Medicaid Contract Purchasing Specifications
User Guides for SCHIP Pediatric Services
Contents
User Guide for State Title V Maternal and
Child Health Agencies
The purchasing specifications include numerous
provisions addressing a wide range of issues. Although many of these
issues directly or indirectly affect state Title V agencies and their grantees,
the following provisions may be of particular interest to Title V Agencies.
The provisions are listed in alphabetical order.
Bright Futures
Coverage Determinations: §101A(a)(5)
of Part 1A relates to the application
of Bright Futures: Guidelines for Health Supervision of Infants, Children,
and Adolescents in the making of coverage determinations with respect
to an individual enrolled child.
Guidelines:
§006(a)(1)(A) of the Overview specifies Bright Futures as one
of the guidelines Purchasers may wish Contractor to follow in delivering
covered items and services to enrolled children.
Quality Measurement and Improvement Program: §802(b)(2)(C)
of Part 8 relates to the use of Bright
Futures in the conduct of compliance reviews.
Utilization Review: §805(a)(2)
of Part 8 relates to the use of Bright
Futures in Contractor's utilization review policies and procedures.
Children with Special Health Care Needs
Definitions
§1401(e) of Part
14 defines children with special health care needs.
§1401(r) of Part
14 defines pediatric specialist.
Network Providers: §505
of Part 5 relates to Contractor's
duty regarding accessibility of providers in its network.
Pediatric Specialists as Primary Care Providers: §402
of Part 4 relates to the selection
of a primary care provider for an enrolled child with special health
care needs, including the choice to select a pediatric specialist as
a primary care provider.
Pediatric Specialists as Participating Providers:
§503 of Part
5 relates to Contractor's duty regarding sufficiency of the number
of participating pediatric specialists and the role of such specialists.
Prior Authorization:
§103A(d)(13) of Part 1A
relates to the exclusion of services for a chronic condition from
Contractor's prior authorization restrictions.
Quality Measurement and Improvement Program
Clinical Study: §803(a)(6)
of Part 8 and §904(b)
of Part 9 relates to Contractor's
duty to conduct study to assess quality of clinical care furnished to
children with special health care needs.
Standards: §802(b)(1)(C)
of Part 8 sets forth an access
standard specific to children with special health care needs.
Coverage Determinations
Evidence: §101A(b)(6)
of Part 1A relates to the use of
evidence from Title V agency professionals in connection with Contractor's
coverage determinations.
Grounds for Denial or Exclusion: §101A(c)(4)
of Part 1A would prohibit the use
by Contractor or an enrolled child�s receipt of Title V services as
a ground for denial or exclusion of services.
Notice: §102A(c)(3)
of Part 1A requires notice of adverse
coverage determination to Title V agency or grantee referring the enrolled
child.
Disenrolled Children:
§703(a) of Part 7 relates
to Contractor's duty to notify disenrolled children of availability of
services from Title V agency or grantees.
Health Education Information: §302(f)
of Part 3 relates to priority illnesses
or conditions about which Contractor could be required to inform enrolled
children.
Memorandum of Understanding: §703(b)
of Part 7 relates to the memorandum
of understanding between Contractor and an interested Title V agency.
Network Providers
Traditional Provider: §508(b)(6)
of Part 5 relates to participation
in Contractor's provider network by Title V maternal and child health
clinics.
Out-of Network Providers
Payment
§510 of Part
5 relates to Contractor's duty regarding payment for services furnished
by out-of-network providers.
§1201(a)(6) of Part
12 relates to Purchaser payment of out-of-network providers and
recoupment of payments from Contractor.
Access: §005(f)
of the Overview relates to Contractor's duty with respect to payment for
public health services received by enrolled children from out-of-network
providers.
Special Supplemental Food Program for Women, Infants, and Children
(WIC)
Coordination by Participating Providers: §501(g)
of Part 5 relates to Contractor's
duty to ensure that providers in its network coordinate with the
WIC program.
Memorandum of Understanding: §704(e)
of Part 7 relates to Contractor's
duty regarding a memorandum of understanding with an interested State
WIC agency.
Referrals: §005(h)
of Overview and §704(b) and (c)
of Part 7 relate to Contractor's
duty regarding WIC referrals.
Publicly-Purchased Vaccines: Part
11 relate to duties of Contractor and providers in Contractor's network
relating to publicly-purchased vaccines.
