Medicaid Contract Purchasing Specifications

Purchasing Specifications For
Child Development Services In
Medicaid Managed Care
July, 2000

§101. In General

§102. Screening Assessment Services

§103. Developmental Health Promotion Services

§104. General Developmental Interventions

§105. Care Coordination

§106. Guidelines and Training

§107. Coverage Determination Standards and Procedures

§108. Definitions

§101. In General

Commentary: The following illustrative language would impose a duty on contracting MCOs to provide (or arrange for the provision of) child development services to children under age 3. This package of services is divided into four elements: screening assessment, developmental health promotion, general developmental interventions, and care coordination. Purchasers interested in ensuring that the MCOs with which they contract provide the full panoply of child development services to all enrolled children under age 3 will need to specify all four elements. However, these specifications are also drafted so as to enable Purchasers interested in covering only a portion of child development services to select out the appropriate language. Purchasers may also elect to limit whatever child development services they wish to cover to a smaller class of enrollees -- e.g., children under age 2, or infants under age 1.

As discussed in the Introduction at pages 3-4, under current law all Medicaid-eligible children under age 3 are entitled to EPSDT services. This broad cluster of services includes (1) screening services; (2) follow-up diagnostic and treatment services; and (3) outreach and informing services. Neither the federal Medicaid statute nor current HCFA administrative guidance speak directly to child development services generally, or to any of the four elements of child development services discussed above. As a result, it is not possible to state with certainty that the services set forth in the illustrative language below would in each case qualify for Federal Medicaid matching payments. That determination is the responsibility of 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.

Note that the following illustrative language is not intended to implement the entire EPSDT benefit. Instead, it is intended to detail child development services that could be provided in the context of EPSDT or otherwise to Medicaid-eligible children. If a purchaser elects to contract with an MCO for the delivery of EPSDT services, additional language to that offered below will be required. For illustrative language implementing EPSDT coverage, see §102 of CHSRP, Optional Purchasing Specifications: Medicaid Managed Care for Pediatric Services (September 1999), www.gwu.edu/~chsrp. (hereinafter referred to as "MEDICAIDSPECS").

(a) Contractor Duties To Each Enrolled Child Under Age 3 - Contractor shall, for each enrolled child under age 3, cover and furnish, or arrange for the furnishing of, the following child development services:

(1) screening assessment services described in §102;

(2) developmental health promotion services described in §103;

(3) general developmental interventions described in §104; and

(4) care coordination services described in §105.

(b) Guidelines and Training - In carrying out its duties to an enrolled child under subsection (a), Contractor shall ensure that the services are furnished in accordance with:

(1) the guidelines enumerated in §106(a);

(2) the training requirement under §106(b); and

(3) coverage determination standards enumerated in §107.

(c) Family Participation Requirements ⁷- In carrying its duties to an enrolled child under subsection (a), Contractor, and each provider participating in Contractor's provider network, shall facilitate the participation of the family or caregiver of an enrolled child in the furnishing of child development services.

(d) Written Agreements with Providers - Consistent with §501(b) of Part 5 of MEDICAIDSPECS, Contractor shall enter into and maintain an enforceable written agreement with each provider participating in Contractor's provider network who furnishes items and services to enrolled children under age 3 that sets forth the provider's duties with respect to:

(1) implementation of Contractor's duties to furnish child development services under subsection (a);

(2) furnishing of child development services in accordance with guidelines and protocols specified under subsection (b)(1); and

(3) facilitation of family participation under subsection (c) in the furnishing of child development services.

Commentary: The illustrative language in these specifications focuses on the elements of child development services. Language regarding other related policies and procedures may be found in MEDICAIDSPECS, www.gwu.edu/~chsrp.

(e) Other Contractor Duties - The duties described in Part 2 through Part 14 of MEDICAIDSPECS shall apply to Contractor with respect to the furnishing of child development services under subsection (a).

§102. Screening Assessment Services - Screening assessment services are the services described in subsections (a) through (c).

Commentary: The following illustrative language would require the administration of an instrument in connection with a developmental screen. Purchasers should note that many of the screening instruments listed below (from which a single instrument is to be selected) are proprietary and may involve acquisition costs. Purchasers will need to determine how these costs will be distributed among Purchaser, the contracting MCO, and the primary care providers administering the instruments. If the cost is to be borne by the administering providers, Purchasers will need to ensure the adequacy of reimbursement by the contracting MCO to the providers to avoid any disincentive for providers to use the specified instrument.

