These sample purchasing specifications were prepared by the George
Washington University Center for Health Services Research and
Policy (CHSRP) with support from the Commonwealth Fund. Technical
guidance on the content of child development services was provided
by experts from the Fund and researchers at Northwestern University's
Institute for Health Services Research & Policy Studies (IHSRPS).
This document is intended as a tool to assist interested state
officials in purchasing child development services from managed
care organizations (MCOs) on behalf of children under age three
who are eligible for Medicaid.
These sample purchasing specifications are optional, and
do not necessarily reflect the views of the Commonwealth Fund
or the Health Care Financing Administration (HCFA).
These child development specifications are a work in process.
The knowledge base relating to child development services is still
evolving. Many of the concepts reflected in these specifications
reflect the "cutting edge" of pediatric practice with respect
to children under age 3 who do not have special health care needs.
As further research and field experience with the provision of
child development services in Medicaid MCOs become available through
the Fund's or other initiatives, these purchasing specifications
will be updated accordingly.
Background
Child Development
Services. There is no universal definition of child development
services. Different state purchasers define these services differently.
As used in these purchasing specifications, child development
services are a set of four interrelated benefits for all children
during the first 2 years of life: (1) screening and developmental
assessment; (2) health promotion; (3) developmental interventions;
and (4) care coordination. This concept of child development services,
which draws upon the work of Neal Halfon, M.D., M.P.H., UCLA School
of Medicine and Health for The Commonwealth Fund, is designed
to address cognitive, emotional, and physical development in children
without special health care needs as well as those with such needs.1
The ABCD Program.2
The Assuring Better Child Health and Development (ABCD) program
is an initiative of The Commonwealth Fund to improve the delivery
and financing of child development services for young children
in low-income families. The major goals of the program include:
(1) identifying innovative state programs that promote the healthy
development of low-income children; (2) analyzing financial incentives
and quality standards for the provision of cost-effective pediatric
developmental services; and (3) encouraging Medicaid and other
state and local programs to implement improvements in the delivery
and financing of developmental services for young low-income children.
In a February 2000 Issue Brief, the Commonwealth Fund found
that:
"Medicaid managed care offers additional, specific opportunities.
States could work collaboratively with plans to improve care,
using their power as purchasers to ensure that important services
are properly provided. These options may include:
- Using specifications in contract language to communicate
policies on pediatric development services to managed care plans;
- Encouraging agreements between plans and public health agencies
to ensure proper delivery of services;
- Making additional payments to MCOs to cover incremental costs
associated with specific child development services, and enhancing
capitation rates for those plans and pediatricians that provide
more comprehensive child development services; and
- Enhancing capitation payments for primary care clinicians."
3
These sample child development specifications are intended to
facilitate the inclusion of pediatric developmental services into
the contracts that state Medicaid agencies use to purchase coverage
for low-income children through managed care plans. Further information
about the ABCD program is available at www.cmwf.org.
The Commonwealth Fund is also sponsoring a 3-year initiative
to provide grants to states to develop or expand service delivery
and financing strategies to enhance healthy child development
for low-income children and their families. The initiative is
taking place in 4 states (North Carolina, Utah, Vermont, and Washington);
it is administered by the National Academy for State Health Policy.4
Healthy Steps. The ABCD program
draws upon the ongoing work of the Healthy Steps for Young Children
program, a national initiative of The Commonwealth Fund, co-sponsored
with the American Academy of Pediatrics. The purpose of Healthy
Steps is to test a new approach to the delivery of pediatric services
that provides parents and practitioners information about the
intellectual, emotional, and social development that takes place
during the first 3 years of life. The Healthy Steps approach is
being tested in 24 pediatric and family practice sites across
the country, 15 of which are part of a national evaluation. The
sites are coordinated and supported by the Commonwealth Fund,
as well as community-based foundations and local health care providers.
Further information is available at www.healthysteps.org.
Medicaid. Medicaid is the federal-state
entitlement program that insures over 20 million low-income children
up to age 21. Although there are over 30 statutory and regulatory
Medicaid benefits categories, there is none labeled "child development
services." As discussed below, Medicaid covers a range of health
care services that overlap with the child development services
set forth in these specifications. However, these specifications
have not been approved by HCFA, and there is no guarantee that
federal Medicaid matching funds are available for the costs of
any particular child development service set forth in this document.
Purchasers interested in an authoritative opinion as to whether
federal matching funds are available will need to contact HCFA.
The primary benefit through which Medicaid finances services
for low-income children under age 3 is the Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) services benefit,
to which every child eligible for Medicaid is entitled. The EPSDT
benefit has 3 main elements: (1) screening services; (2) follow-up
diagnostic and treatment services; and (3) outreach and informing
services. Screening services, which include a comprehensive health
and developmental history, as well as health education, must be
provided to all eligible children at periodic intervals specified
by each state. EPSDT services can be paid for on a fee-for-service
basis or as part of a capitation payment to a managed care organization
(MCO); the focus of these specifications is on the provision of
child development services through an MCO.
