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Medicaid Contract Purchasing Specifications
Access to Services
Part
A3. Services That Promote Access85
A Technical Assistance Document
June, 2000
§A3-1.
Transportation Services 86
§A3-2. Care Coordinator Services
§A3-3. Information Services
Print PDF File
A3-1.
Transportation Services 87
(a)
Emergency transportation - In complying with the requirements of
§A1-1relating to access to emergency services,
Contractor shall ensure that ambulance or other transport for emergency
services (as defined in §A1-1(b)) arrives
to secure the enrollee by or for whom emergency transport is requested:
(1) within [ ] 88minutes
of receipt of the request on Contractor's toll-free telephone line described
in §A2-5(a)(2); or
(2) within [ ] minutes of
receipt of the request by [drafter insert reference to local 911 agency].
(b) Non-emergency
transportation 89
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(1) Duty of Payment
(A) Duty of Contractor
- Contractor shall make payment for the costs of transportation (as
defined in paragraph (5)) incurred on behalf of an enrollee (and in
the cases described in paragraph (4), an attendant) travelling to
and from a site (whether a physician's office, clinic, hospital, or
other location) at which the enrollee may receive:
(i) urgent services described
in §A1-2;
(ii) preventive and routine
services described in §§A1-3and A1-4;
or
(iii) diagnostic services
integral to the furnishing of the services described in clauses
(i) and (ii).
(B) Enrollee Cost-Sharing
- If an enrollee using transportation services is specifically responsible
under [drafter insert reference to applicable provisions of State
Medicaid Plan] for the payment of any copayment or coinsurance amount
for such service, Contractor shall:
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(i) not be required to
make payment under subparagraph (A) for the copayment or coinsurance
amounts, if any; and
(ii) ensure that the
transportation service provider does not withhold the provision
of transportation services in the event of a failure by the enrollee
to pay the copayment or coinsurance amount. 90
(2) Role of Care Coordinator
- Contractor shall ensure that an enrollee's care coordinator under
§A3-2 arranges for transportation services
as required under §3-2(b)(2)(A) (relating
to enrollees without treatment plans) and §§A3-2(a)(4)(A)
(relating to enrollees with treatment plans).
(3) Mode
(A) In General -
As authorized under 42 C.F.R. §440.170(a)(3)(i), Contractor shall
make payment for transportation required under paragraph (1) through
taxicab, common carrier, or other appropriate means, including [drafter
insert name of transportation facilities of community-based nonprofit
service organizations serving the area in which enrollees reside].
(B) Enrollees with Disabilities — As required by §A4-1, Contractor shall
ensure that, in the case of an enrollee with physical disabilities,
the mode of transportation for which payment is required under paragraph (1) is accessible to the enrollee.
(4) Attendants - As
authorized under 42 C.F.R. §440.170(a)(3)(iii), Contractor shall furnish,
or arrange for the furnishing of or the payment for, transportation
required under paragraph (1) (and, if the attendant is not a member
of the enrollee's family, a salary) for an attendant to an enrollee
under the following circumstances:
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(A) the enrollee is a child
under age [ ] and the attendant is the child's parent, caregiver,
or attendant; or
(B) the enrollee is an
individual with disabilities who requires the services of an attendant.
(5) Costs of Transportation
91- For purposes of this section, as authorized
under 42 C.F.R. §440.170(a), the costs of transportation for which Contractor
shall make payment are:
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(A) the cost of ambulance,
taxicab, common carrier, or other appropriate mode of transportation;
(B) the cost of meals and
lodging en route to and from medical care, and while receiving medical
care; and
(C) the cost of an attendant
to accompany the enrollee, the cost of the attendant's transportation,
meals, lodging, and, if the attendant is not a member of the enrollee's
family, a salary.92
(6) Construction -
The duty of payment described in paragraph (1) shall apply with respect
to the costs of transportation (as defined in paragraph (5)) whether
incurred between the enrollee's home and a site or between a hospital
or other facility in which the enrollee resides and a site.
Compliance Measures:
Contractor shall make available on request to Purchaser:
(1) Copies of provisions
of Contractor's operating manual, provider manual, memoranda and other
materials relating to emergency transportation for enrollees; and
(2) Copies of provisions
of Contractor's operating manual, provider manual, memoranda, and other
materials relating to non-emergency transportation for enrollees.
A3-2.
