Medicaid Contract Purchasing SpecificationsPURCHASING MEDICAID MANAGED CARE FOR CHILDREN WITH BEHAVIORAL HEALTH NEEDSA TECHNICAL ASSISTANCE DOCUMENTChapter I: "Prime/Prime" ApproachTable of ContentsPart 1. Services for Children with Behavioral Health Needs§104. Substance Abuse Services §105. Case Management Services §105B. Inpatient Discharge Plan §108. Coverage Determination Standards and Procedures §101. In General (a) Basic Service Duty — Contractor shall, for each enrolled child with behavioral health needs (as defined in §110(f)), cover and furnish, or arrange for the furnishing of, the items and services enumerated under §102(a)in accordance with:
(b) Treatment Plan and Inpatient Discharge Plan _ Contractor shall, for each enrolled child with behavioral health needs (as defined in §110(f)), comply with:
(c) Delivery of Services — Contractor shall furnish, or arrange for the furnishing of, items and services covered under §102(a)for each enrolled child with behavioral health needs (as defined in §110(f)), in accordance with the requirements for delivery of services enumerated in Part 2. Commentary: The following illustrative language provides for the participation of an enrolled child's family or caregiver in certain aspects of management of the child's behavioral health needs by the Contractor, such as the development and implementation of the child's treatment plan. Participation would be voluntary on the part of the family or caregiver. Note that under this language the enrolled child would have no opportunity to object to such participation. (d) Family Participation
(3) Family Advisory Board — Contractor shall establish and maintain a Family Advisory Board that:
§102. Scope of Benefit Commentary: The December 17, 1997 letter from HCFA to State Medicaid Directors explains that each Medicaid risk contract with an MCO "...must include provisions that address the responsibility of the managed care entity to furnish care and services when medically necessary in sufficient detail to ensure that beneficiaries receive needed services to which they are entitled under the contract." With respect to behavioral health services for children, the most critical benefit category is Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services. All children eligible for Medicaid are entitled to EPSDT. This entitlement is of particular importance to children with behavioral health needs and the providers who serve them. See Medicaid Managed Care and Children with Special Needs: An EPSDT Checklist, http://www.nhelp.org/pubs/mc1997checklist-epsdt.html. The EPSDT benefit guarantees coverage of "screening services" which must, at a minimum, include "a comprehensive health and developmental history (including assessment of both physical and mental health development)." Section 1905(r)(1)(B)(i) of the Social Security Act, 42 U.S.C. §1396d(r)(1)(B)(i). The EPSDT benefit also guarantees that if a "mental illness or condition" is discovered during the course of an EPSDT screening, whether periodic or interperiodic, the child will be covered for all "necessary health care, diagnostic services, treatment, and other measures ...to correct or ameliorate" the illness or condition, "whether or not such services are covered under the State plan," so long as the service is eligible for federal matching funds. Section 1905(r)(5) of the Social Security Act, 42 U.S.C.§1396d(r)(5). For example, if a child is determined through an EPSDT screening to require family education and support services, and the state has not opted to cover rehabilitative services under 42 C.F.R. 440.130(d), the child is entitled to coverage for the family education and support services. Similarly, if a child is determined through a screening to need 6 months of residential treatment, and the state Medicaid plan covers only 1 month of such treatment per year for an adult, the child is entitled to coverage for the full 6 months of treatment. State Medicaid agencies are not required to contract with MCOs or BHOs for EPSDT services, or for the full scope of EPSDT services. Of course, the state remains responsible for coverage on a fee-for-service basis of those EPSDT services for which it does not contract with an MCO or BHO. To the extent that states do contract with BHOs for the provision of some or all EPSDT services, they remain accountable for the delivery of such services by the contracting BHOs. See Complaint and Consent Decree in John B. v. Menke, C.A. No. 3-98 0168 (M.D. Tenn., February 25, 1998), http://www.ichp.edu/managed/materials/902962074.html. The following language is designed to assist interested purchasers in articulating which EPSDT services will be provided under the purchasing agreement with the BHO, and which will remain the responsibility of the state Medicaid agency to pay for directly or to purchase through an agreement with an MCO. The delineation of responsibilities between a BHO and an MCO for furnishing EPSDT services in a "prime/prime" contracting arrangement is addressed in the illustrative language at §109 relating to joint MCO/BHO protocols. For illustrative language spelling out the EPSDT benefit, see Part 1 of the Medicaid Pediatric Purchasing Specifications (September, 1999)("MEDICAIDSPECS"), www.gwu.edu/~chsrp. For an analysis of EPSDT provisions in state Medicaid managed care contracts, see Rosenbaum, S., et al., "Key Findings in Pediatric Coverage and Services," Negotiating the New Health System, (3rd Edition, 1999) Volume 1, pp. 12 - 17, www.gwu.edu/~chsrp. (a) Covered Items and Services2 — Contractor shall furnish, or arrange for the furnishing of, to each enrolled child with behavioral health needs (as defined in §110(f)) the items and services that are:
(b) Items and Services for Which Purchaser or MCO Remains Responsible
§103. Mental Health Services — Mental health services covered under [drafter insert name of purchasing document] are: Commentary: The following illustrative language lists a number of categories of mental health services appropriate to children with behavioral health needs:
This listing is intended as guidance for interested purchasers in determining the particular benefits categories for which purchaser will contract with a "prime" BHO. A purchaser could select one, several, or all of these illustrative service categories as the basis for negotiating and purchasing a benefit package from a BHO. Because definitions of mental health services vary from state to state, the benefits categories set forth below may need to be adapted to a particular state's statutory and regulatory framework. For an overview of mental health service interventions for children and adolescents, see DHHS, Mental Health: A Report of the Surgeon General (1999), pp. 168-179. It is important to understand what this illustrative language is NOT intended to do. First, this language is not a recommendation for a minimum benefit package for children with behavioral health needs to be purchased through a BHO. Nor is it intended to reflect a professional consensus on a uniform set of mental health service categories or definitions of those categories. Instead, this illustrative language simply reflects the views of knowledgeable professionals who reviewed these purchasing specifications. Interested purchasers may wish to adapt the format and content of the following illustrative language to the mental health service definitions in common use in the purchaser's state. Interested purchasers may also wish to refer to other sources such as Moss, Contracting for Managed Substance Abuse and Mental Health Services: A Guide for Public Purchasers Center for Substance Abuse Treatment, SAMHSA (1998), Appendix C. Second, this language does not, and is not intended to, define mental health services to which Medicaid-eligible children are entitled or for which federal Medicaid matching funds are available. As discussed in the commentary accompanying §102 above, Medicaid-eligible children are entitled to EPSDT services, which include a range of mental health screening, diagnostic, and treatment services. These services are defined in each state's Medicaid plan or regulations in a manner consistent with applicable federal regulations, 42 C.F.R. 42 C.F.R. §§440.40(b), 441.50 et seq., and §§5150, 5123.2, 5240, and 5310 of the State Medicaid Manual, http://www.hcfa.gov/pubforms/progman, Pub. 45. Because these regulations and guidelines allow states discretion in the definition of individual services, these definitions tend to vary from state to state. For service categories and definitions used in state Medicaid risk contracts during 1997, see Negotiating the New Health System, (3rd Edition, 1999) Volume 2, Part 2, Table 2.2, pp. 2-390 - 2-600, www.gwu.edu/~chsrp. The following illustrative language has not been approved by HCFA; interested purchasers should not assume that the definitions set forth below are either required by Federal EPSDT law or are qualified for federal Medicaid matching payments. A recent review by the HHS Inspector General of Medicaid mental health managed care programs in 7 states concluded with a recommendation that HCFA encourage states to specify services for children's mental health in managed care contracts: "Providing more detailed specifications on services that managed care organizations will provide will help ensure that children receive the specialized care they require." DHHS Office of Inspector General, Mandatory Managed Care: Children's Access to Medicaid Mental Health Services (January 2000), OEI-04-97-00344, p. 2, www.dhhs.gov/progorg/oei. (a) Assessment, Diagnosis, and Related Services
Commentary: As discussed above, the contractor would be required under §102(a)(1) to furnish or arrange for the furnishing of the mental health services described in this section as selected by purchaser. If the screening services described in the following subparagraph (A) are included, the purchaser may wish to add language to §102(a)(1)allowing a contractor to waive the screening services requirement in the case of enrolled children who, within a specified time of enrollment, have been screened for developmental, health, and behavioral health needs.