Current HCFA administrative guidance relating to EPSDT does
not speak specifically to "child development services for children
under 3." While there is considerable overlap between EPSDT services
for children under 3 and child development services for this age
cohort, the final determination as to whether federal Medicaid
matching funds are allowable (through EPSDT or otherwise) for
a particular child development service is made by HCFA. This document
has been shared with HCFA, but HCFA has not approved or endorsed
its contents. As a general rule, if an item or service falls into
a statutory or regulatory Medicaid benefit category (such as EPSDT
services or physician services), and if that service category
is covered under a State's Medicaid Plan, federal matching funds
will be available for that item or service in that State. For
a detailed discussion of the relationship between child development
services and EPSDT, see Perkins and Olson, National Health Law
Program, Medicaid Early and Periodic Screening, Diagnosis and
Treatment as a Source of Funding Early Developmental Services
(forthcoming), The Commonwealth Fund.
These purchasing specifications are designed to enable interested
states that enroll Medicaid-eligible children into managed care
organizations (MCOs) for some or all EPSDT services to describe
MCO duties with respect to child development services. Some states
have already begun to address these issues in their Medicaid MCO
contracts. For example, South Carolina's Medicaid program, in
its 1997 HMO contract, included an Appendix of examples of "best
practices" for contractors for use in designing their service
delivery package; the State also included in its rate calculations
the costs of these "best practices." Among the "best practices"
was "BabyNet," South Carolina's single point of entry for children
under age 3 into a system of coordinated early intervention services.
Process for Developing this Technical
Assistance Document
Since 1995, CHSRP has conducted an intensive examination of contracts
between state Medicaid agencies and MCOs. This analytic work has
produced three editions of a comprehensive study of contract provisions.
The most recent version is the five-volume document, Rosenbaum,
et al., Negotiating the New Health System: A Nationwide Study
of Medicaid Managed Care Contracts (3rd Ed. 1999), www.gwu.edu/~chsrp.
The study breaks down the contracts into a series of analytic
tables. While there is no table specific to child development
services, there are tables that address services generally (Table
2.1) and EPSDT in particular (Table 2.4).
Negotiating the New Health System is a part of a broader analytic
studies and technical assistance project on managed care contracts
financed by numerous funders, including the Health Resources and
Services Administration (HRSA), Centers for Disease Control and
Prevention (CDC), the Substance Abuse and Mental Health Services
Administration (SAMHSA), the David and Lucile Packard Foundation,
and The Commonwealth Fund. Original funding for this project was
supported by the Pew Charitable Trusts and the Annie E. Casey
Foundation. The development of optional specifications for purchasing
managed care products constitutes one component under this project.
The process for developing these particular specifications began
with guidance from research conducted for The Commonwealth Fund
by child health researchers at UCLA and Northwestern University.
Drafts of these specifications were reviewed by a working group
from The Commonwealth Fund and Northwestern University and through
a series of vetting meetings involving state Medicaid and public
health officials, providers, MCO representatives, consumers and
child development experts. The changes suggested at these vetting
meetings have been incorporated into the specifications and have
been reviewed by representatives from these meetings. The specifications
are also available at www.gwu.edu/~chsrp.
Organization and Structure of this
Technical Assistance
Document The illustrative language in this document specifies
a child development services benefit. It is not intended to be
used as a stand-alone contract. Instead, it is designed to be
incorporated by interested state purchasers into the broader benefits
provisions of their contracts with Medicaid MCOs. It is also designed
to supplement the more general specifications developed by CHSRP
for the purchase of pediatric health services from MCOs by state
Medicaid agencies, www.gwu.edu/~chsrp.
In particular, the illustrative language in this document is intended
to assist purchasers in articulating child development services
for children under age 3 in the context of a basic Medicaid benefits
package such as that set forth in Part 1 of CHSRP's general Medicaid
pediatric specifications.5
The specifications for child development services in this document
focus on the benefit itself. For illustrative language on such
related issues as enrollment, provider networks, and quality improvement,
interested purchasers should refer to the CHSRP general pediatric
specifications. Specific cross-references within this document
to the general pediatric specifications are cited as "MEDICAIDSPECS".
