).
(B) In the case of a grievance involving an urgent medical condition
(as defined in subparagraph (C)), Contractor shall resolve such grievance
within [ ] hours.
(C) As defined in §1401(z), an urgent medical
condition is a condition in a child manifesting itself by acute symptoms
of sufficient severity (including severe pain) that a prudent lay
caregiver, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of same day medical attention
to result in:
(i) placement of the child's health in serious jeopardy;
(ii) serious dysfunction of a child's bodily functions; or
(iii) serious dysfunction of a child's bodily organ or part.
(2) Qualifications of Decision-Maker — A grievance relating to
a determination to deny, or reduce coverage based on a lack of medical
necessity shall be resolved only by a physician with expertise in the
appropriate field of medicine who is other than a physician directly
or indirectly involved in the initial determination.
(3) Written Resolution
(A) In the case of a grievance filed under this section that is not
resolved to the satisfaction of the party filing the grievance, Contractor
shall provide to the party within the timeframe specified in paragraph
(1) a copy of Contractor's resolution in writing.
(B) The written resolution described in subparagraph (A) shall include:
(i) the facts established in relation to the grievance; and
(ii) Contractor's reasons for its determination.
(e) No Charge — Contractor shall not impose any charge on any party
to a grievance under this section in connection with the filing and resolution
of the grievance.
[Back to Top]
K§1006. Complaint Procedure
(a) In General
(1) Basic Duty — Contractor shall establish and maintain a complaint
procedure in compliance with the requirements of this section.
(2) Scope — The complaint procedure maintained by Contractor
under this section shall resolve disputes (other than those described
in §1005(a)(2)) relating to:
(A) the accessibility of providers participating in Contractor's
provider network under Parts 4, 5
and 6;
(B) access (by the enrolled child or others) to the child's personal
medical information;
(C) the manner or setting in which a covered item or service will
be or has been furnished; 29 or
(D) [drafter insert other matters about which an enrolled child is
aggrieved].
(b) Filing of Complaints
(1) Oral or Written Filing — The family or caregiver of an enrolled
child (or in the case of an enrolled adolescent, the adolescent) involved
in a dispute with Contractor enumerated in subsection (a)(2) may invoke
the complaint procedure under this section by filing a complaint orally
or in writing.
(2) Relationship to Grievances — The family or caregiver (or
adolescent) described in paragraph (1) may file a complaint with Contractor
under this section whether or not any of the parties has filed a grievance
under §1005.
(c) Facilitation of Complaint Procedures
(1) Information — Contractor shall provide on a timely basis
to the party filing a complaint under subsection (b) reasonable access
to, and copies of, all documents, records, and other data and information
which, in judgment of the party, is needed to enable the party to:
(A) fully understand the basis for the dispute; and
(B) effectively argue for an alternate resolution.
(2) Interpreter Services — Contractor shall make available professional
interpreter services at any stage in the complaint procedure under this
section upon request of the enrolled child's family or caregiver.
(3) Telephone Access — Contractor shall provide a toll-free,
24-hour telephone number for the filing of complaints.
(d) Resolution of Complaints — Contractor shall resolve a complaint
filed under this section in accordance with paragraphs (1), (2), and (3).
(1) Timeframe — Contractor shall resolve a complaint no later
than [ ] days after the date of receipt of the complaint.
(2) Qualifications of Decision-Maker — Contractor shall ensure
that a complaint is resolved by an impartial individual.
(3) Written Resolution — Contractor shall ensure that each complaint
is resolved in writing, and shall provide a copy of the written resolution
to the complainant. The written resolution shall include:
(A) the facts established in relation to the complaint; and
(B) the actions, if any, which Contractor has taken or will take
in response to the complaint.
(e) No Charge — Contractor shall not impose any charge on any
party to a complaint under this section in connection with the filing
and resolution of the complaint.