Care Coordinator Services 93
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(a) Duty with
respect to Enrollees with Treatment Plans -94
In the case of an enrollee with a treatment plan under [drafter insert
reference to relevant provisions in Purchasing Agreement], 95Contractor
shall ensure that a care coordinator (as defined in subsection (d)), consistent
with the prohibition against utilization management in subsection (c),
shall:
(1) review and explain the
contents of the treatment plan with the enrollee;
(2)
assist the enrollee in accessing:
(A) items and services
and providers specified in the treatment plan; and
(B) items and services
not described in subparagraph (A) but covered under [drafter insert
name of Purchasing Agreement];
(3) review and update the
treatment plan with the primary care provider and the enrollee at least
every [ ] months;
(4) arrange for:
(A) transportation services
described in §A3-1; and
(B) interpreter services
described in [drafter insert reference to relevant provisions in Purchasing
Agreement];
(5) refer the enrollee to,
and assist the enrollee in obtaining timely access to, [drafter insert
references to appropriate agencies and programs];
(6) facilitate, consistent
with [drafter insert references to confidentiality protections under
state law and Purchasing Agreement], the exchange of information and
medical records among Contractor, the enrollee's primary care provider,
specialists, and [drafter insert references to appropriate agencies
and programs];
(7) assist the enrollee in
invoking grievance and appeal rights under the Contractor's grievance
procedure and the State fair hearing process; and
(8) assist the enrollee in
documenting, establishing, and maintaining the enrollee's eligibility
for [drafter insert references to state Medicaid program and other public
program benefits].
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(b) Duty with
respect to Enrollees without Treatment Plans - In the case of [drafter
insert description of enrollees not described in subsection (a) to whom
Purchaser seeks to extend the less intensive care coordination services
specified below], Contractor shall make available to the enrollee within
[ ] days of enrollment the names and office phone numbers of care coordinators
employed by Contractor or participating in Contractor's provider network:
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(1) from whom the enrollee
may obtain information on how to access items and services covered under
[drafter insert name of Purchasing Agreement]; and
(2) through whom the enrollee
may arrange for:
(A)
transportation services described in §A3-1;
and
(B) interpreter services
described in [drafter insert reference to relevant provisions of Purchasing
Agreement]; and
(3) inform the enrollee of
the enrollee's grievance and appeal rights under the Contractor's grievance
procedure and the State fair hearing process.
(c) Prohibition
Against Use of Care Coordinator for Utilization Management96
(1) Prohibition on Participation
in Coverage Determination - Contractor shall ensure that no care
coordinator (as defined in subsection (d)) participate directly in a
determination as to whether an item or service sought by an enrollee
for whom the care coordinator is responsible will be covered under [drafter
insert name of Purchasing Agreement]. 97
(2) Provision of Information
for Coverage Determination - Contractor may authorize a care coordinator
to provide to the individuals responsible for coverage determinations
under [drafter insert reference to provisions on coverage determination
standards and procedures in Purchasing Agreement] information material
to the determination regarding an enrollee for whom the care coordinator
is responsible, but only if the enrollee consents to the provision of
such information. 98
(d) Care Coordinator
Defined - A care coordinator is [drafter insert reference to applicable
provisions of Purchasing Agreement].
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Compliance Measures:
Contractor shall make available on request to Purchaser:
(1) the name and practice
site address of each care coordinator;
(2) the number of
enrollees for which each care coordinator has responsibility;
(3) the credentialing
rules and other criteria for selection of care coordinators;
(4) provider manuals
or protocols relating to responsibilities of care coordinators; and
(5) a copy of the focus study under §A2-11 on access to
care coordinators by enrollees with treatment plans.
§A3-3.
Information Services 99 Top
(a) Basic
Information Services - Contractor shall comply with:
(1) the requirements of §A2-5(a)(2)
relating to the maintenance of a toll-free telephone line for enrollees
for emergency or urgent care services;
(2) the requirements of subsection
(c) relating to the maintenance of a toll-free-telephone line for general
enrollee information; and
(3) [drafter insert reference
to provisions in Purchasing Agreement relating to contents and distribution
of enrollee handbook, provider directory, and health education information].
100
(b) New Enrollees
- In addition to meeting the basic information requirements under subsection
(a), Contractor shall, with respect to new enrollees (as defined in subsection
(d)):
(1) offer an orientation
within [ ] days of enrollment on a group basis 101
by a qualified individual or by video to explain:
(A) how items and services
covered under [drafter insert name of Purchasing Agreement] are accessed;
(B) the rights and responsibilities
of enrollees under [drafter insert name of Purchasing Agreement];
and
(C) [drafter insert other
information to be provided];
(2) who have not had an encounter
with a provider participating in Contractor's provider network within
[ ] 102days of enrollment, ensure that
at least [ ] attempts are made to establish telephone contact with the
enrollee;
(3) make available the toll-free
enrollee information line described in subsection (c)(1); and
(4) [drafter insert other
information services].