(b) Crisis Services
(c) Nonresidential Treatment Services
Commentary: Many states employ day treatment models of service delivery that integrate educational and therapeutic services in neighborhood schools. These models offer an environment that more closely resembles an environment for children without disabilities or mental health conditions than do models involving institutionally based services. In these models, school districts, often in partnership with public mental health systems, implement programming that integrates educational and therapeutic components, using an IEP format that meets mental health and special education requirements.
(d) Residential Services
(e) Service Supports and Coordination Commentary: The following illustrative language describes two service categories, collateral contacts services and consultation services, that involve the exchange of medical information concerning an enrolled child with behavioral health needs. The provision of these services, like the provision of other covered services, would be subject to the confidentiality requirements set forth in §210.
§104. Substance Abuse Services — Substance abuse services covered under [drafter insert name of purchasing document] are: Commentary: The following illustrative language lists a number of categories of substance abuse services appropriate to children with behavioral health needs. This listing is intended as guidance for interested purchasers in determining which particular categories to contract for on a risk basis with a "prime" BHO. A purchaser could select one, several, or all of these illustrative service categories as the basis for negotiating and purchasing a benefit package from a BHO. Because definitions of substance abuse services vary from state to state, the benefits categories set forth below may need to be adapted to a particular state's statutory and regulatory framework (see, e.g., footnotes to subsections (h) - (j) below). It is important to understand what this illustrative language is NOT intended to do. First, this language is not a recommendation for a minimum benefit package for children with behavioral health needs to be purchased through a BHO. Nor is it intended to reflect a professional consensus on a uniform set of substance abuse service categories or definitions of those categories. Interested purchasers may wish to adapt the format and content of the following illustrative language to the substance abuse service definitions in common use in the purchaser's state. Interested purchasers may also wish to refer to other sources such as Moss, Contracting for Managed Substance Abuse and Mental Health Services: A Guide for Public Purchasers, Center for Substance Abuse Treatment, SAMHSA (1998), Appendix C. Second, this language does not, and is not intended to, define substance abuse services to which Medicaid-eligible children are entitled or for which federal Medicaid matching funds are available. As discussed in the commentary accompanying §102 above, Medicaid-eligible children are entitled to EPSDT services, which include a range of mental health screening, diagnostic, and treatment services. These services are defined in each state's Medicaid plan or regulations in a manner consistent with applicable federal regulations, 42 C.F.R. 42 C.F.R. §§440.40(b), 441.50 et seq., and §§5150, 5123.2, 5240, and 5310 of the State Medicaid Manual, http://www.hcfa.gov/pubforms/progman, Pub. 45. Because these regulations and guidelines allow states discretion in the definition of individual services, these definitions tend to vary from state to state. For service categories and definitions used in state Medicaid risk contracts during 1997, see Negotiating the New Health System, (3rd Edition, 1999) Volume 2, Part 2, Table 2.2, pp. 2-390 - 2-600, www.gwu.edu/~chsrp. The illustrative language below has not been approved by HCFA; interested purchasers should not assume that the definitions set forth below are either required by Federal EPSDT law or are qualified for federal Medicaid matching payments. (a) Assessment, Diagnosis, and Related Services — The services described in §103(a). (b) Crisis Services — The services described in §103(b). (c) Outpatient Services — Services for the evaluation of, treatment of, and recovery from substance abuse-related disorders furnished to an enrolled child with behavioral health needs (as defined in §110(f)) by a qualified substance abuse provider (as defined in §110(o)) in office practice sites, behavioral health clinics, primary care clinics, and other nonresidential sites that meet [drafter insert reference to state licensing or certification criteria] in regularly-scheduled sessions of fewer than [ ]4 hours per week. (d) Intensive Outpatient Treatment Services — Counseling and education regarding substance abuse-related disorders furnished to an enrolled child with behavioral health needs (as defined in §110(f)) by a qualified substance abuse provider (as defined in §110(o)) for [ ]5 or more hours per week in a setting other than a hospital or a residential treatment facility. (e) Partial Hospitalization Services — Medical, laboratory, and psychiatric services furnished on an ambulatory basis to an enrolled child with behavioral health needs (as defined in §110(f)) by a qualified substance abuse provider (as defined in §110(o)) for a period of up to [ ]6 hours per week in [drafter insert reference to state law definition of structured therapeutic settings]. (f) Residential Treatment Services — Services for the treatment of, and recovery from, substance abuse-related disorders furnished to an enrolled child with behavioral health needs (as defined in §110(f)) who lives in a residential treatment facility staffed 24 hours per day that is licensed or certified by the