Medicaid Contract Purchasing SpecificationsMedicaid Managed Care for Children in Subsitute CareA TECHNICAL ASSISTANCE DOCUMENT(December 2001) This document, Optional Purchasing Specifications: Medicaid Managed Care for Children in Substitute Care, was prepared by the George Washington University Center for Health Services Research and Policy (CHSRP) in consultation with officials from the Substance Abuse and Mental Health Services Administration (SAMHSA). This technical assistance document should be viewed as a tool to assist state officials in purchasing services from managed care organizations (MCOs) on behalf of children in the child welfare system who are eligible for Medicaid. These sample purchasing specifications are optional, and do not necessarily reflect the views of SAMHSA or the Centers for Medicare and Medicaid Services (CMS, formerly Health Care Financing Administration, HCFA). Children in the child welfare system are more likely to be in poor health than other children and often do not receive basic preventive and primary pediatric care (e.g., immunizations, dental care). In addition, they are disproportionately affected by serious emotional, psychological, and social disorders, developmental delays and disability, and physically disabling conditions. The General Accounting Office notes that "as a group, they are sicker than homeless children and children living in the poorest sections of inner cities."1 Most children in the child welfare system are eligible for Medicaid, either because of receipt of foster care maintenance payments under Title IV-E of the Social Security Act (or under a state-only program) or because of their poverty income status. Not surprisingly given their health status, children in foster care account for a disproportionate share of Medicaid spending on children.2 Any Medicaid managed care population may be expected to include subpopulations of children and youth involved with child welfare but not necessarily in out-of-home care. These may be: (1) infants, children, and youth living in family homes or kinship care under informal supervision of a child welfare agency; (2) youth who have been discharged from a juvenile justice facility into the care of a child welfare agency; (3) children of all ages who have been reunified with their families, adopted or settled in some other permanent placement; or (4) youth "aging out" of the child welfare system who are receiving "independent living" services. Medicaid is of particular value to these needy children because of the comprehensive Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services benefit to which every eligible child is entitled.3 A number of State Medicaid agencies have attempted to meet the health care needs of this population through the use of managed care, either for health care services, behavioral health services (e.g., mental health and substance abuse treatment services), or both. As a recent report by the National Academy for State Health Policy (NASHP) observes, "Enrolling foster children in risk-based managed care can be tricky because they move frequently, tend to have very complex needs, and require special services (such as initial assessments, care coordination, and increased record-keeping). Concerns exist that these complex needs will not be met, and that foster children—being such a small subset of the Medicaid population—will 'fall through the cracks.'"4 These concerns prompted the Congress in 1997 to permit a state to require these children to enroll in managed care plans only if the state obtains a waiver from the Secretary of Health and Human Services (HHS).5 Voluntary enrollment of these children in managed care, the NASHP report concludes, has the potential to "improve access, coordination, flexibility, emphasis on preventive care, and accurate record keeping."6 However, some in the field have a different perspective: "I have mixed feelings about children in substitute care enrolling in Medicaid managed care. While there are benefits, such as value-added services, navigating managed care is difficult under the best of circumstances. Foster parents need medical resources readily available and accessible in order to provide the best care for the children for whom they are responsible. I am not sure managed care is the answer to that need."7 A number of state and local child welfare agencies have explored the use of managed care for the delivery of child welfare services other than medical and behavioral health services. Contracting by child welfare agencies present numerous issues for state Medicaid agency purchasers in that the child welfare contractors are commonly charged to develop reimbursement arrangements for their Medicaid-eligible enrollees. A study of these child welfare purchasing agreements by CHSRP found, among other things, that medical and health services were "adjuncts" to the primary duties of the contractors, and that the scope of those services was left "mostly to the discretion of contractors and their subcontractors." See Elizabeth Wehr, et al., Managing Child Welfare: An Analysis of Contracts for Child Welfare Service Systems (1999), GW Center for Health Services Research and Policy, p. 11, (HHS Publication No. 99-334-8), www.samhsa.gov (hereinafter GW's child welfare study). GW's child welfare study noted that funding for medical and behavioral health services is controlled not by the child welfare agency or its contractors, but rather by Medicaid managed care contractors, "whose choice of network, access, and performance measures, and allocation of premium funds, will largely determine the accessibility and quality of health care for children in the system."8 Accordingly, GW's child welfare study recommended "the development of sample purchasing specifications for use by Medicaid and child welfare agencies in the development of agreements."9 Subsequent studies have