Medicaid Contract Purchasing SpecificationsMedicaid Managed Care for Children in Substitute CareTable of Contents§101. Contractor's Basic Duties to Enrolled Children in Substitute Care §102. Identification and Enrollment of Children in Substitute Care §103. Initial Screening and Comprehensive Health Assessment §105. Assignment to Primary Care Provider §106. Disenrollment of Enrolled Children in Substitute Care §109. Relationship with Other Agencies §110. Data Collection and Reporting §101. Contractor's Basic Duties to Enrolled Children in Substitute Care
Commentary: The following illustrative language sets forth each of the four statutory categories through which children in substitute care can be covered under Medicaid. It also includes a category that the state purchaser can define based on state law. A state purchaser may choose to buy managed care services for children qualifying for Medicaid under one, several, or all of these categories.
§102. Identification and Enrollment of Children in Substitute Care Commentary: The illustrative language in subsection (a) assumes that the Purchaser knows whether a child is a child in substitute care as the Purchaser has defined this group using the language in §101(b) and (c), and that the Purchaser has the administrative capacity to make that information available to the Contractor on a timely basis. Because of the wide variation among the states in the administration of child welfare programs, the language in subsection (a) is silent on how the Purchaser obtains this information. Instead, it merely frames the duty of the Purchaser to make the information it has available to the Contractor so that the Contractor can carry out its service duties under these specifications toward these children. It should be noted that state child welfare agencies are entitled to 50 percent of the administrative costs of establishing a data system that has the capability of interfacing with other state data systems (e.g., relating to TANF eligibility) for purposes of verifying the eligibility of foster children, §474(a)(3)(C)(iii) of the Social Security Act, 42 U.S.C. §674(a)(3)(C)(iii). Issues relating to confidentiality of information about children under supervision are addressed in §111 and the accompanying commentary. If the Purchaser does not have information as to the identity of all enrolled categories of children in substitute care defined in §101(b) and (c), or if the Purchaser does not wish to make all this information available to Contractor (for example, by limiting identification to children in Title IV-E foster care only), the children will need to be identified by Contractor in order for service duties to be triggered. Thus, the illustrative language at subsections (b) and (c) would impose duties on the Contractor to identify children in substitute care from among new enrollees as well as from among children who have been enrolled for a specified period of time (e.g., 90 days) if the Contractor does not receive identifying information from the Purchaser.
Commentary: The following illustrative language addresses the situation in which a contracting MCO has not been notified by the State agency that an enrolled child is a child in substitute care (as per subsection (a)) and has had no contact with the enrolled child through its provider network. Thus, the MCO has not had an opportunity to identify the child as a child in substitute care at the first encounter with a provider (as per paragraph (1)). The MCO knows only that the child is an enrolled Medicaid beneficiary. The problem in this situation is that none of the duties that the MCO may have under this purchasing agreement specific to children in substitute care are triggered, and an enrolled child in substitute care may "fall through the cracks." The illustrative language would require the contracting MCO to notify the Purchaser of the name and identification number of the enrolled child if, based on the data in its management information system or other sources, there has been no contact between the child and the MCO's provider network over a number of months (during which capitation payments continue to flow to the MCO) specified by the Purchaser. (An alternative option would be for the Purchaser to flag this information by analyzing encounter data supplied by Contractor). With this information, the Purchaser would be able to take appropriate action, such as attempting to locate the child or its foster parents and determine whether the child's health care needs are being addressed.
Commentary: The following illustrative language would require Contractor to identify enrolled children who are in substitute care but have not been identified as such in the information supplied by Purchaser to Contractor or in the first encounter between an enrolled child and a provider participating in Contractor's provider network. The purpose of this requirement is to increase the likelihood that children in substitute care are known to Contractor and its affiliated providers. An alternative approach would be to rely solely upon the Purchaser or another state agency to notify the Contractor of an enrolled child's status as a child in substitute care.