User Guide for Delivery of Services for
Adolescents1
The purchasing specifications include numerous
provisions addressing a wide range of issues for SCHIP-eligible children
and adolescents. The review process focused on specific policies
for adolescents, including confidentiality protections and services for
adolescents. The following provisions may be of particular interest
to purchasers interested in issues around the delivery of services for
adolescents. The provisions are listed in alphabetical order.
Access Standards
§604 of Part 6 relates to ways
purchasers can encourage MCOs to promote access to enrolled adolescents
and ways of measuring such access.
Bright Futures
Coverage Determinations: §101A(a)(5)
of Part 1A relates to the application
of Bright Futures: Guidelines for Health Supervision of Infants, Children,
and Adolescents in the making of coverage determinations with respect
to an enrolled adolescent.
Guidelines: §006(a)(1)(A)
of the Overview specifies Bright Futures as one of the guidelines Purchasers
may wish Contractor to follow in delivering covered items and services
to enrolled adolescents.
Quality Measurement and Improvement Program: §802(b)(2)(C)
of Part 8 relates to the use of Bright
Futures in the conduct of compliance reviews.
Utilization Review: §805(a)(2)
of Part 8 relates to the use of Bright
Futures in Contractor's utilization review policies and procedures.
Confidentiality Protections
§1002(b) of Part
10 relates to confidentiality protections for enrolled adolescents.
Information about an enrolled adolescent should not be disclosed except
if required by law or to avoid imminent harm to the adolescent.
Coverage Determinations
Qualified Providers: §102A(e)(2)
of Part 1A relates to personnel qualified
to make coverage determinations in the case of an enrolled adolescent.
Definition
§014(a) of the Overview
and 1401(a) of Part
14 defines adolescent as a child age 11 through 18.
Guidelines for Adolescent Preventive Services (GAPS)
Coverage Determinations: §101A(a)(5)
of Part 1A relates to the application
of Guidelines for Adolescent Preventive Services (GAPS) in the making
of coverage determinations with respect to an enrolled adolescent.
Guidelines: §006(a)(1)(B)
of the Overview specifies GAPS as one of the guidelines Purchasers may
wish Contractor to follow in delivering covered items and services to
enrolled adolescents.
Quality Measurement and Improvement Program: §802(b)(2)(C)
of Part 8 relates to the use of GAPS
in the conduct of compliance reviews.
Utilization Review: §805(a)(2)
of Part 8 relates to the use of GAPS
in Contractor's utilization review policies and procedures.
Enrollment
Information: §303
of Part 3 relates to Contractor's
duty to provide a pamphlet to each enrolled adolescent that includes
information on confidentiality protections, self-referral policies and
procedures, and other information of specific interest to adolescents.
Disenrollment: §401(d)(2)
and §401(e)(2) of Part
4 relate to an enrolled adolescent�s disenrollment right for inaccurate
provider information or no appropriate provider in Contractor'�s provider
network.
Prior Authorization
§103A(d)(5), (10), and (12) of
Part 1A relates to the exclusion
from prior authorization for STD, and HIV services and for an examination
to determine physical or sexual abuse.
Quality Measurement and Improvement Program
Clinical Study: §803(a)(7)
of Part 8 and §904(b)
of Part 9 relate to Contractor's
duty to conduct a study to assess the quality of family planning services
furnished to enrolled adolescents.
School-based Providers
Network Participation: §507
of Part 5 relates to the participation
of school-based health and related service providers in Contractor's
provider network and referral arrangements to school-based health centers.
MOU: §706(b)(2)
of Part 7 relates to the financial
and administrative responsibilities enumerated in a memorandum of understanding
regarding the furnishing of covered services by the state educational
agency or the Part C Lead agency.
Services for Adolescents
Preventive Services: §102B
of Part 1B relates to delivery of
screens, preventive services, and counseling to enrolled adolescents.
Self-Referrals:
§005(f)(1) of the Overview
relates to the right to self-referral for certain public health services,
including family planning, from any provider.
§005(g)(1) of the Overview
relates to the right to self-referral for covered items and services
from any school-based health center.
§104A of Part
1A relates to self-referral by an enrolled adolescent for family
planning, STD, and dental services to a provider in Contractor's network
without prior authorization.