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(c) Enrollee
Information Line103- Contractor
shall maintain and staff on a [ ] hour per day, [ ] day per week basis,
a toll-free enrollee information line for use by the enrollee to:
(1) obtain information on
how to access items and services covered under [drafter insert name
of Purchasing Agreement];
(2) automatically transfer
requests for emergency or urgent care to the toll-free line maintained
by Contractor under §A2-5(a)(2);
(3) arrange for:
(A) transportation services
described in A3-1; and
(B) interpreter services
described in [drafter insert reference to relevant provision of Purchasing
Agreement];
(4) inform the enrollee of
the enrollee's grievance and appeal rights under the Contractor's grievance
procedure and the State fair hearing process; and
(5) provide information on,
and upon request by the enrollee, referral to local, state, or federal
agencies that are responsible for the provision of:
(A) housing assistance;
(B) nutritional assistance;
(C) [drafter insert other
federal and state programs]; and
(D) [drafter insert other
enrollee services].
(d) New Enrollee
Defined - For purposes of this section, a new enrollee is an individual
who:
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(1) has been enrolled in
Contractor for no more than [ ] months; and
(2) prior to the individual's
current enrollment, has not been enrolled for a period of [ ] months.
Compliance Measure: Contractor
shall make available to Purchaser on request all handbooks, pamphlets,
and other written information given to potential and new enrollees.
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Endnotes:
- Commentary:
The Oregon Primary Care Association and the American Express Tax and Business
Services have identified 7 categories of enabling services for purposes
of establishing a statewide fee schedule for such services (February,
1999). These categories are: case management, eligibility assistance,
health education, interpretation, information and referral, outreach,
and transportation. The illustrative language in this Part addresses 3
of these categories (transportation, case management, and information
and referral). The forthcoming cultural competence specifications will
address interpreter services. The remaining 3 categories (eligibility
assistance, outreach, and health education) are not addressed. See also
Bernstein and Falik, Enabling Services: A Profile of Medicaid Managed
Care Organizations, Kaiser Commission on Medicaid and the Uninsured, October
2000, (publication #2214) http://www.kff.org.
This report examined the extent to which Medicaid MCOs were providing
such enabling services as transportation, interpretation and translation,
education and community outreach, and case management services and the
scope of these enabling services.
- Commentary:
Of the 3 service categories set forth in this Part, only transportation
services are required by federal law to be covered by State Medicaid programs.
As discussed in footnote 81, States may but are not required to contract
with MCOs for the provision of such services.
- Commentary:
Under federal law, state Medicaid programs are required to "ensure necessary
transportation for recipients to and from providers," 42 C.F.R. §431.53.
Transportation services include "expenses for transportation and other
related travel expenses determined to be necessary by the [State Medicaid]
agency to secure medical examinations and treatment for a recipient."
42 C.F.R. §440.170(a)(1). "Travel expenses" are defined to include "(i)
the cost of transportation for the recipient by ambulance, taxi cab, common
carrier, or other appropriate means; (ii) the cost of meals and lodging
en route to, and from, medical care, and while receiving medical care;
and (iii) the cost of an attendant to accompany the recipient, if necessary,
and the cost of the attendant's transportation, meals, lodging, and, if
the attendant is not a member of the recipient's family, salary." 42 C.F.R.
§440.170(a)(3). A state Medicaid agency does not have to contract with
an MCO for the provision of required transportation services for MCO enrollees;
it may "carve out" these services from the risk contract. The following
illustrative language assumes that the state purchaser has decided to
purchase transportation services from the MCO, either on a risk basis
or on a separate "cost-incurred" basis. For language in state Medicaid
MCO contracts relating to transportation services, see Tables 2.1 and
2.6, Negotiating the New Health System, 3rd Ed., Volume 2, Part 2 www.gwu.edu/~chsrp/contracts.html.
- State
contract provisions specify within 30 minutes travel time or a response
to ambulance within 15 minutes.
- In a state
with public transportation, an alternative option would be to require
Contractor to agree to become a party to the State's agreement with the
transportation authority to offer bus or rail passes to enrollees. The
capitation rate shall include a per-member per month for such transportation
services.
- Commentary:
Under federal Medicaid law, States have the option of imposing nominal
cost-sharing amounts upon certain groups of beneficiaries with respect
to certain types of services. For example, no cost-sharing may be imposed
on any child under 18 with respect to any covered service, §1916(a)(2)(A)
of the Social Security Act, 42 U.S.C. §1396o(a)(2)(A). For additional
information on cost-sharing, see Families USA, A Guide to Cost-Sharing
and Low-Income People (October 1997), http://www.familiesusa.org/factlow.htm.
- Commentary:
For additional information, see National Health Law Program's Q & A on
Transportation Costs(April 26,2000),www.healthlaw.org/pubs/200004QandA.html.
- An alternative
option would be to add the following costs which are not expressly authorized
under 42 C.F.R. §440.170: "(D) in the case of a family with an enrolled
child in need of transportation to a provider with one or more siblings
under the age of [ ] who is not in need of transportation, the cost of
child care for the siblings while the parent and enrolled child are en
route to and from medical care."