§103. Initial Screening and Comprehensive Health Assessment Commentary: This section would require a contracting MCO to conduct (1) an initial screening and (2) a comprehensive health assessment of each enrolled child in substitute care. Both the initial screening and the comprehensive health assessment would be conducted by a primary care provider in the MCO's network. For the initial screening, the provider would have to use an encounter form specified by the state purchaser. For the comprehensive health assessment, the provider would have to use guidelines specified by the state purchaser. To avoid duplication, the requirement to conduct a comprehensive health assessment would not apply to children who have already received assessments for their special needs from other providers or agencies. Under current federal law, state (or local) child welfare agencies must develop "case plans" for children receiving family preservation services (Title IV-B) and children receiving foster care or adoption assistance (Title IV-E). A case plan must include "to the extent available and accessible, the health and education records of the child, including (i) the names and addresses of the child's health and educational providers;... (v) a record of the child's immunizations; (vi) the child's known medical problems; and (vii) any other relevant health and education information concerning the child determined to be appropriate by the State agency...." §475(1)(C) of the Social Security Act, 42 U.S.C. §675(1)(C). The child welfare agency must supply an updated version of the child's case plan "to the foster parent or foster provider with whom the child is placed at the time of placement,..." §475(5)(D) of the Social Security Act, 42 U.S.C. §675(5)(D). Under the approach taken in the following illustrative language, the existence of a Title IV-E case plan for a newly enrolled child would not cancel the duty of the Contractor to conduct both an initial screening and a comprehensive health assessment. The Contractor would also be required to make the results of the initial screening and the comprehensive health assessment available upon request to an enrolled child's foster care parent or the Child Welfare Agency. The Child Welfare Agency, in turn, could use the results of the initial screening in developing its case plan for the child. However, the initial screening requirement is not intended to satisfy the Title IV-E case plan requirement. Instead, it is intended to enable the contracting MCO to identify children in foster care newly enrolled in their plans and the immediate treatment needs, if any, of such children. Note that this illustrative language specifies that the initial screening and the comprehensive health assessment be conducted by a primary care provider participating in the Contractor's provider network. The language does not, however, specify who that provider should be. In some states, clinics that specialize in the screening and assessment of children in the child welfare system subcontract with Medicaid MCOs to perform these services. For example, the South Main Clinic in Salt Lake City, Utah performs initial assessments for many foster children, and subcontracts with all the Medicaid MCOs. The Clinic bills the MCOs for the initial screen and other services, and staff meet monthly on children with special needs to monitor and coordinate the needed care.18 An interested state purchaser could require inclusion of such clinics in the Contractor's provider network.
Commentary: Note that the following illustrative language would require that the comprehensive health assessment be conducted by a primary care provider, which in turn is defined as a physician, nurse practitioner, or physician assistant (§105(f)). The working assumption is that the provider conducting the comprehensive health assessment for children in substitute care is the same provider conducting assessments for other Medicaid-eligible children.
(d) No Duplicative Comprehensive Health Assessment Required Commentary: As discussed in the Introduction to this document, CHSRP has developed sample purchasing specifications that relate to the purchase of Medicaid managed care for all children (including those in the child welfare system), as well as certain subpopulations (including children with special health care needs, children with behavioral health needs, and children with HIV). In each case, the CHSRP purchasing specifications set forth illustrative language for health assessments tailored to the subpopulation. Many of the children in substitute care addressed in this document will also fall into one or more of these subpopulations. In order to avoid duplicating the comprehensive health assessment in such cases, the following illustrative language would direct the Contractor to treat an enrolled child in substitute care as a member of one of these subpopulations where the initial screening so indicates. For example, if a newly enrolled child in substitute care is determined by the initial screening to have severe asthma, the Contractor would be required to treat the child as a child with special health care needs and develop an initial assessment and a care plan for the child as per §102 and §105 of Children with Special Health Care Needs Purchasing Specifications (August 2000), www.gwhealthpolicy.org.