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K§1007. Written Policies
on Enrolled Child Rights
(a) Contractor shall:
(1) adopt written policies regarding the rights of enrolled children
enumerated in this Part and in §302(c)(18)
of Part 3; and
(2) ensure that Contractor's employees and providers participating
in Contractor's provider network respect such rights when furnishing
covered items and services to an enrolled child.
Compliance measure: Contractor shall make available to Purchaser
on request a copy of the most recent version of each of the following:
(1) Contractor's Provider Manual, Operations Manual, and
any other directives, guidelines, or protocols transmitted in writing
or electronically by Contractor to providers participating in Contractor's
provider network relating to:
(A) protection of enrolled child-provider communications;
(B) confidentiality;
(C) liability of enrolled children for payment;
(D) discrimination;
(E) grievance procedures; and
(F) complaint procedures;
(2) the subcontract or any other written agreement between
Contractor and each provider participating in Contractor's provider
network;
(3) Contractor's enrollee handbook and any other written
information made available to enrolled children relating to:
(A) protection of enrolled child-provider communications;
(B) confidentiality;
(C) liability of enrolled children for payment;
(D) discrimination;
(E) grievance procedures; and
(F) complaint procedures;
(4) the name of the individual with primary responsibility
for the operation of Contractor's:
(A) grievance procedure; and
(B) complaint procedure;
(5) a log of each grievance received by Contractor, including
the date on which the grievance was received, the nature of the grievance,
the date on which the grievance was resolved, and the nature of the
resolution; and
(6) a log of each complaint received by Contractor, including
the date on which the complaint was received, the nature of the complaint,
the date on which the complaint was resolved, and the nature of the
resolution.
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Part 11
Publicly Purchased Vaccine Programs
On May 11, 1998, CMS's Center for Medicaid and State Operations sent
a letter to state health officials providing guidance regarding coverage
of immunizations under Title XXI and the Vaccines for Children (VFC) program
(http://cms.hhs.gov/schip/chivfc.asp).
The letter states in part that children enrolled in
a separate state SCHIP insurance program are neither Medicaid-eligible
nor uninsured as required under Title XIX and therefore they are not
federally vaccine-eligible. The letter sets forth two options for states
in these circumstances:
"First, states may define these children as 'state
vaccine-eligible' under §1928(b)(3) and purchase vaccine at the
federal contract price for these children without these expenditures
being subject to the 10 percent cap...to do this, states must retain responsibility
for the provision of benefits to Title XXI children and subcontract
portions of the benefit package to insurers, except the purchase of
vaccine. States must distribute vaccines purchased through the federal
contract to their Title XXI providers...Second, states may choose to contract
with insurers for the provision of vaccine as they do for other services.
States electing this approach will have to pay private sector market
prices for vaccine. Under both options, state expenditures are matched
at the SCHIP-enhanced matching rate."
In a subsequent letter to State Health Officials dated June 25, 1999,
CMS clarified that there are two ways in which state SCHIP agencies may
obtain vaccines at federally discounted prices. First, the agencies may
enter into written interagency agreements with State Immunization Programs
to buy vaccine from federal contracts negotiated by the CDC. In the alternative,
state SCHIP agencies may include vaccine purchase costs in their contracts
with MCOs. CMS emphasizes that in the latter case, "the Contractor is
responsible for furnishing immunization service benefits. A Contractor
paid to furnish immunization services that refers children to public health
clinics for such services would violate contract requirements to provide
those benefits. In addition to violating contract requirements, the practice
could be seen as fraud against the program. States should refer alleged
violations to SCHIP program integrity units for review and further action,
including prosecution if applicable." http://cms.hhs.gov/schip/ch062599.asp.
This interpretation was upheld in a case in California where a federal
judge ruled that the federal government is not required to provide free
vaccines to California SCHIP enrollees through its Vaccines for Children
program (California Medical Association v. Shalala, E.D. Cal., CVS-98-855-LKKPAN,
4/30/99).