- Commentary:
Federal Medicaid matching funds are available for a wide range of "case
management" services. The federal Medicaid statute does not contain a
"care coordinator services" category. Instead, Medicaid covers services
of this type under:
(1) the mandatory early and
periodic screening, diagnostic, and treatment (EPSDT) services benefit
category, §1905(r) of the Social Security Act, 42 U.S.C. §1396d(r);
(2) the optional targeted
case management benefit, §1915(g) of the Social Security Act, 42 U.S.C.
§1396n(g); and
(3) home and community-based
services, §1915(c)(4)(B) of the Social Security Act, 42 U.S.C. §1396n(c)(4)(B).
HCFA's State Medicaid Manual
at §4302.2H notes that "Care coordination, including aspects of case management,
has always been an integral component of the EPSDT program§." Medicaid
makes a further distinction between administrative case management services
(such as intake processing, eligibility determinations, and outreach)
which the federal government will match at a 50 percent rate, and non-administrative
case management services, such as EPSDT services and targeted case management
services, which are matched at each state's regular matching rate for
services (ranging from 50 to 80 percent). HCFA's State Medicaid Manual
§4302.2H explains that when case management services are found to be medically
necessary, states have several options:
(1) EPSDT: "Case management
services may be provided to persons participating in the EPSDT program
by an existing service provider such as a physician or clinic referring
the child to a specialist.
(2) Administrative Case Management:
"Case management services may be provided to EPSDT participants by the
Medicaid agency or another state agency, such as Title V, the Health
Department, or an entity with which the Medicaid agency has an interagency
agreement."
(3) Targeted Case Management
Services: "The service must meet the statutory definition of case management
services as defined in §1915(g)" (e.g., "services which will assist
individuals eligible under the plan in gaining access to needed medical,
social, educational, and other services").
- For a
detailed discussion of Medicaid coverage of case management services in
the context of child development services for children up to 3, see Rosenbaum
and Sonosky, "Case Management as a Medicaid-covered Services" GW CHSRP
Memorandum to Commonwealth Fund's ABCD Grantees (May, 2000), forthcoming
on www.nashp.org. For language in state
Medicaid MCO contracts relating to care coordination or case management
services, see Table 2.1, Negotiating the New Health System, 3rd Ed., Volume
2, Part 2 www.gwu.edu/~chsrp/contracts.html.
- Commentary:
Models for identifying the need for, and providing care coordination or
case management services to, a population of enrollees may vary. For illustrative
language on both identification of, and provision of services to, different
populations, see CHSRP's purchasing specifications with respect to HIV/AIDS
(August 1999) and individuals who are homeless (June 2000), www.gwu.edu/~chsrp;
children with special health care needs (forthcoming); children with behavioral
health needs (forthcoming).
- Commentary:
There is no consensus on the appropriate role for a care coordinator in
the MCO's decision-making as to whether an item or service will be covered
for an enrollee for whom the care coordinator is responsible. Some believe
that, because of his or her knowledge of the enrollee's circumstances,
the care coordinator is the most appropriate person to make coverage determinations
affecting that enrollee. For example, some MCOs use care coordinators
both to review the use of inpatient services by enrollees whose care they
manage and to promote the enrollees' access to covered outpatient services.
Others believe that the care coordinator's primary responsibility is to
advocate within the MCO on behalf of the enrollee for all covered services,
and that requiring the care coordinator to manage the enrollee's utilization
of services would be inconsistent with this responsibility. The illustrative
language attempts to strike a balance between these two views.
- An alternative
option would be to limit the prohibition on participation of the care
coordinator in utilization management to cases in which the enrollee's
primary care provider is also the enrollee's care coordinator.
- An alternative
option would be to authorize the provision of such information to individuals
responsible for coverage determinations whether or not the enrollee consents.
- For language
in state Medicaid MCO contracts relating to information to enrollees,
see Tables 1.5 and 1.6, Negotiating the New Health System, 3rd Ed., Volume
2, Part 1, www.gwu.edu/~chsrp.
- For
illustrative language on information services for Medicaid-eligible children
enrolled in MCOs, see Part 3 of CHSRP, Optional Purchasing Specifications:
Medicaid Managed Care for Pediatric Services, ../peds/nov99/toc.html.
- An alternative
option would be to require Contractor to make telephone contract with
the new enrollee to inform the individual of the items in subparagraphs
(A) through (C).
- State
contract provisions specify contact within 45 days of effective date of
enrollment to encourage enrollee to schedule an appointment for baseline
physical or contact within 5 business days of enrollment to provide information
on PCP selection options.
- Commentary:
Sections A2-5(a)(2)and A2-9(a)would
require Contractor to maintain separate toll-free lines for emergency
and urgent care services and for prior authorization requests, respectively.
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