User Guide for Community Health Centers2
The purchasing specifications include numerous provisions addressing
a wide range of issues. In the case of community health centers
that own or operate an MCO, all of these provisions are obviously relevant.
In the case of other centers, many of these issues directly or indirectly
affect them, whether they subcontract with an MCO or not. The following
provisions may be of particular interest to these centers. The provisions
are listed in alphabetical order.
Coverage Determinations
Evidence: §101A(b)(6)
of Part 1A relates to the use of
evidence from providers such as community health centers in connection
with Contractor's coverage determinations.
Notice: §102A(c)
of Part 1A requires notice of adverse coverage determinations to
publicly-supported providers (including community health centers) referring
the enrolled child for diagnosis or treatment.
Homeless3
Access to Out-of-Network Primary Care Providers: §510(e)
of Part 5 relates to Contractor's
duty under certain circumstances to permit a homeless child (or the
child's family or caregiver) to select a primary care provider that
does not participate in Contractor's provider network.
Assignment of Non-Selecting Children: §403(d)
of Part 4 relates to Contractor's
duty to assign a homeless child who does not select a primary care provider
to a network provider with experience in serving the homeless.
Definition: §1401(m)
of Part 14 defines a homeless
child.
Service Waiting Time: §603(c)(1)(D)
of Part 6 relates to Contractor's
duty to ensure that homeless children receive appointments with primary
care providers within a specified timeframe.
Information to Enrolled Children
Provider List: §304(a)(1)(B)
of Part 3 relates to the inclusion,
in the information given to new and potential enrollees, of the name
of the community health center with which a physician or other health
professional practices.
Involuntary Disenrollment
Children Receiving Treatment: §204(b)
of Part 2 relates to Contractor's
duty to ensure completion of treatment for children receiving treatment
at the time of involuntary disenrollment.
Children Not Receiving Treatment: §205
of Part 2 relates to Contractor's
duty to arrange for the transfer of the medical records of a child who
is not receiving treatment at the time of involuntary disenrollment
to the successor provider assuming responsibility for the care of the
child.
Migratory or Seasonal Agricultural Worker Families
Access to Out-of-Network Primary Care Providers: §510(d)
of Part 5 relates to Contractor's
duty under certain circumstances to permit a migrant child (or the child�s
family or caregiver) to select a primary care provider that does not
participate in Contractor's provider network.
Assignment of Non-Selecting Children: §403(c)
of Part 4 relates to Contractor's
duty to assign a migrant child who does not select a primary care provider
to a network provider with experience in serving migrant or seasonal
agricultural worker families.
Definition:
§1401(q) of Part
14 defines a migratory agricultural worker.
§1401(x) of Part 14 defines
a seasonal agricultural worker.
Service Waiting Time: §603(c)(1)(C)
of Part 6 relates to Contractor's
duty to ensure that migratory or seasonal farmworker children receive
appointments with primary care providers within a specified timeframe.
Network Providers
Enrollee Access to Network Providers: §501(f)
of Part 5 relates to the Contractor's
duty to make the services of any provider participating in Contractor's
provider network available to an enrolled child.
Traditional Provider: §508
of Part 5 relates to participation
of traditional Medicaid providers, including federally qualified health
centers, in Contractor's provider network, and to the reimbursement
of such providers.
Out-of-Network Providers
Payment
§510 of Part
5 relates to Contractor's duty regarding payment for covered services
furnished by out-of-network providers, including those with necessary
primary care expertise.
§1201(a)(6) of Part
12 relates to Purchaser payment of out-of-network providers and
Recoupment of payments from Contractor.
Access
§005(f) of the Overview
relates to Contractor's duty with respect to payment for certain public
health services (e.g., family planning and STD diagnosis and treatment)
received by enrolled children providers such as community health centers,
whether or not such providers participate in Contractor's provider
network.
§104A of Part
1A relates to Contractor's duty to allow self-referral by adolescent
enrollees for certain public health services (e.g., family planning
and STD diagnosis and treatment).
§103A of Part 1A relates to
Contractor's duty to exempt from prior authorization requirements
certain items and services, including immunizations, family planning
services and supplies, STD diagnosis and treatment, tuberculosis diagnosis
and treatment, and HIV diagnosis and treatment.