examined and monitored the experience of a number of states with both types of managed care purchasing affecting children in the child welfare system. The studies reviewed the use of managed care arrangements with respect to child welfare services by child welfare agencies, as well as the purchase of behavioral health services through Medicaid MCOs by state Medicaid agencies. One study recommended, among other things, that state agencies should "address the special needs of the child welfare and juvenile justice populations in planning and implementing managed care systems with respect to...contracts and agreements...." Jan McCarthy and Carl Valentine, Child Welfare Impact Analysis 1999 (Health Care Reform Tracking Project): Tracking State Managed Care Reforms as They Affect Children and Adolescents with Behavioral Health Disorders and Their Families (December 2000), p. 24. A special analysis of children and families in the child welfare system has been conducted since 1996 to determine the impact of public sector managed care reforms on children and adolescents with behavioral health disorders and to identify positive policy, practices and quality improvement strategies that states have developed and implemented. See Beth Stroul, et al., Health Care Reform Tracking Project: Tracking State Managed Care Reforms as They Affect Children and Adolescents with Behavioral Health Disorders and Their Families (2000 State Survey) (August 2001 ), p. 134.10 The purchasing specifications set forth in this document are intended for use by state Medicaid agencies in buying medical and behavioral health services on behalf of children in the child welfare system. State child welfare agencies interested in purchasing managed child welfare services may wish to refer to GW's child welfare study and Alfred Kahn and Sheila Kamerman, Contracting for Child and Family Services: A Mission-Sensitive Guide (1999), Annie E. Casey Foundation, www.aecf.org/publications/Child_Family.pdf. The Balanced Budget Act of 1997, P.L. 105-33 (BBA), made a number of changes in the managed care provisions of the federal Medicaid statute. On January 19, 2001, CMS published final regulations implementing many of these changes (66 Fed. Reg. 6228). The provisions of the regulations that must be implemented through contracts between State Medicaid agencies and MCOs are effective with respect to contracts that are up for renewal or renegotiation on or after August 17, 2002 (66 Fed. Reg. 43090 (August 17, 2001)). On August 20, 2001, CMS issued a proposed rule which would amend the January 19 final regulation (66 Fed. Reg. 43614). These purchasing specifications are consistent with the provisions of the BBA and with CMS's letters to state Medicaid directors and CMS's revised Preprint Renewal Submittal for a section 1915(b) Waiver (September 23, 1999), www.hcfa.gov/medicaid. However, these specifications are not, and should not be viewed as, an official interpretation of the BBA or of CMS's regulations or policy guidances. When CMS implements final regulations, these purchasing specifications will be revised accordingly. Process for Developing this Technical Assistance DocumentSince 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 CHSRP's et al., Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, 4th Edition (2001), www.gwhealthpolicy.org (hereinafter Negotiating the New Health System). The study breaks down the contracts into a series of analytic tables. While there is no table specific to children in the child welfare system, a number of the tables contain provisions that address issues specific to this population (see Tables 1.1, 1.4, 2.4, 2.8, and 4.1). 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 SAMHSA, the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), 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. CHSRP has developed sample purchasing specifications that relate to the purchase of Medicaid managed care for children, including those in the child welfare system: Medicaid Pediatric Purchasing Specifications (September 1999) (referred in specifications as MEDICAIDSPECS); Children with Special Health Care Needs Purchasing Specifications (August 2000) (referred in specifications as CSHCN SPECIFICATIONS); and Children with Behavioral Health Needs Purchasing Specifications (October 2000) (referred in specifications as CBHN SPECIFICATIONS). In addition, CHSRP has developed other purchasing specifications that relate to issues affecting subpopulations of children in the child welfare system, including HIV/AIDS Purchasing Specifications (August 1999) (referred in specifications as HIV SPECIFICATIONS). All of the references in the specifications are cross-linked with the citation and all four of these sample specification documents are posted at CHSRP's website, www.gwhealthpolicy.org. This technical assistance document is designed to supplement the four sets of specifications discussed above by focusing on those purchasing issues that are unique to the population of children in the child welfare system. The format of this document parallels that used in the four specifications. In order to minimize duplication, these child welfare specifications include cross-references to illustrative language in the other specifications as appropriate. Other purchasing specifications relevant to this population of children, including those relating to pediatric dental care and sexually transmitted diseases, are listed in Table 1 and are posted on CHSRP's website. The process for developing these child welfare purchasing specifications began with guidance from SAMHSA officials and experts in child welfare purchasing arrangements. The draft specifications were reviewed by a working group and through a series of vetting meetings involving state Medicaid and public health officials, providers, MCO representatives, consumers and experts and advocates