(a) Developmental Screen - A developmental screen is:

(1) an assessment, at every well-child visit beginning at age [ ] months⁸, 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)): [drafter insert one of following standardized validation development screening tests, which are listed in alphabetical order]

(A) of the Ages and Stages Questionnaires (ASQ): A Parent-Completed, Child-Monitoring System (2nd Ed.) (1995);⁹

(B) at age [ ] months and [ ] months, of the Bayley Infant Neurodevelopmental Screen (BINS) (1995); ¹⁰

(C) at age [ ] months, of the Brigance Screens (1996)¹¹;

(D) at age [ ] months and [ ] months, Child Development Inventories (CDI) (1992);¹²

(E) at age [ ] months, of the Denver II Developmental Screening Test;¹³

(F) at age [ ] months, of the Nursing Child Assessment Satellite Training (NCAST) (1994);¹⁴

(G) at age [ ] months, Parents' Evaluations of Developmental Status (PEDS)(1997)¹⁵;

(H) of the [drafter insert reference to other standardized and validated assessment tools approved by Purchaser].

(b) Family Psychosocial Screen

(1) Defined - A family psychosocial screen is: [drafter insert one of following standardized validation development screening tests]

(A) the administration, by or under the supervision of a licensed health professional (as defined in §108(d)) of an instrument described in paragraph (2);

(B) performed with the participation of the child's family or caregiver under paragraph (3); and

(C) conducted within the time frames described in paragraph (4).

(2) Instrument - An instrument for a family psychosocial screen is:

(A) the Family Psychosocial Screen (1996);¹⁶

(B) the Center for Epidemiologic Studies - Depression (CES-D);¹⁷ or

(C) [drafter insert reference to other formal assessment tools approved by Purchaser].

(3) Family Participation - Consistent with §101(c), Contractor shall ensure that a family psychosocial screen described in this subsection is administered only with the knowledge and consent of the family or caregiver of the enrolled child.

(4) Timeframes

(A) Newly Enrolled Child - Contractor shall ensure that, in the case of a newborn enrolled child or other newly enrolled child under age 3, the family psychosocial screen described in this subsection is administered no later than the earlier of:

(i) the first encounter between the newborn enrolled child and a provider participating in Contractor's provider network (whether at a home visit under §103(c) or at a provider practice site); or

(ii) within [ ] months of the child's enrollment.

(B) Other Enrolled Children - Contractor shall ensure that, in the case of an enrolled child under age 3 not described in subparagraph (A), the family psychosocial screen described in this subsection is administered whenever in the professional judgment of a provider participating in Contractor's provider network a screen is warranted (consistent with the family participation requirements under paragraph (3)).

(c) Construction - Contractor shall not be construed to be out of compliance with the requirements of subsection (b) (relating to family psychosocial screen) with respect to an enrolled child if:

(1) a provider participating in Contractor's provider network has made, and documented in the child's medical record, reasonable efforts to inform the child's family or caregiver of the importance of the family psychosocial screen to the child's well-being; and

(2) after such reasonable efforts have been made, the child's family or caregiver has decided not to consent to the administration of the family psychosocial screen.

(d) Documentation - Contractor shall ensure that an enrolled child's primary care provider (as defined in §108(e)) documents, in the enrolled child's medical record, the screening assessment services under this section furnished to the child.

§103. Developmental Health Promotion Services - Developmental health promotion services are the services described in subsections (a) through (c).

Commentary: Under current law, all Medicaid-eligible children under 3 are entitled to EPSDT services, which includes a range of screening services. As discussed in the Introduction at pages 3-4, the current HCFA administrative guidance on the EPSDT benefit does not speak directly to child development services generally, or developmental health promotion services in particular. HCFA's administrative guidance does, however, specify health education as part of the periodic and interperiodic screening services that states must cover under EPSDT:

"Health education is a required component of screening services and includes anticipatory guidance. At the outset, the physical and dental screening gives you the initial context for providing health education. Health education and counseling to both parents (or guardians) and children is required and is designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention." Health Care Financing Administration, Medical Assistance Manual §5123.2E, http://www.hcfa.gov/pubforms/pub45pdf/smm5t.pdf.

For illustrative language relating to anticipatory guidance, see §102(b)(1)(E) and §1401(b) of MEDICAIDSPECS, www.gwu.edu/~chsrp.

Commentary: The following illustrative language would require the administration of an instrument in connection with a developmental screen. Purchasers should note that many of the anticipatory guidance materials referenced in subsection (a) and behavioral screening instruments referenced in subsection (b) below are proprietary and may involve acquisition costs. Purchasers will need to determine how these costs will be distributed among Purchaser, the contracting MCO, and the primary care providers administering the materials and instruments. If the cost is to be borne by the administering providers, Purchasers will need to ensure the adequacy of reimbursement by the contracting MCO to the providers to avoid any disincentive for providers to use the specified materials or instrument.