The illustrative language in this document is drafted to minimize
ambiguity and maximize clarity. In its summary of a June, 1999
symposium on Medicaid managed care and children with special health
care needs, the National Academy for State Health Policy reports
that "MCO representatives caution states that they must be absolutely
clear in the contract as to what the MCO's responsibilities are
and that they cannot hold MCOs accountable for what is not in
the contract."6 The more clearly an
MCO understands what is expected of it by the purchaser, and the
more clearly a purchaser understands what the MCO is obligating
itself to provide, the more likely it is that any agreement between
the two parties will be carried out to the mutual satisfaction
of each and to the benefit of the enrolled children.
One exception to the specificity of the illustrative language
concerns procedural time frames. In many cases, such timeframes
are not specified; instead, a bracket ([ ]) is supplied as a placeholder,
indicating that the state purchaser should insert a timeframe
of its choosing.
In addition to the illustrative language, this document contains
sample contract compliance measures. CHSRP's reviews of state
Medicaid contracts with MCOs "have consistently observed an absence
of clear and articulated measures for reviewing the extent to
which contractors are in compliance with performance specifications,
as well as a failure to specify the data that contractors will
be expected to submit to demonstrate their compliance." Rosenbaum
et al., Negotiating the New Health System, Special Report: Mental
Illness and Addiction Disorder Treatment and Prevention, GW Center
for Health Policy Research, March 1998, p.56. The compliance measures
in these purchasing specifications have been drafted to assist
interested purchasers in specifying data and articulating measures
for reviewing the extent of compliance by contractors with their
duties under the purchasing agreement.
How to Use this Technical Assistance Document
The drafting format used in these sample specifications is
as follows:
- The specifications are divided into sections, identified
by "�".
- Each section, in turn, is divided into one or more subsections:
"(a)", "(b)", etc.
- A subsection may be divided into one or more paragraphs: "(1)",
"(2)", etc.
- A paragraph may be divided into one or more subparagraphs:
"(A)", "(B)", etc.
- A subparagraph may be divided into one or more clauses: "(i)",
"(ii)", etc.
Every state purchaser has its own drafting format. The particular
format used in these sample specifications is NOT intended as
a substitute for each state's own format. Instead, this division
and subdivision format is designed to enable a user of this document
to identify quickly the policy choices contained in each provision
and to identify which, if any, of the elements the user wishes
to adopt. This format also serves as a checklist for those users
who wish to compare portions of their current purchasing documents
with the relevant portions of these sample specifications.
For example, assume that a state purchaser currently uses the
following language relating to developmental/interperiodic screening
in specifying a contracting Medicaid MCO's duties with respect
to EPSDT services:
"D. Members under the age of 21 years will be scheduled for
periodic health assessments in accordance with the periodicity
schedule recommended by the American Academy of Pediatrics�."
Assume that this purchaser is interested in clarifying that,
as part of their obligation to furnish EPSDT services to enrolled
children under age 3, contracting Medicaid MCOs must conduct a
developmental screen using a specified developmental assessment
tool. The sample specifications at �102(a) suggest the following
language (this particular draft assumes that the purchaser has
selected, from among the standardized validation development screening
tests listed in �102(a)(2), the Ages and Stages Questionnaire):
"(a) Developmental Screen - A developmental screen is:
(1) an assessment, at every well-child visit beginning at
age [ ] months, through the taking of a patient history and
the conduct of a physical examination by or under the supervision
of a licensed health professional (as defined in �108(d));
and
(2) the administration, by or under the supervision of a
licensed health professional (as defined in �108(d)):
(A) of the Ages and Stages Questionnaires (ASQ): A Parent-Completed,
Child-Monitoring System (2nd Ed.) (1995)�"
The purchaser could then adapt this sample specification to its
own drafting format as follows (suggested language in italics):
"D. Members under the age of 21 years will be scheduled for
periodic health assessments in accordance with the periodicity
schedule recommended by the American Academy of Pediatrics.
D.1. Members under age of 3 years will have an assessment
at every well-child visit beginning at age [drafter insert
desired months], through the taking of a patient history,
the conduct of a physical examination, and the administration,
by or under the supervision of a licensed health professional,
of the Ages and Stages Questionnaires (ASQ): A Parent-Completed,
Child-Monitoring System (2nd Ed.) (1995).
Related CHSRP Activities
As discussed above, CHSRP has developed optional specifications
for the purchase of Medicaid services from MCOs on behalf of all
Medicaid-eligible children. In addition, CHSRP is developing a
number of sample purchasing specifications that overlap with this
document (see below). Each set of specifications is (or will be)
posted on CHSRP's website, www.gwu.edu/~chsrp
- children with special health care needs;
- children with behavioral health needs;
- children in foster care;
- pediatric dental care (March 2000);
- prevention of lead poisoning (November 1998);
- immunizations (May 1998);
- individuals who are homeless (June 2000);
- access standards (June 2000);
- cultural competence standards;
- memoranda of understanding between MCOs and public health
agencies; and
- data and information collection and reporting.