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 publicly purchased vaccine programs
is for your consideration.
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§1101. Participation in Publicly Purchased
Vaccine Programs
Contractor shall ensure that all providers who participate in Contractor's
provider network and furnish immunizations participate in any publicly
purchased vaccine program that is available in Contractor's service area
and for which enrolled children qualify.
§1102. Definitions
(a) Publicly purchased vaccine programs ? any state or local program
for the purchase of vaccines other than the Vaccines for Children (VFC)
program, §1928 of the Social Security Act, 42 U.S.C. §1396s,
except with respect to enrolled children who are vaccine eligible children
(as the term is defined in §1928(c) of the Social Security Act, 42
U.S.C. §1396s(c).
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Part 12
Remedies for Noncompliance
Table of Contents
§1201. In General
§1202. Covered Items and Services
§1203. Enrollment and Disenrollment
of Enrolled Children
§1204. Quality Measurement and Improvement
§1205. Data Collection and Reporting
§1206. Enrolled Child Safeguards
§1207. Relationship to Other Remedies
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 remedies for noncompliance is for
your consideration.
K§1201. In General
(a) If Contractor does not comply with, or otherwise fails to perform,
a requirement of [drafter insert name of purchasing document] or applicable
federal or state law or regulation, Purchaser may apply one or more of
the following remedies:
(1) Withholding of Capitation Payments — Notwithstanding [drafter
insert references to provisions relating to capitation payments to Contractor]:
(A) Purchaser may withhold capitation payments under [drafter insert
name of purchasing document] from the date Purchaser notifies Contractor
that Purchaser has determined that Contractor does not comply with
a requirement of [drafter insert name of purchasing document].
(B) Purchaser shall pay to Contractor any capitation payments withheld
under subparagraph (A) within [ ] days after the date Purchaser determines
that Contractor complies with such requirement and that Contractor's
noncompliance is not likely to recur.
(2) Suspension of Enrollment
(A) Purchaser may suspend enrollment of eligible children under [drafter
insert name of purchasing document] from the date Purchaser notifies
Contractor that Purchaser has determined that Contractor does not
comply with a requirement of [drafter insert name of purchasing document]
until the date Purchaser determines Contractor complies with such
requirement and that Contractor's noncompliance is not likely to recur.
(B) The enrollment to which the suspension remedy described in subparagraph
(A) applies includes voluntary enrollment, mandatory enrollment, and
default enrollment by enrolled children under [drafter insert name
of purchasing document].
(3) Notification of Right to Disenroll Without Cause
(A) Noncompliance — Contractor understands and agrees that
Purchaser may permit each enrolled child to terminate enrollment without
cause and may notify each enrolled child's family or caregiver of
his or her right to terminate enrollment without cause from:
(i) the date Purchaser notifies Contractor that Purchaser has determined
that Contractor does not comply with a requirement of [drafter insert
name of purchasing document], until
(ii) the date Purchaser determines that Contractor complies with
such requirement and that Contractor's noncompliance is not likely
to recur.
(B) Contractor shall comply with §203
of Part 2 (relating to duties of
Contractor to children receiving treatment at the time of disenrollment)
with respect to an enrolled child who disenrolls under subparagraph
(A).
(4) Liquidated Damages
(A) Contractor agrees that if Contractor does not comply with or
otherwise perform a requirement of [drafter insert name of purchasing
document] or applicable federal or state laws or regulations, damage
to Purchaser will result, and Purchaser may impose liquidated damages
in the amount of:
(i) [$ ] per requirement not complied with or performed; or
(ii) [$ ] for each day during which Contractor does not comply
with or perform a requirement of [drafter insert name of purchasing
document]; or
(iii) both clauses (i) and (ii).
(B) Notwithstanding [drafter insert references to provisions relating
to capitation payments to Contractor], Purchaser may impose liquidated
damages imposed under subparagraph (A) in the form of a reduction
in capitation payments otherwise due Contractor under [drafter insert
name of purchasing document].