(a) Anticipatory Guidance ¹⁸- Contractor shall ensure that, at each encounter between an enrolled child and the child's primary care provider (as defined in §108(e)), the provider makes available, and upon request by the child's family or caregiver, explains to the child's family or caregiver: [drafter insert one or more of following materials which are listed in alphabetical order]

(1) the anticipatory guidance suggestions incorporated in Bright Futures under §106(a)(1);¹⁹

(2) the anticipatory guidance suggestions incorporated in Guidelines for Health Supervision III under §106(a)(2);²⁰

(3) the Healthy Steps LINKletters²¹ appropriate to the child's age at the time of the encounter;

(4) the Healthy Steps Parent Handouts²² (1996) appropriate to the child's age at the time of the encounter;

(5) the Injury Prevention Program (TIPP) Age-Related Safety Sheets²³ appropriate to the child's age at the time of the encounter;

(6) the Parents' Evaluations of Developmental Status (PEDS) Manual²⁴ (August 1998); or

(7) [drafter insert other materials on anticipatory guidance approved by Purchaser].

(b) Behavioral Assessment to Assist Parents - A behavioral assessment to assist parents in understanding their child is the administration, performed by or under the supervision of a licensed health professional (as defined in §108(d)): [drafter insert one of following instruments which are listed in alphabetical order]

(1) at age [ ], of the Behavioral Assessment of Baby's Emotional and Social Style (BABES) (1994);²⁵

(2) at age [ ], of the Eyberg Child Behavior Inventory (1999);²⁶

(3) at age [ ], of the Neonatal Behavioral Assessment Scale (NBAS); ²⁷

(4) at age [ ], of the Temperament and Atypical Behavior Scale (TABS)(1999)²⁸; or

(5) at age [ ], of [drafter insert reference to other standardized and validated assessment tools approved by Purchaser].

Commentary: The following illustrative language sets forth the full scope of home visit services for children under age 3 recommended for child development services. Interested Purchasers may wish to limit the populations to whom contracting MCOs would have a responsibility to provide home visits. The language below is drafted to enable Purchasers to target home visits on particular subpopulations, such as newborns or certain children at risk.

(1) In General - Contractor shall comply with the home visit requirements under:

(A) paragraph (2) (relating to newborns);

(B) paragraph (3) (relating to newly enrolled children);

(C) paragraph (4) (relating to children at risk); and

(D) paragraph (5) (relating to children in need of follow-up).

(2) Home Visit Services for Newborns

(A) Initial Home Visit - In the case of a child whose mother is enrolled in Contractor at the time of the child's birth (whether or not the child is a pre-term or low-birthweight infant), Contractor shall ensure that, within [ ] days of birth, a trained home visitor (as described in paragraph (6)) conducts a home visit to:

(i) administer the family psychosocial screen consistent with §102(b) to determine whether the enrolled child needs a follow-up home visit under subparagraph (B);

(ii) educate the child's family or caregiver about child development and parenting skills; and

(iii) identify risks of injury to the child, if any, observed during the course of the visit.

(B) Follow-up Home Visit for Newborns - Within [ ] days of a determination under subparagraph (A) or otherwise that a newborn needs a follow-up home visit, Contractor shall furnish a visit to the child's home by a trained home visitor (as described in paragraph (6)) for the purpose of:

(i) educating the child's family and caregiver about child development and parenting skills; and

(ii) assessing the needs of the child and the child's family or caregiver for:

(I) behavioral health (including substance abuse) treatment or referrals;

(II) more stable housing arrangements;

(III) protection from domestic violence or abuse or neglect; and

(IV) care coordination services under §105.

(3) Home Visit Services for Newly Enrolled Children Under Age 3 - In the case of a child under age 3 who is newly enrolled, Contractor shall ensure that, within [ ] days of Contractor's receipt of notice of the child's enrollment, a trained home visitor (as described in paragraph (6)) conducts a home visit in order to:

(A) administer, consistent with §102(b), the family psychosocial screen to determine whether the enrolled child is at risk for purposes of paragraph (4);

(B) educate the child's family or caregiver about child development and parenting skills; and

(C) identify risks of injury to the child, if any, observed during the course of the visit.

(4) Home Visits for Enrolled Children at Risk

Commentary: The following illustrative language sets forth a broad definition of an enrolled child at risk for purposes of triggering a duty on the part of a contracting MCO to provide a home visit. Interested Purchasers seeking to limit the scope of this duty may wish to select from among the categories listed in subparagraph (B).

(A) Home Visit - Within [ ] days of a determination (under paragraph (2) or otherwise) that an enrolled child is at risk (as described in subparagraph (B)), Contractor shall furnish a visit to the child's home by a trained home visitor (as described in paragraph (6)) for the purpose of:

(i) assessing the needs of the child and the child's family or caregiver for:

(I) behavioral health (including substance abuse) treatment or referrals;

(II) more stable housing arrangements;

(III) protection from domestic violence or abuse or neglect; and

(IV) care coordination services under §105; and

(ii) educating the child's family or caregiver about child development or parenting skills specific to the child's risk factors.