state under [drafter insert appropriate state law reference] by a qualified substance abuse provider (as defined in §110(o)). (g) Inpatient Hospital Services — Services for the evaluation of, treatment of, and recovery from substance abuse-related disorders furnished to an enrolled child with behavioral health needs (as defined in §110(f)) who is admitted to an acute care general hospital or acute psychiatric hospital licensed by the state under [drafter insert appropriate regulatory reference] furnished by a qualified substance abuse provider (as defined in §110(o)). (h) Ambulatory Detoxification Services — Services for the withdrawal from alcohol, opiates, or other drugs furnished by a qualified substance abuse provider (as defined in §110(o)) to an enrolled child with behavioral health needs (as defined in §110(f)) on an outpatient basis in a program certified by the state under [drafter insert reference to state licensure categories for outpatient chemical dependency programs for children and adolescents].7 (i) Residential Detoxification Services — Services for the withdrawal from alcohol, opiates, or other drugs furnished by a qualified substance abuse provider (as defined in §110(o)) to an enrolled child with behavioral health needs (as defined in §110(f)) in [drafter insert reference to state licensure categories for residential treatment facilities for children or adolescents with chemical dependency].8 (j) Inpatient Detoxification Services — Services for the withdrawal from alcohol, opiates, or other drugs furnished by a qualified substance abuse provider (as defined in §110(o)) to an enrolled child with behavioral health needs (as defined in §110(f)) in a hospital, [drafter insert state law term for "step-down" unit], or other facility licensed or certified by the state to medically manage detoxification of children or adolescents under [drafter insert appropriate state law references].9 (k) Service Supports and Coordination — The services described in §103(e) (relating to collateral contracts services, consultation services, transportation services, wrap-around services and supports, and case management services). §105. Case Management Services Commentary: The following illustrative language assumes that the Purchaser wishes to provide case management services to children with behavioral health needs through the contracting BHOs in which such children are enrolled. It should be noted that states are not required to offer case management services to Medicaid beneficiaries generally, or to this population in particular, and some states may not cover these services for this population as a whole. (Of course, for an individual child who is determined through an EPSDT screen to have a medical need for case management services, such services must be covered even if they are not generally covered by under the state's Medicaid program). For a review of the case management models used by Colorado, Delaware, New Mexico, Oregon, and Washington with respect to various beneficiary populations, see Rosenbach and Young, Care Coordination in Medicaid Managed Care: A Primer for States, Managed Care Organizations, Providers, and Advocates (March 2000), www.chcs.org. The federal Medicaid statute does not contain a single "case management services" category. Instead, Medicaid covers services of this type under:
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:
The following sample specifications assume that, in the case of Medicaid-eligible children, that the services characterized as "case management" services for purposes of this purchasing agreement are covered under the state's Medicaid plan. These specifications also assume that these "case management" services are covered under the state Medicaid plan as services, not as administrative costs, and are therefore eligible for federal matching payments at the state's regular matching rate, just as any other Medicaid service covered under this purchasing agreement. Note, however, that it is not possible to state with certainty that the case management services set forth in the following illustrative language would qualify for federal Medicaid matching funds. That determination can be made only by HCFA. (a) In General — Contractor shall comply with the requirements of this section relating to:
(b) Selection of Case Manager Commentary: The following illustrative language assumes that the family or caregiver of an enrolled child with behavioral health needs has the option of refusing to accept a case manager for the child. It also assumes that the family or caregiver has the option of declining to accept the particular case manager Contractor wishes to assign to the child. The language would not, however, require Contractor to hire or subcontract with any particular case manager in order to meet the wishes of the family or caregiver. The family or caregiver's choice would be limited to those case managers (including a member of the multidisciplinary team, if the family or caregiver so chooses).
Note: need to address reassignment of case manager (c) Responsibilities of Case Manager — Contractor shall ensure that, in the case of an enrolled child with behavioral health needs (as defined in §110(f)) who has selected or been assigned to a case manager under subsection (b), the case manager, consistent with the prohibition in §108(b)(3)(relating to utilization management), shall:
Commentary: The illustrative language in paragraph (7) assumes that the BHO's case manager has the responsibility for assisting an enrolled child's family or caregiver in having payment made for services covered under a state's Medicaid program that are not the duty of the BHO. Another approach would be for the family or caregiver to be referred to appropriate state or local agencies.