§104. Case Management Commentary: As discussed above, current federal law requires state (or local) child welfare agencies to develop "case plans" for children receiving family preservation services (Title IV-B) and children receiving foster care or adoption assistance (Title IV-E). These "case plans" differ from, and do not substitute for, the Medicaid "case management plan." The fundamental purpose of both plans, however, is to coordinate the provision of services to individual beneficiaries. A NASHP study of the provision of services to children in foster care observes: "The most common entity responsible for care coordination and tracking tends to be either the Child Welfare caseworker or (if the child is enrolled in managed care) the primary care provider. This may create problems: primary care providers may be coordinating physical health care but may be unable to coordinate behavioral health care, education-related, or long-term care services. Assigning coordination responsibility to Child Welfare caseworkers can result in a lack of health care understanding or focus that has traditionally plagued the system. Multiple case managers for the same child (e.g., the Child Welfare case worker, the primary care physician, and the staff or foster parents with whom the child resides) can create confusion and problems in delineating responsibilities." (NASHP, Efforts in Ensuring Health Care to Children in Foster Care (December 1999), p. 12-13, www.nashp.org). The following illustrative language requires that Contractors develop and implement a case management plan for those enrolled children in substitute care. In order to avoid duplication of case management plan and related care coordination requirements, subsection (d) would clarify that, in the case of enrolled children in substitute care who also fall into other categories of children with special health care needs, Contractor would comply with the duties applicable to the other categories. These duties include the provision of case management or care coordination services tailored to the unique circumstances of each population. One issue that arises with respect to the provision of case management services under Medicaid to children in Title IV-E foster care concerns which activities qualify for federal Medicaid matching funds and which qualify for Title IV-E matching funds. In a letter to State Child Welfare Directors and State Medicaid Directors dated January 19, 2001, www.hcfa.gov/medicaid/smd119c1, CMS and the Administration for Children and Families (ACF) identify following activities as "part of the direct delivery of foster care services and therefore may not be billed to Medicaid as a case management activity...research gathering and completion of documentation required by the foster care program, assessing adoption placements, recruiting or interviewing potential foster care parents, serving legal papers, home investigations, providing transportation, administering foster care subsidies, and making placement arrangements." Another issue of particular importance to children in substitute care has to do with the allowability of payment for services to members of the child's foster care (or biological) family who are not eligible for Medicaid. For example, if the child's biological mother needs treatment for substance abuse but is not eligible for Medicaid, may a State pay for the services needed by the mother under its Medicaid program in order to promote reunification of the child with its mother? As a general rule, Medicaid coverage is not available to individuals who are ineligible for Medicaid, even if those individuals are members of the immediate family of a Medicaid beneficiary. There are exceptions, however, as explained in the CMS January 19 letter regarding the circumstances under which federal Medicaid matching funds are available for case management services provided to members of an enrolled child's family who are not themselves eligible for Medicaid: "[CMS] policy permits contacts with non-eligible or non-targeted individuals to be considered a Medicaid case management activity, and to be billed to Medicaid, when the purpose of the contact is directly related to the management of the eligible individual's care...it may be appropriate to have family members involved in all components related to the eligible individual's case management because they may be able to help identify needs and supports, assist the eligible individual to obtain services, provide case workers with useful feedback, and alert them to changes." The CMS January 19 letter also clarifies when case management services cannot be reimbursed by Medicaid: "...contacts with[ineligible individuals] that relate directly to the identification and management of the[ineligible individual's] needs and care cannot be billed to Medicaid. While the nature of the contacts may squarely fall into one of the components of case management (i.e., assessments, care planning, referral and follow-up), Medicaid cannot be used to pay for them due to the fact that the individual is not Medicaid eligible...." www.hcfa.gov/medicaid/smd119c1. (a) Basic Duty — In the case of an enrolled child in substitute care (as defined in §101(b)) who, under an initial screening described in §103(b), has been determined to be pregnant or to have special health care needs, Contractor shall manage the delivery of covered services to the child by implementing a case management plan that meets the requirements of subsection (b), except as provided in subsection (c). (b) Case Management Plan