(B) Enrolled Child At Risk - An enrolled child is at risk if:

(i) in the professional judgment of the child's primary care provider (as defined in §108(e)), the circumstances of the child's family or caregiver are such that the child is at risk;

(ii) the child's mother is an adolescent;

(iii) the child's family or caregiver has a mental health condition;

(iv) the child's family or caregiver has a cognitive impairment or developmental disability; ³⁰

(v) the child's family or caregiver has a history of, or is currently engaged in, substance abuse;

(vi) the child's family or caregiver has a history of, or is currently engaged in, domestic violence;

(vii) the child has a chronic illness or a mental health condition;

(viii) the child is at risk for, or is a victim of, abuse or neglect;

(ix) the child has not resided in the same dwelling for at least [ ] consecutive months; ³¹

(x) the child is at least [ ] months old, but at birth was a pre-term or low-birthweight infant; or

Commentary: The following category would be necessary only if the Contract did not require home visits in the case of all newborns as per paragraph (2) above.

(xi) the child is a pre-term or low-birthweight infant.

(5) Enrolled Children in Need of Follow-up

(A) Duty - In the case of an enrolled child determined to be in need of follow-up described in subparagraph (B), Contractor shall ensure that a trained home visitor (as described in paragraph (6)) conducts a visit to the child's home within [ ] days of the determination in order to:

(i) remind the child's family or caregiver of the child's scheduled appointments or medication schedules;

(ii) educate the child's family or caregiver about child development and parenting skills; and

(iii) identify risks of injury to the child, if any, observed during the course of the visit.

(B) Enrolled Child in Need of Follow-up - An enrolled child in need of follow-up is a child who is not a newborn described in paragraph (2), newly enrolled described in paragraph (3), or at risk described in paragraph (4), and who the child's primary care provider determines:

(i) repeatedly misses a scheduled appointment; or

(ii) is not complying with the medication regimen prescribed by the child's primary care provider.

(6) Trained Home Visitor - A trained home visitor is a nurse or nurse practitioner, an individual with a masters in social work or in early childhood education, a health educator, or a layperson who is adequately trained in the furnishing of home visitation services and is:

(A) an employee of Contractor;

(B) a provider participating in Contractor's provider network; or

(C) an employee of a provider or a group or providers participating in Contractor's provider network.

(7) Referrals to Appropriate Public Authorities - Contractor shall ensure that the trained home visitor conducting a home visit for a child at risk under paragraph (4) promptly complies with the requirements of [drafter insert reference to applicable state law] relating to reporting instances of child abuse or neglect observed by, or made known to, the professional during the home visit.

(d) Documentation - Contractor shall ensure that an enrolled child's primary care provider (as defined in §108(e)) documents, in the enrolled child's medical record, the developmental health promotion services specified under this section and furnished to the child.

§104. General Developmental Interventions - General developmental interventions are the items, services, and activities described in subsections (a) through (c).

(a) Child Development Information Line ³²

(1) In General - Contractor shall maintain [ ] hours per day, [ ] days per week a toll-free telephone line that meets the requirements of:

(A) the Barton-Schmidt Pediatric Telephone Protocol; or

(B) [drafter insert reference to other telephone protocol approved by Purchaser].³³

(2) Staffing - Contractor shall ensure that the child development information line described in paragraph (1) is staffed during its hours of operation with a licensed health professional (as defined in §108(d)) who has expertise in child development.

(3) Separate Line - Contractor shall ensure that the child development information line described in paragraph (1) is not the same telephone line as the telephone line through which enrolled children and their families or caregivers may:

(A) request emergency or urgent care services; ³⁴

(B) schedule appointments for non-emergency, non-urgent services; or

(C) obtain information regarding prior authorization for payment and other inquiries relating to the operations of Contractor.

(b) Child Health and Development Record - Contractor shall make available to the family or caregiver of an enrolled child the American Academy of Pediatrics Child Development Record³⁵ at the earlier of:

(1) the birth of the child;

(2) the child's enrollment; or

(3) the first encounter between the child and a primary care provider.

(c) Reading Readiness - Contractor shall ensure that, at each well-child visit by an enrolled child to a provider participating in Contractor's provider network, the provider administers, or supervises a licensed health professional (as defined in §108(d)) in the administration of:

(1) the Reach Out and Read Protocols;³⁶ or

(2) [drafter insert reference to other reading protocols approved by Purchaser].

(d) Documentation - Contractor shall ensure that an enrolled child's primary care provider (as defined in §108(e)) documents, in the enrolled child's medical record, the interventions described in subsections (b) and(c) furnished to the child.