Commentary: In tracking a child's progress under a treatment plan, the child's case manager will need to have access to information regarding the services provided to the child. The following illustrative language assumes that Contractor will have such information with respect to the services received by the child from providers participating in Contractor's provider network, and that Purchaser will have information with respect to services received from providers outside of Contractor's provider network that bill Purchaser for the care they furnish to the child.
§105A. Treatment Plan Commentary: The following illustrative language would require Contractor to develop a treatment plan for each enrolled child with behavioral health needs. These children exhibit a wide variety of behavioral health conditions. Treatment plans will vary depending upon the complexity of a child's behavioral health needs: children with multiple diagnoses are likely to require more extensive treatment plans than those with less complex needs. The following illustrative language is designed to identify the elements of a treatment plan regardless of the complexity of the child's needs. (a) Duty to Develop Treatment Plan for Enrolled Children with Behavioral Health Needs — In the case of an enrolled child with behavioral health care needs (as defined in §110(f)), Contractor shall comply with the requirements of subsections (b), (c) and (d). (b) Development of Treatment Plan — Contractor shall ensure that the child's multidisciplinary team under §204 shall develop, no later than the date described in paragraph (3), a treatment plan for the child consistent with the consultation requirements of paragraph (1), the family participation requirements of paragraph (2), and the requirements to update the treatment plan under paragraph (5).
Commentary: The following illustrative language would require periodic updating of the treatment plan of each enrolled child with behavioral health needs. The updates would have to be done at a frequency determined by the contracting BHO and the purchaser through negotiations. The duty on the Contractor to update periodically would expire when the enrollee is no longer a child with behavioral health needs as defined in §110(d) — i.e., is age 21 or older, or no longer has behavioral health needs.
Commentary: In some states, the treatment plan serves as a payment authorization specifying the items and services that do not require prior approval from Contractor's utilization control procedures. For illustrative language implementing this approach, see §108(c)(2). The following illustrative language would require that a treatment plan identify not only the services for which the Contractor is responsible, but also the services needed by the child for which the Purchaser or the child's MCO is responsible. This should assist the child's family or caregiver in knowing which party is responsible for covering each particular item or service needed by the child. (c) Contents of Treatment Plan — A treatment plan, developed under subsection (b), for an enrolled child with behavioral health needs (as defined in §110(f)) shall:
Commentary: The following illustrative language in paragraph (5) addresses those cases in which enrolled children with behavioral health needs are receiving services under an IEP or other treatment plan developed independently of Contractor. Under this language, Contractors would be required to furnish services identified in the child's IEP or other treatment plan even if the child's multidisciplinary team did not judge those services to be necessary to meeting the child's behavioral health needs, but only so long as the services are specified as covered under the agreement with the Purchaser as per §102(a). For example, if a child's IEP called for the provision of family education and support services, but the child's multidisciplinary team did not indicate that such services are necessary, the Contractor would be obligated to furnish the services if they are included in its agreement with Purchaser under §102(a). On the other hand, if a child's IEP called for the provision of ventilator or physical therapy services, the BHO would not have the duty to furnish such services because they presumably would not be included in the BHO's agreement with the Purchaser under §102(a)(such services are generally furnished by MCOs, not BHOs).