(c) Prior Authorization — Contractor shall provide coverage (or make payment) for any item or service specified in the case management plan of an enrolled child in substitute care (as defined in §101(b)), regardless of whether prior authorization for the item or service has been sought or obtained on the child's behalf. (d) No Duplicative Case Management Plan Required — Contractor shall not have a duty under subsection (a) to develop and implement a case management plan with respect to an enrolled child in substitute care (as defined in §101(b)) if one of the following paragraphs applies:
§105. Assignment to Primary Care Provider Commentary: There are two basic approaches to beneficiary choice of primary care providers when beneficiaries are enrolled in MCOs. One approach is to offer the beneficiary a choice between two or more MCOs and, once enrolled in an MCO, a choice among primary care providers. This approach is reflected in §105(b). The other approach, reflected in §105(a), is to offer the beneficiary a choice among primary care providers and, once that selection has been made, to assign the beneficiary to an MCO based on its affiliation with the provider. For a review of these differing approaches, see Kathleen Maloy, et al., Results of a Multi-Site Study of Mandatory Medicaid Managed Care Enrollment Systems: Implications for Policy and Practice (May 1999), GW Center for Health Services Research and Policy, www.gwhealthpolicy.org. (Note that these two approaches are not as common when beneficiaries are enrolled in behavioral health organizations, or BHOs, since states often contract with a single BHO to serve all beneficiaries in a particular geographic area.) Yet another approach to ensuring access to and coordinating the provision of covered services is the use of a multidisciplinary team of providers (e.g., primary care practitioners, behavioral health practitioners, case managers), rather than a single primary care provider. This approach is reflected in §204 of CHSRP's Children with Behavioral Health Needs Purchasing Specifications (October 2000), www.gwhealthpolicy.org. (a) Duty to Allow Selection Prior to Enrollment 30— In the case of a child in substitute care (as defined in §101(c)) who is eligible to enroll with Contractor under[drafter insert name of purchasing document], Contractor shall permit the child's custodian (as defined in §101(d)) to select for the child a primary care provider (as defined in subsection (f)) from among the primary care providers participating in Contractor's provider network. (b) Duty to Allow Selection on or after Enrollment — Contractor shall permit the custodian (as defined §101(d)) of an enrolled child in substitute care (as defined in §101(b)) to select for the child a primary care provider (as defined in subsection (f)) from among the primary care providers participating in Contractor's provider network. — In the event that an enrolled child in substitute care (as defined in §101(b)) (or the child's custodian (as defined in §101(d)) on the child's behalf) does not select a primary care provider under subsection (a) or (b) within[ ] days of the effective date of enrollment, Contractor shall notify[drafter insert name of state Child Welfare Agency] that:
Commentary: The following illustrative language addresses the situation of an enrolled child in substitute care who has not selected or been assigned to a primary care provider who meets the requirements of paragraph (2). In these cases, the Contractor would be required to allow the child's custodian to select a primary care provider who participates in Medicaid but is not in the Contractor's provider network. One alternative option would be to allow the child to disenroll and see the out-of-network provider on a fee-for-service basis. Another alternative option would be to direct the Contractor to assign the child to an in-network primary care provider who does not meet the requirements of paragraph (2).
(d) Duty to Allow Re-Selection — In the case of an enrolled child in substitute care (as defined in §101(b)) who has selected a primary care provider under subsections (a) or (b), or who has been assigned a primary care provider under subsection (c), Contractor shall permit the child's custodian (as defined in §101(d)) or Agency case worker to select another primary care provider participating in Contractor's provider network whenever there is a change in the child's foster residence or other out-of-home placement. (e) Duty to Honor Selection or Re-Selection — Contractor shall honor any selection or re-selection of a primary care provider made by or on behalf of an enrolled child in substitute care (as defined in §101(b)) under subsections (a), (b), or (d) unless:(1) the provider is no longer participating in Contractor's provider network; orCommentary: The following illustrative language defines "primary care provider" for purposes of identifying who is responsible for (and authorized to) conduct the initial screening and the comprehensive health assessment with respect to an enrolled child in substitute care under §103. (f) Primary Care Provider Defined — A primary care provider is a physician, nurse practitioner, or physician assistant participating in Contractor's provider network who:
§106. Disenrollment of Enrolled Children in Substitute Care Commentary: The following illustrative language, which is drawn from Part 2 of CHSRP's Medicaid Pediatric Purchasing Specifications (September 1999), addresses situations in which children in substitute care are receiving services at the time of disenrollment (whether voluntary or involuntary) for a course of treatment, whether in connection with an acute episode or a chronic condition. Purchasers considering this language may also wish to consider adjusting their premium payments to reflect additional costs which Contractors may incur in complying with these duties for this subpopulation of children in substitute care. (a) Children Receiving Treatment at the Time of Disenrollment — In the case of an enrolled child in substitute care (as defined in §101(b)) who, at the time of disenrollment (for any reason), is under treatment, Contractor shall:32