§105. Care Coordination ³⁷- Care coordination is the set of activities and services described in subsections (a) through (c).

Commentary: Under current law, all Medicaid-eligible children under age 3 are entitled to EPSDT services, which includes case management. As discussed in the Introduction at pages 3-4, the current HCFA administrative guidance on the EPSDT benefit does not speak directly to child development services generally. It does, however, address case management. 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§." The State Medicaid Manual further explains that when case management services are found to be medically necessary, states have several options, the first of which is 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.³⁸" EPSDT case management services are matched at each state's regular matching rate for services (ranging from 50 to 80 percent), rather than at the administrative (50 percent) matching rate.

Under §1905(a)(19) of the Social Security Act, 42 U.S.C. §1396d(a)(19), States have the option of receiving federal Medicaid matching funds for the costs of case management services targeted at particular groups of Medicaid beneficiaries, such as children under age 3. The statute defines case management services as "services which will assist individuals eligible [for Medicaid] in gaining access to needed medical, social, educational, and other services." Using this authority, the State of Vermont has obtained HCFA approval of federal Medicaid matching funds for the cost of case management services to Medicaid-eligible children age 1 to 5 years who are at risk for unnecessary and avoidable medical interventions and who do not otherwise have a case manager. These include children who have "an observable and measurable delay in one or more of the following developmental areas: cognitive, physical (includes hearing and visual), communication, social or emotional and adaptive." Supplement 1 to Attachment 3.1-A, p. 15, Vermont State Plan under Title XIX of the Social Security Act (Approval date: 7/27/98)

For an extensive discussion of options for paying for case management services, see Rosenbaum and Sonosky, "Case Management as a Medicaid-covered Service," GW CHSRP Memorandum to ABCD Grantees (May 2000), forthcoming on www.nashp.org.

(a) Notification - Contractor shall ensure that, at the first encounter between an enrolled child under age 3 and a provider participating in Contractor's provider network, the child's family or caregiver is notified of the availability of:

(1) the opportunity to request the assignment of a care coordinator under subsection (b); and

(2) care coordination services under subsection (c).

(b) Request for Assignment of Care Coordinator

(1) Request - Contractor shall ensure that the family or caregiver of each enrolled child under age 3 has an opportunity to request the assignment of a care coordinator to furnish care coordination services under subsection (c).

(2) Assignment of Care Coordinator - In the case of a family or caregiver who has requested a care coordinator under paragraph (1), Contractor shall, within [ ] of the request, assign to the child and notify the family or caregiver of such assignment of a care coordinator (as defined in paragraph (4)).

(3) Reassignment - In the event that a family or caregiver is dissatisfied with the care coordinator assigned by Contractor to the enrolled child under paragraph (2), Contractor shall allow the family or caregiver to select a new care coordinator from among the care coordinators (as defined in paragraph (4)) participating in Contractor's provider network or employed by Contractor.

(4) Care Coordinator Defined - A care coordinator is an individual who has demonstrated experience and appropriate training in the coordination of medical and related services to children under age 3 and is one of the following:

(A) a physician (including the primary care provider selected by the enrolled child's family or caregiver);

(B) a registered nurse;

(C) a social worker;

(D) a family counselor;

(E) a service coordinator assigned by an early intervention program under Part C of the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. §1400 et seq.; or

(F) a health educator.

(c) Care Coordination Services - Care coordination services are services that will assist enrolled children in gaining access to needed medical, social, educational, and other services that are:

(1) identified through a screen under §102 as needed by the child or the child's family or caregiver;

(2) covered under:

(A) §103 (relating to developmental health promotion services);

(B) §104 (relating to general developmental interventions); or

(C) other sections of [drafter insert name of purchasing document]; or

(3) available from [drafter insert reference to appropriate state or local agencies or programs, including Part C Agencies under the Individuals with Disabilities Education Act (IDEA) 20 U.S.C. §1400 et seq.].³⁹

§106. Guidelines and Training

(a) Guidelines⁴⁰ - Contractor shall furnish, or arrange for the furnishing of, child development services under §101 to an enrolled child in a manner which is consistent with generally accepted principles of professional pediatric practice as reflected in the following guidelines:

(1) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Second Edition (National Center for Education in Maternal and Child Health, 2000) www.brightfutures.org;

(2) Guidelines for Health Supervision III (American Academy of Pediatrics, 1997) http://www.aap.org/acb2/index.html?&DID=15; or

(3) [drafter insert reference to periodicity schedule or child health guidelines required by State Medicaid Plan].