Referral by Contractor: §509(a)
of Part 5 relates to Contractor's
duty to refer enrolled children to out-of-network providers, including
community health centers, under certain circumstances and to reimburse
for such referrals.
Special Supplemental Food Program for Women, Infants, and Children
(WIC)
Coordination by Participating Providers: §501(g)
of Part 5 relates to Contractor's duty to ensure that providers in its
network coordinate with WIC programs.
Memorandum of Understanding: §704(e)
of Part 7 relates to Contractor's
duty regarding a memorandum of understanding with an interested State
WIC agency.
Referrals: §005(h)
of the Overview and §704(b) and
(c) of Part 7 relate to Contractor's
duty regarding referrals of enrolled children under age 5 to local WIC
providers.
User Guide for Service Coordination with
School Health 4
The purchasing specifications include numerous provisions addressing
a wide range of issues for SCHIP-eligible children and adolescents.
The review process focused on specific policies for school health issues,
including how IEPs and IFSPs can be coordinated with a child's traditional
medical services.5 The following provisions may
be of particular interest to purchasers interested in issues around school
health issues. The provisions are listed in alphabetical order.
IEPs and IFSPs
Coverage Determinations:
§101A(b)(7) of Part
1A relates to provisions of an IEP or an IFSP as evidence to be
considered in making coverage determinations.
§101A(c)(5) of Part
1A specifies prohibited grounds for denial or exclusion of services
with respect to an enrolled child in an IEP or an IFSP.
§102A(f)(3) of Part
1A specifies personnel qualified to make coverage determinations
for an enrolled child with an IEP or an IFSP.
Definitions:
§1401(n) of Part
14 defines an individual educational program (IEP) as a plan of
services developed by an educational agency which sets forth the special
education, health, medical, and other related services required by
a child.
§1401(o) of Part
14 defines an individualized family services plan (IFSP) as a
plan of services developed by an early intervention agency which sets
forth the early intervention services required by a child and the
child�s family or caregiver.
MOU:
§706(b) of Part
7 relates to the financial and administrative responsibilities
enumerated in a memorandum of understanding regarding the implementation
of IEPs and IFSPs for enrolled children.
Prior Authorization:
§103A(d)(7) of Part
1A relates to the exclusion of services provided under an
IEP or an IFSP from Contractor's prior authorization restrictions.
School-based Health Services: §005(g)
of the Overview relates to an enrolled child�s right to receive covered
services from any school-based health center and Contractor's duty with
respect to payment for school-based services received by enrolled children
from out-of-network providers.
Coverage Determinations:
§101A(c)(6) of Part
1A specifies prohibited grounds for denial or exclusion of services
with respect to services provided in a school setting.
School-based Providers
Network Participation:
§507 of Part
5 relates to the participation of school-based health and related
service providers in Contractor's provider network and referral arrangements
to school-based health centers.
- For additional information, see Access to Care
for S-CHIP Adolescents (Kaiser Commission on Medicaid and the Uninsured,
December 2000, www.kff.org); Improving and Adolescent
Health: An Analysis and Synthesis of Health Policy Recommendations and
Adolescents and the State Children's Health Insurance Program (CHIP):
Healthy Options for Meeting the Needs of Adolescents
(National Adolescent Health Information Center, September 1999, http://youth.ucsf.edu/nahic);
Adolescents in Public Health Insurance Programs: Medicaid and CHIP
(Center for Adolescent Health and the Law, December 1999, www.adolescenthealthlaw.org);
and Adolescent Health and Managed Care Information Packet (Society for
Adolescent Medicine,www.adolescenthealthlaw.org).
- For further discussion, see CHIP�s Impact on
Changing Service Delivery of Federal Health Centers, Dept. of Health and
Human Services, Office of Inspector General (October 1999), http://oig.hhs.gov/oei/reports/a417.pdf.
- See also GW CHSRP's Purchasing Specification
Medicaid Managed Care for Individuals Who Are Homeless (June 2000), available
at www.gwhealthpolicy.org/.
- For additional illustrative language on School-based
Health Center services in managed care, see GW CHSRP's Purchasing Specifications,
School-based Health Center Services, (January 2002), available at www.gwhealthpolicy.org/.
- For additional provisions, see GW CHSRP's Purchasing
Specifications, Medicaid Managed Care for Children with Special Health
Care Needs, (August 2000), available at www.gwhealthpolicy.org/.