§107. Provider Network Commentary: The following illustrative language is intended to supplement provisions in a purchasing document relating to the composition of a contracting MCO's provider network. The language would require the MCO to include in its provider network primary care providers experienced in the treatment of children in the child welfare system. The language would also require coordination between primary care providers and specialists to ensure prompt access by a child in substitute care to needed specialist services. Finally, the language would require the MCO to furnish or arrange for training for its network primary care providers in the medical management of these children. For an example of comprehensive provisions relating to provider networks (e.g., specifying the content of subcontracts, relationships with out-of-network providers, types of specialists, and provider payment provisions), see Part 5 of the Medicaid Pediatric Purchasing Specifications; §205 of the Children with Behavioral Health Needs Purchasing Specifications; and §204 of the Children with Special Health Care Needs Purchasing Specifications. (a) In General — Contractor shall establish and maintain a provider network that meets the requirements of:
(b) Inclusion of Experienced Providers — Contractor shall make its best effort to include in its provider network primary care providers (as defined in §105(f)) with experience in the medical management of children in substitute care (as defined in §101(c)) sufficient in number to enable enrolled children in substitute care (as defined in §101(b)) to select under §105 among at least[ ] such providers with the capacity to accept the child as a patient. (c) Coordination with Specialists33— Contractor shall ensure that primary care providers participating in Contractor's provider network who have responsibility for the medical management of an enrolled child in substitute care (as defined in §101(b)) coordinate with specialists (whether or not participating in Contractor's provider network) who furnish services needed by the child to facilitate prompt access of the child to such services. Commentary: A 1998 report on child welfare issues in California noted, "Many providers are uncomfortable with children in foster care because they do not understand reporting requirements, the child welfare system, the legal system, and the need for court authorizations for some procedures. Training should be offered not only to pediatricians, but also to pediatric nurse practitioners, emergency room personnel, and family practice physicians." Institute for Research on Women and Families, California State University, Code Blue: Health Services for Children in Foster (March 1998), p. 15. A 1999 study by the National Academy for State Health Policy identified training programs and materials for health care providers in Alaska, California, Maine, Massachusetts, and Utah. NASHP, Efforts in Ensuring Health Care to Children in Foster Care: Case Studies of Nine States (December 1999), pp. 39-43, www.nashp.org. The following illustrative language would require contracting MCOs to offer training in the identification and medical management of children in substitute care to network primary care providers. The language would not specify a training protocol or timetable and does not require that network providers participate in the training. (d) Training of Providers — Contractor shall offer each primary care provider (as defined in §105(f)) participating in Contractor's provider network the opportunity to receive training at Contractor's expense in the identification and medical management of children in substitute care (as defined in §101(c)) from a primary care provider with at least[ ] years experience in the medical management of such children. §108. Access Standards Commentary: Most purchasing agreements contain standards for timely access to emergency services for all enrollees, including children in substitute care. The following illustrative language sets forth a standard for timely access to non-emergency services (whether furnished by primary care providers or by specialists) that is specific to children in substitute care. For additional access standards appropriate to Medicaid-eligible children generally, see Part 6 of Medicaid Pediatric Purchasing Specifications (September 1999) and Access to Services Purchasing Specifications (June 2000) (both can be found at www.gwhealthpolicy.org). Note that the definition of "emergency medical condition" used in the following language is narrow in relation to the breadth of the health and related needs of children in substitute care. This definition is statutory in nature and applies to all enrolled Medicaid beneficiaries. However, the effect of this relatively narrow definition in the context of the illustrative language below is to broaden the types of health conditions or incidents that would trigger the duty to schedule an appointment with a provider within the timeframe ([ ] days) specified by Purchaser. If the time frame selected by the Purchaser is short &em; e.g., within 24 hours of removal of a child from the home &em; then concerns about lack of timely access to needed medical care should be alleviated. (a) Appointment Times for Non-Emergency Care — In the case of an enrolled child in substitute care (as defined in §101(b)) who does not have an emergency medical condition (as defined in §1932(b)(2)(C) of the Social Security Act, 42 U.S.C. §1396u-2(b)(2)(C)),34 Contractor shall ensure that the child has an opportunity for an encounter with a provider participating in Contractor's provider network within:
(b)[drafter insert other access standards specific to children in substitute care]. §109. Relationship with Other Agencies Commentary: The following illustrative language could be used to frame a memorandum of agreement between the Contractor and the State Child Welfare Agency (or a local child welfare agency with jurisdiction in the Contractor's service area) to coordinate responsibilities for enrolled children in the child welfare system. Of course, the State Child Welfare Agency would not be a party to a purchasing agreement relating to Medicaid (not child welfare) services between Purchaser and Contractor unless the Purchaser and the Child Welfare Agency were units of the same state agency. Accordingly, this language would only require Contractor to enter into such a memorandum if the State (or local) Child Welfare Agency were willing to do so. As discussed in the introduction, GW's child welfare study found that a number of states have used managed care approaches to the purchase of child welfare services other than medical and behavioral health services. The following illustrative language would direct MCOs contracting with Medicaid agencies in these states to attempt to coordinate, through a written agreement, the provision of Medicaid services to enrolled children in substitute care with the provision of child welfare services to this same population by entities contracting with the Child Welfare Agency to furnish child welfare services on a risk basis. The negotiation of a coordination agreement between the MCO and the child welfare contractor could be facilitated by the inclusion of parallel provisions in the contract between the Child Welfare Agency and the managed child welfare entity. Note that under this suggested language, the MCO would be responsible for coordinating with public agencies that seek to coordinate with it. The MCO would not, however, be responsible for coordinating the actions of one public agency with that of another. In addition, the final decision as to whether to coordinate with the MCO rests with the public agency, not the MCO. (a) Memorandum of Understanding with Child Welfare Agency
(b) Coordination Agreement with Child Welfare Agency's Managed Child Welfare Services Contractor
(c) Memorandum of Understanding with Juvenile Justice Agency36
(d) Memorandum of Understanding with State Mental Health and Substance Abuse Services Agency — Contractor shall comply with the requirements of §207(b) of CBHN SPECIFICATIONS. §110. Data Collection and Reporting Commentary: The GW child welfare study found that data relating to children in the child welfare system are "virtually invisible" in Medicaid MCO contracts. The following illustrative language sets forth reporting requirements specific to this population. For additional reporting requirements applicable to Medicaid-eligible children generally, see Part 937 of Medicaid Pediatric Purchasing Specifications. There are two data tracking systems under Title IV-E: (1) the Adoption and Foster Care Analysis and Reporting System (AFCARS); and (2) the State Automated Child Welfare Information System (SACWIS). Interested Purchasers may wish to coordinate with the State agencies that operate these systems in order to facilitate the exchange of data relating to the use of Medicaid services by children under supervision who are enrolled in Medicaid MCOs. This agency to agency communication is outside the scope of a contract between the State Medicaid agency and an MCO. However, §109(a)(3)(I) contains illustrative language that would provide for the exchange of data between Contractor and a child welfare agency relating to Medicaid services needed and furnished to enrolled children under supervision. (a) Utilization Data — Contractor shall collect and report to Purchaser, on a[drafter insert frequency] basis, in such form and manner and for such period as Purchaser specifies, the following data with respect to enrolled children in substitute care (as defined in §101(b)):
(b) Adverse Incidents Reporting
Commentary: Under current law, states are required to collect and report data relating to the use of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services by Medicaid beneficiaries, including the conduct of the basic health and developmental screening that assesses both physical and mental health development. See General Accounting Office, Stronger Efforts to Ensure Children's Access to Health Screening Services (August 2001), GAO-01-749, Table 2, pp. 15-20. In states purchasing EPSDT services for Medicaid beneficiaries through MCOs, the MCOs and their network providers will be the original source of such data. The following illustrative language would require a contracting MCO to break out separately for children in substitute care EPSDT data that the MCO is otherwise required to report to the state Medicaid agency. (c) EPSDT Data — Contractor shall submit to Purchaser, in such form and manner as Purchaser specifies, the data enumerated in[drafter insert reference to EPSDT data reporting provision in purchasing document] that pertains to enrolled children in substitute care (as defined in §101(b)). Commentary: A 1999 study by the National Academy for State Health Policy identified Utah as a state that uses health status indicators based on national standards of care as a means of measuring access to health services by children in substitute care. Based upon initial and follow-up assessments, the state sorts children into one of 6 categories (e.g., child has acceptor chronic conditions and is receiving adequate care; child has suspected or significant undiagnosed/untreated problems). NASHP, Efforts in Ensuring Health Care to Children in Foster Care (December 1999), pp. 45-49, www.nashp.org. The following illustrative language would require contracting MCOs to submit data to enable a state purchaser to measure the health status of enrolled children in substitute care in relation to indicators specified by the purchaser. (d) Health Status Indicators — Contractor shall submit to Purchaser, in such form and manner as Purchaser specifies, the number of children in each of the following health status categories:
§111. Confidentiality Commentary: The following illustrative language would require a Contractor and its network providers to comply with the confidentiality rules under both Title IV-E and Medicaid, as well as under the laws of the State in which the enrolled child resides. Note that final regulations implementing the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, require compliance by most health plans and health care providers by April 2003. The purchasing specifications referred to below do not reflect the requirements of these regulations, which were issued in December 2000. For an analysis of these regulations, see Brian Kamoie and Phyllis Borzi, A Crosswalk Between the Final HIPAA Privacy Rule and Existing Federal Substance Abuse Confidentiality Requirements (forthcoming), Managed Behavioral Health Care Issue Brief Series, #18-19, GW Center for Health Services Research and Policy, www.gwhealthpolicy.org. (a) In General — Contractor, and providers participating in Contractor's provider network, shall comply with the following requirements in connection with the collection, maintenance, and disclosure of medical or other information relating to an enrolled child in substitute care (as defined in §101(b)):
§112. Payment Issues As noted in the introduction, these purchasing specifications do not address payment issues. In developing language concerning payment issues, purchasers may wish to address the following payment issues: (1) those relating to the determination of capitation rates paid to MCOs by state purchasers on behalf of enrolled children under supervision; and (2) payment methodologies used by MCOs with respect to network and out-of-network providers. For language used by state purchasers relating to both of these issues, see Table 7.1 (Plan Payment Terms) and Table 7.2 (Provider Payment Terms) in CHSRP's Negotiating the New Health System, 4th Edition (2001), www.gwhealthpolicy.org. Payments to Plans from Purchasers. Federal Medicaid law requires that payment rates in risk contracts between state Medicaid agencies and MCOs be set on "an actuarially sound basis," §1903(m)(2)(A)(iii) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(iii). In a letter to State Medicaid Directors dated October 5, 1998, CMS notes that "[t |
Commentary: A CHSRP study of state Medicaid MCO contacts found that, in 31 contracts, children in foster care or other out-of-home placement (or some subgroups of this population) are included among the Medicaid beneficiaries enrolled. See CHSRP's Negotiating the New Health System, 4th Edition (2001), Table 1.1, www.gwhealthpolicy.org. Very few of these contracts, however, contain provisions specifically addressing the needs of this population.11 GW's child welfare study found that "[d]espite the fact that children receiving child welfare services comprise a potentially significant proportion of any Medicaid managed care organization's pediatric and family enrollment, their unique circumstances rarely receive attention."12
As noted above, State Medicaid agencies may not require children under 19 who are in foster care or other out-of-home placements (whether or not they are receiving foster care assistance under Title IV-E) to enroll in Medicaid managed care without obtaining a waiver from the Secretary of HHS. However, if children in foster care or other out-of-home placements enroll in Medicaid MCOs, whether voluntarily or under waiver, certain federal statutory requirements apply. These requirements are referenced in the illustrative language and commentary.
Many of the children in the child welfare system have conditions or attributes that place them in other subpopulations that a state Medicaid agency might seek to enroll in an MCO. For example, some of these children may have special health care needs, behavioral health needs, or need services for HIV/AIDS. As discussed in the Introduction at page 4, CHSRP has, with support from SAMHSA, CDC, and HRSA, developed sample purchasing specifications for these populations. The purpose of the purchasing specifications set forth in this document is to complement the other CHSRP purchasing specifications with respect to children who fall into these populations but are also in the child welfare system. Accordingly, these purchasing specifications address only those issues that are not adequately addressed for the child welfare population by the other specifications.
Under the approach taken in these purchasing specifications, the duties of the MCO Contractor are triggered by a determination that a child (who is a Medicaid beneficiary and who is enrolled with the Contractor) is under the supervision of the State Child Welfare Agency (or a local child welfare agency with jurisdiction in the Contractor's service area). Sections 101(b) and (c) of the following illustrative language defines this class of children; §101(a) sets forth the Contractor's duties with respect to such children. Note that the Medicaid entitlement to early and periodic screening, diagnostic, and treatment (EPSDT) services for children extends up to age 21.
In these specifications, as in the other CHSRP sample purchasing specifications, the term "Purchaser" refers to the state Medicaid or other purchasing agency. The term "Contractor" refers to the managed care organization (MCO) that has entered into an agreement with the purchasing agency to arrange for the furnishing of covered services to enrolled Medicaid beneficiaries.