Commentary: The following illustrative language assumes that Contractor will ensure that each practitioner participating in Contractor's provider network has access to training in the use of screening instruments and anticipatory guidance and other materials required in connection with the provision of child development services. The language does not, however, assume that the practitioners must receive this training from Contractor or from an entity with which Contractor subcontracts for this purpose. The Contractor would be required to offer, or arrange for, the training at Contractor's expense if requested to do so by a network practitioner. If a practitioner prefers to obtain such training from a source other than Contractor or Contractor's designee, the practitioner would bear the cost.

(b) Training - Contractor shall, upon request of a provider participating in Contractor's provider network, furnish, or arrange for the furnishing of, at Contractor's expense, training in the use of:

(1) the developmental screening instrument specified in §102(a);

(2) the family psychosocial screening instrument specified in §102(b);

(3) the anticipatory guidance materials specified in §103(a);

(4) the behavioral assessment specified in §103(b); and

(5) the general developmental interventions specified in §104.

§107. Coverage Determination Standards and Procedures

(a) In General - Contractor shall comply with the requirements of §§101A -103A of MEDICAIDSPECS and the requirements of this section relating to the standards and procedures used in determining whether a child development service under §101 is covered with respect to an enrolled child.

(b) Personnel Qualified to Make Coverage Determinations - In the case of an enrolled child who seeks child development services under §101, at least one licensed health professional (as defined in §108(d)) with expertise or experience in child development services shall participate in the coverage determination (as defined in subsection (d)) with respect to the child.

(c) Exclusion from Prior Authorization - Contractor shall not require prior authorization of the following items and services:

(1) screening assessment services under §102;

(2) developmental health promotion services under §103;

(3) general developmental interventions under §104; and

(4) care coordination under §105.

(d) Coverage Determination Defined - A determination by Contractor (or by the provider or other entity to whom Contractor has delegated such determination) as to whether, in the case of an enrolled child, an item or service enumerated under §101 is necessary to:

(1) prevent, correct, or ameliorate a condition, disability, illness, or injury;

(2) prevent, correct, or ameliorate a developmental disability or delay; ⁴¹or

(3) maintain functioning.⁴²

§108. Definitions

(a) Contractor - the managed care organization doing business as [drafter insert name] that has entered into an agreement with Purchaser under [drafter insert name of purchasing document].

(b) Enrolled child - an individual under age 3 with respect to whom Contractor assumes financial responsibility for furnishing, or arranging for the furnishing of, items and services covered under §101.

(c) Family or caregiver - a natural or adoptive parent of an enrolled child, a grandparent, or stepparent with whom the child lives, or an individual or entity that is a foster parent, legal guardian, or other individual or agency with legal authority or responsibility to care for the child.

(d) Licensed health professional - a physician, nurse, nurse practitioner, physician assistant, clinical psychologist, or [drafter insert reference to other appropriate licensure categories under state law, such as social worker or health educator].

(e) Primary care provider - a physician, nurse practitioner, or physician assistant who is responsible for delivering primary care to, and monitoring the growth and development of, an enrolled child.

(f) Provider - a health care professional, clinic, hospital, school, or other entity licensed by the State to furnish medical, dental, mental health, or other health care services.

(g) Provider network - the set of providers that have entered into enforceable written agreements with Contractor that comply with the requirements of [drafter insert name of purchasing document] to furnish, or arrange for the furnishing of, the items and services covered under §101 to enrolled children.

(h) Purchaser - [drafter insert name of state purchasing agency].

Compliance Measures

Contractor shall make available to Purchaser upon request copies of the following:

(1) Information Provided to Enrollees

(A) Anticipatory guidance materials made available to families or caregivers of enrolled children under age 3;

(B) The child health and development record offered to family or caregiver of enrolled children under age 3; and

(C) The listing of available care coordinators for enrolled children under age 3.

(2) Contractor Guidance to Providers Participating in Contractor's Provider Network

(A) The written agreement between Contractor and primary care providers treating enrolled children under age 3; and

(B) Training materials or programs, provider manuals, memoranda, and other materials used by Contractor to instruct participating providers regarding their duties to enrolled children relating to the provision of covered services and documentation thereof.

(3) Instruments and Protocols Used by Participating Providers

(A) Screening instruments and assessment tools used by providers in connection with the provision of services to enrolled children under 3 and their families;

(B) Reading readiness protocol used by providers; and

(C) Telephone protocol used by Contractor or participating providers in responding to enrollee inquiries relating to child development.

(4) Contractor Guidance Relating to Home Visits

(A) Manuals, memoranda, and other materials used by Contractor to instruct employees or participating providers regarding the conduct of covered home visits.

(5) Care Coordination Services

(A) Manuals, memoranda, and other materials used by Contractor to instruct employees or participating providers regarding the furnishing of care coordination services to enrolled children under age 3.