(d) Standing Referrals to Behavioral Health Providers Specified in Treatment Plan
Commentary: The following illustrative language addresses the relationship between Medicaid and the Individuals with Disabilities Education Act (IDEA). Under Federal Medicaid law, §1903(c) of the Social Security Act, 42 U.S.C. §1396b(c), States must pay for items and services covered under their state Medicaid plan even if the item or service is also required under a child's IEP or IFSP: "Nothing in this title shall be construed as prohibiting or restricting, or as authorizing the Secretary [of HHS] to prohibit or restrict, payment [for services covered under Medicaid to a child with behavioral health needs] because such services are included in the child's [IEP or IFSP]." HCFA has issued a clarification of its policy vis-à-vis state claiming for school health-related transportation services for children with IEPs under the IDEA in (1) a Letter to State Medicaid Directors (May 21, 1999), www.hcfa.gov/medicaid/smd52199.htm and (2) a draft Guide on Medicaid School-Based Administrative Claiming (February 2000), www.hcfa.gov. There has been some critical commentary on the draft Guide; for example, the Department of Education has recommended that HCFA revise the draft because, in its view, the draft "could be harmful by limiting access by school districts to Medicaid reimbursement for some activities that should be claimable...." HCFA recently testified before the Senate Finance Committee that "[o]nce we have reviewed the feedback, we expect to make changes before issuing a final Guide." Testimony of Tim Westmoreland, Director, HCFA Center for Medicaid and State Operations (April 5, 2000), www.senate.gov/~finance/4-5hcfa.htm. (e) Coordination of Treatment Plans with IFSPs or IEPs — In the case of an enrolled child with behavioral health needs (as defined in §110(f)) who is receiving services under an IFSP (as defined in §110(i)) or an IEP (as defined in §110(h)) (whether or not at the time of enrollment), Contractor shall:
Commentary: The following illustrative language would clarify that the "natural environment" and "least restrictive environment" requirements of federal law apply to Contractors in the delivery of services through their own provider networks. In some states, early intervention services are provided by free-standing, state-certified agencies that do not participate in MCO provider networks. The following language would not impose any obligations upon Contractors with respect to services furnished to enrolled children by such free-standing, out-of-network agencies.
§105B. Inpatient Discharge Plan Commentary: The Surgeon General recently noted: "Under public managed care, hospitalization for mental disorders is being substantially cut, with youths being discharged from the hospital before adequate personal and/or community safety plans can be instituted. Child welfare and juvenile justice agencies have been compelled to create and pay for services to support those children who are no longer kept in hospitals. Thus, while Medicaid's mental health costs may be decreasing in such cases, there may be a substantial cost increase to the other agencies involved, resulting in little, if any, overall cost saving." DHHS, Mental Health: A Report of the Surgeon General (1999), p. 185. The following illustrative language relating to inpatient discharge plans is based on a provision in a directive agreed to by the State of Tennessee and Medicaid beneficiaries in litigation relating to access to EPSDT services by children with behavioral health needs. Under the court-approved language, the State has agreed that it and its BHO contractors shall:
In addition to the requirement for an inpatient discharge plan, the State of Tennessee and its BHO contractors are also subject to a separate notice requirement in the event that inpatient psychiatric hospital services are being terminated:
Because the discharge plan would be linked to a particular inpatient episode, it by definition would not be as comprehensive as the treatment plan described in §105A. Under the illustrative language below, Contractor would have to ensure the inclusion of any discharge plan in the child's broader treatment plan in order to promote coordination of care. (a) Duty — In the case of an enrolled child with behavioral health needs (as defined in §110(f)) who is admitted to a psychiatric or chemical dependency inpatient facility or a residential treatment facility, Contractor shall ensure that:
(b) Content of Written Discharge Plan — A written discharge plan shall:
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Commentary: Under the "prime/prime" approach to contracting for managed behavioral health services, the purchaser (generally the state Medicaid agency) enters into contracts with one or more MCOs and one or more BHOs for the provision of services to Medicaid enrollees and makes capitation payments directly to both the MCOs and the BHOs. The MCOs furnish medical care; the BHOs, behavioral health services. Of course, the line between medical care and behavioral health services is not always clear, and there can be substantial overlap between the two categories. The illustrative language in this Chapter is designed to assist interested purchasers, MCOs and BHOs in clarifying the allocation of responsibility for these overlapping service categories.
In some instances (e.g., Tennessee), all Medicaid beneficiaries are enrolled in both an MCO and a BHO, whether or not they have behavioral health needs. In other cases (e.g., Hawaii), all Medicaid beneficiaries are enrolled in MCOs, but only those identified as having behavioral health needs are enrolled in BHOs. The illustrative language in this Chapter assumes that a purchaser has decided to enroll Medicaid-eligible children in a BHO only if the children have been identified either by the purchaser or by the other "prime" contractor (e.g., the MCO), as needing behavioral health services. Thus, the Chapter does not contain language relating to the identification of children with behavioral health needs. Instead, it focuses on the duties that the BHO owes to the children enrolled in it: what services it must cover, how it should deliver those services, and how its service duties relate to those of the MCO in which the child is also enrolled. Purchasers that elect to enroll all Medicaid-eligible children in a BHO may wish to refer to the illustrative language in Chapter II: " Prime/Subprime" relating to identification of children with behavioral health needs (§102).