(5) Civil Money Penalties — In addition to the remedies available
to Purchaser under §§1202, 1203,
1205, and 1206, Purchaser may
impose civil monetary penalties of not more than [$ ] for each failure
by Contractor to comply with or otherwise perform the requirements of
[drafter insert name of purchasing document] or federal or state law.
(6) Recoupment of Purchaser Payments to Out-of-Plan Providers —
Notwithstanding [drafter insert references to provisions relating to
capitation payments to Contractor], if Contractor has failed to provide
one or more item or service covered under §102(a)
of Part 1 to an enrolled child, and
the child receives the item or service from a provider not participating
in Contractor's provider network, Purchaser may:
(A) pay the provider for the item or service; and
(B) reduce the payments otherwise owed Contractor in an amount equal
to the amount Purchaser pays or expects to pay for the item or service,
plus any administrative costs incurred by Purchaser in connection
with the transaction.
(7) Termination
(A) Purchaser may terminate performance by Contractor of duties under
[drafter insert name of purchasing document] in whole, or in part,
if:
(i) Contractor fails to comply with any provision of this [drafter
insert name of purchasing document] and does not correct its non-compliance
within [ ] business days;
(ii) Contractor has taken an action that threatens the health,
safety, or welfare of enrolled children; or
(iii) Contractor has taken an action that threatens the fiscal
integrity of [drafter insert name of SCHIP program].
(b) Right to Disenroll in Event of Termination — Contractor understands
and agrees that if Purchaser seeks to terminate [drafter insert name of
purchasing document], Purchaser may permit an enrolled child to disenroll
immediately without cause.
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K§1202. Covered Items and Services
(a) In addition to the remedies set forth in §1201,
Purchaser may impose the following remedy if Contractor does not comply
with, or otherwise fails to perform, the requirements of §002
of the Overview, §102(a) of Part
1 and Part 1A:
(1) Civil Money Penalty
(A) Purchaser may impose a civil money penalty of not more than [$
] for each instance in which Purchaser determines that Contractor
has failed substantially to provide medically necessary items and services
that are required under law or under [drafter insert name of purchasing
document] to be provided to an enrolled child.
(B) Purchaser may impose a civil money penalty of not more than [$
] for each instance in which Purchaser determines that Contractor
has unduly delayed the provision of items and services covered under
§102(a) of Part
1 to an enrolled child.
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K§1203. Enrollment and Disenrollment
of Enrolled Children
(a) In addition to the remedies set forth in §1201,
Purchaser may impose the following remedy if Contractor does not comply
with, or otherwise fails to perform, the requirements of §003
of the Overview and Part 2:
(1) Civil Money Penalty for False Information — Purchaser may
impose a civil money penalty of not more than [$ ] for each instance
in which Purchaser determines that Contractor has misrepresented or
falsified information that is furnished to an enrolled child (or the
enrolled child's family or caregiver) or to a potential enrolled child
(or such child's family or caregiver), or that Contractor has distributed
directly or through any agency or independent contractor marketing materials
that do not comply with the requirements of federal law or [drafter
insert name of purchasing document].
(2) Civil Money Penalty for Health Status Discrimination — Purchaser
may impose a civil money penalty of not more than [$ ] for each instance
in which Purchaser acts to discriminate among enrolled children on the
basis of their health status or the requirements for health care services.
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K§1204. Quality Measurement
and Improvement
(a) In addition to the remedies set forth in §1201,
Purchaser may impose the following remedy if Contractor does not comply
with, or otherwise fails to perform, a requirement of §007
of the Overview and Part
8:
(1) Corrective Action Plan
(A) Purchaser may require Contractor to prepare and execute a corrective
plan under which Contractor shall correct any failure to comply with
or otherwise perform such requirement and shall correct any resulting
deficiencies in the quality of items and services covered under [drafter
insert name of purchasing document] within [ ] days of notification