____________________________________________________________________________

Endnotes:

7. For more extensive language on family participation requirements applicable to all enrolled children under age 21, see GW CHSRP's Optional Purchasing Specifications: Medicaid Managed Care for Children with Special Health Care Needs (forthcoming) and Optional Purchasing Specifications: Medicaid Managed Care for Children with Behavioral Health Needs (forthcoming).

8. The AAP's Committee on Children with Disabilities recommends the administration of a standardized assessment at each well-child visit. Most screening measures do not begin until age 3-4 months. See Committee on Children with Disabilities, "Screening Infants and Young Children for Developmental Disabilities," Pediatrics (1994) 93: 863-865, http://www.pediatrics.org.

9. There are 19 ASQ questionnaires designed to be administered at well-child visits at ages 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months. Only the first 15 questionnaires would be applicable to a population under age 3. Each form has 35 "yes-sometimes-not yet" questions to parents, is available in English, Spanish, and French, and takes about 7 minutes to administer. Available from Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285 (800-638-3775), http://www.pbrookes.com.

10. BINS is one form (in English only) of 10-13 items per each 3 to 6 month age interval for children age 3 months to 2 years. BINS uses direct measurement of children's skills to assess reflexes and tone, movement and symmetry, and developmental skills. Administration requires 10 to 15 minutes. Available from: The Psychological Corporation, 555 Academic Court, San Antonio, TX 78204 (800-228-0752), http://www.psychcorp.com.

11. The Brigance Screens consist of 6 forms, one for each 12-month age range, for children 21 to 84 months of age. They are available in English, Spanish, and other languages. Administration takes 10 to 15 minutes. These Screens elicit skills from children in all developmental areas. Brigance Screens for children 0 to 21 months of age will available in 2001. Available from: Curriculum Associates, Inc., 153 Rangeway Road, P.O. Box 2001, North Billerika, MA 01862. (800-225-0248), http://www.curriculumassociates.com.

12. The Child Development Inventories (CDIs) use 3 forms, one for 0-18 months, one for 18-36 months, and one for 36-72 months, containing 60 "yes-no" questions to parents in English only. Administration takes 10 minutes. Available from: Behavior Science Systems, P. O. Box 580274, Minneapolis, MN 55458 (612-929-6220).

13. Available from: Denver Developmental Materials, Inc., P.O. Box 371075, Denver, CO 80207-5075 (800-419-4729). There is a debate within the pediatric community relating to this instrument. See Glascoe et al., "The Accuracy of the Denver-II in Developmental Screening," Pediatrics (1992); 89: 1221-1225. For further information regarding developmental screening instruments, see AAP's Section on Developmental and Behavioral Pediatrics, www.dbpeds.org/articles/dbtesting.

14. Available from: University of Washington School of Nursing, P.O. Box 357920, Seattle, WA 98195-7920 (206-543-8528).

15. Parents' Evaluations of Developmental Status (PEDS) (1997) uses one form throughout the 0-8 year age range containing 10 questions to parents eliciting their concerns. A second longitudinal form is placed in the child's medical records to help providers track developmental/behavioral status, guidance, referrals, etc. Indicates when to refer, advise, or reassure, and when to monitor or screen more closely. Form is available in English or Spanish; administration requires 2 minutes. Available from: Ellsworth & Vandermeer Press Ltd., P.O. Box 68164, Nashville, TN 37260 (615-226-4460), www.pedstest.com.

16. Ambulatory Child Health, 1996; 4:325-339. Also included in "Collaborating With Parents: Using Parents' Evaluations of Developmental Status To Detect and Address Developmental and Behavioral Problems," in Parents' Evaluations of Developmental Status (PEDS) Manual (August 1998), Ellsworth & Vandermeer Press, Ltd., Box 68164, Nashville, TN 37206 (615-226-4460), http://www.pedstest.com/peds-frames.html.

17. J.G. Orme, J. Reis, and E.J. Herz. "Factorial and discriminant validity of the Center for Epidemiologic Studies Depression (CES-D) Scale." Journal of Clinical Psychology (1986); 42:28-33. Also included in PEDS Manual cited in footnote 16, http://www.pedstest.com/peds-frames.html.

18. See Glascoe et al., "Brief Approaches to Educating Parents and Patients in Primary Care," Pediatrics (1998); http://www.pediatrics.org/cgi/content/full/101/6/e10. There are numerous websites offering information to parents on issues relating to child development, including: Nemours Foundation (http://kidshealth.org/parent); The National Parenting Center (www.tnpc.com); and Parent Partners (http://parentpartners.com).

19. Bright Futures has produced Anticipatory Guidance Cards. For more information on how to obtain this product, call (703) 356-1964 or see www.brightfutures.org.

20. AAP has produced parenting brochures covering such issues as violence, television, single-parenting, toilet-training, hospital stays, health and safety issue. See www.aap.org/family/mnbroc.html for more information on child-care books, videos, hand-held health records, waiting room magazines and additional materials for parents.

21. See http://www.healthysteps.org/healthysteps/homepage.nsf/All/Link18mos.pdf/$file/Link18mos.pdf.

22. See http://www.healthysteps.org/healthysteps/homedocuments.nsf/key/parenthandouts.

23. See www.aap.org/family/tippintr.htm.

24. See http://www.pedstest.com/peds-frames.html.

25. Available from: California School of Professional Psychology-LA, 1000 S. Fremont Ave., Alhambra, CA 91803 (818-284-2777, ext. 3030).

26. The Eyberg Child Behavior Inventory is one form in English only of 36 questions to parents of children 2-16 years of age. Administration requires about 5 minutes. Available from: Psychological Assessment Resources, Inc. (PAR), P.O. Box 998, Odessa, FL 33556 (800-331-8378), www.parinc.com. See also Journal of Clinical Child Psychology, (1980); 9:22-8.

27. T. Barry Brazelton and J. Kevin Nugent. 3rd Edition. London: MacKeith Press, 1995.

28. The Temperament and Atypical Behavior Scale (TABS) is one 15-item form in English only for the children aged 11-71 months. TABS uses parent report and requires 5 minutes to administer. Available from: Paul H. Brookes Publishers, P.O. Box 10624, Baltimore MD, 21285 (800-638-3775), www.pbrookes.com.

29. For additional information on evaluations and analyses of home visiting programs, see "Home Visiting: Recent Program Evaluations" in The Future of Children, Vol. 9, No. 1 (Spring/Summer 1999), www.futureofchildren.org.

30. HCFA's Key Approaches to the Use of Managed Care Systems for Persons with Special Health Care Needs (October 1998), www.hcfa.gov/medicaid/smd-snpf.htm, provides that states should consider that "[c]ommunications with MCO enrollees must be consistent with the ADA prohibition on unnecessary inquiries into the existence of a disability."

31. For illustrative language relating to the identification of, and provision of services to, enrolled individuals who are homeless, see Optional Purchasing Specifications: Medicaid Managed Care for Individuals Who are Homeless (June 2000) on www.gwu.edu/~chsrp.

32. An alternative option would be to require Contractor to ensure that each primary care provider participating in Contractor's provider network make available to the family or caregiver of an enrolled child under age 3 who is a patient of the provider the opportunity to obtain answers to questions relating to child development services by telephone during the provider's business hours.

33. See http://www.aap.org. An alternative option would be Healthy Steps Telephone Information Line (October 1996), http://www.healthysteps.org/healthysteps/homedocuments.nsf/key/telephoneinfoline.

34. For illustrative language relating to a toll-free telephone line for emergency services, see §A2-5 of CHSRP's Optional Purchasing Specifications: Access to Services (June 2000), www.gwu.edu/~chsrp.

35. See http://www.aap.org. An alternative option would be a child health and development record developed by or for Contractor.

36. See http://www.reachoutandread.org.

37. See also care coordination or case management sections of the following optional purchasing specifications available or under development from GW CHSRP, www.gwu.edu/~chsrp: HIV/AIDS (August 1999); Children with Special Health Care Needs (forthcoming); Children with Behavioral Health Needs (forthcoming); Individiuals Who Are Homeless (June 2000); and Access to Services (June 2000).

38. See http://www.hcfa.gov/pubforms/pub45pdf/smm4t.htm.

39. For additional information on each state's Part C Programs, see National Early Childhood Technical Assistance Service at http://www.nectas.unc.edu/contact/ptccoord.html.

40. For other guidelines, see §006(a)(1) of MEDICAIDSPECS.

41. The EPSDT benefit includes developmental assessments under §1905(r)(1)(B)(i) of the Social Security Act (42 U.S.C. §1396d(r)(1)(B)(i)), the purpose of which is to detect evidence of delays or disabilities among Medicaid-eligible children. Under HCFA guidelines for younger children, the required developmental assessments must at a minimum include the following elements: (1) gross motor development; (2) fine motor development; (3) communication skills or language development; (4) self-help and self-care skills; (5) social-emotional development; and (6) cognitive skills, Medical Assistance Manual, §5123.2A.1.a. This illustrative definition of medical necessity is intended to clarify Contractor's obligation to treat and prevent not just developmental disabilities, but also developmental delays.

42. This illustrative language is intended to address items and services needed by enrolled children with chronic conditions, disabilities, or delays that cannot be prevented, corrected, or ameliorated.

Medicaid Contract Purchasing Specifications

Purchasing Specifications For Child Development Services In Medicaid Managed Care July, 2000

Table of Contents

Compliance Measures

Purchasing Specifications For
Child Development Services In
Medicaid Managed Care
July, 2000