in the service delivery of health care to children in the child welfare system. The changes suggested at these vetting meetings have been incorporated into the specifications and have been reviewed by representatives of these meetings. The specifications are also available at www.gwhealthpolicy.org. Organization and Structure of this Technical Assistance DocumentThis document is organized into 12 different sections that address a particular purchasing issue affecting children in the child welfare system. This format is designed to enable interested purchasers to select the precise language they want and incorporate it into their own purchasing documents without having to reformat their documents or to include language that does not reflect their policy preferences. Thus, a purchaser could select language from one, several, or all of the 12 sections. In addition to the illustrative language, this document, like the other CHSRP purchasing specifications, 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." Sara Rosenbaum, et al., Negotiating the New Health System (2nd Edition), Special Report: Mental Illness and Addiction Disorder Treatment and Prevention (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. This document has been developed for use by interested state purchasers throughout the nation. It therefore does not reference standards or requirements unique to specific states. Some states may have in effect laws or regulations that set forth standards or requirements relating to the treatment of children in the child welfare system. For example, New York's Social Services regulations, 18 NYCRR §441.22, establish health care standards for children in foster care, including requirements for health care assessments, access to care, periodicity of care, authorization for care, authorization for release of medical records, and assessment of risk factors for HIV infection and HIV testing. States with such detailed laws or regulations may wish to reference the applicable statutory or regulatory provisions in these contracts rather than setting forth in the contract the substantive standards or requirements themselves. How to Use This Technical Assistance DocumentThe drafting format used in these sample specifications is as follows:
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, it is intended simply to divide each suggested provision into the smallest, practicable policy elements. This division and subdivision format is designed to enable a user 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 detailed 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 a state purchaser uses the following contract language relating to case management plans:
Assume further that this purchaser is interested in extending this comprehensive services plan requirement to children in substitute care (whether or not they are diagnosed to be seriously emotionally disturbed). Assume also that the purchaser would like the foster care parents of these children consulted in the development of the child's comprehensive services plan. This issue is addressed in §104(b)(2) of these specifications:
In order to include this policy in its contract, the purchaser could, without modifying its current format, adapt the illustrative language as follows (underlined):
Issues Not Addressed in this Technical Assistance DocumentThese specifications do not contain illustrative language for a separate benefits package for enrolled children in the child welfare system. There are a number of services that are often required by these children in the child's natural environment (e.g., home, school, or other non-clinical settings), including therapeutic foster care, sexual abuse treatment, hospital step-down services, in-home therapeutic services, and domestic violence treatment. A number of these services are addressed, in whole or in part, in §§103-104 of CHSRP's Children with Behavioral Health Needs Purchasing Specifications (October 2000). In addition, Part 1 of Medicaid Pediatric Purchasing Specifications (September 1999) sets forth illustrative language on all the services covered under the Medicaid program for children. Both of these specifications may be found at www.gwhealthpolicy.org.These specifications do not address issues relating to cultural competence or general issues relating to access to services in managed care. CHSRP has developed sample purchasing specifications in both of these areas: Access to Services Purchasing Specifications (June 2000) and Cultural Competence Purchasing Specifications (Updated, November 2001). Both are posted at www.gwhealthpolicy.org.These specifications also do not address payment issues. However, §112 reviews the following issues in some detail and suggests other sources of information for interested purchasers: (1) the determination of capitation rates paid to MCOs by state purchasers on behalf of enrolled children in the child welfare system; and (2) payment methodologies used by MCOs with respect to network and out-of-network providers. However, §112 does not contain illustrative language on either of these issues. For language used by state purchasers relating to these issues, see CHSRP's Negotiating the New Health System,4th Edition (2001), Table 7.1 (payment to plans) and Table 7.2, (plan payment to providers), www.gwhealthpolicy.org. As in the case of the other CHSRP purchasing specifications, these specifications do not specify any procedural time frames. Instead, a bracket ([ ]) is supplied as a placeholder, indicating that the state purchaser should insert a timeframe of its choosing. However, if statutory requirements for child welfare services require specific timelines, such timelines will be incorporated into the text. Related CHSRP ActivitiesAs discussed above, CHSRP has developed a number of optional specifications that are posted on CHSRP's website, www.gwhealthpolicy.org. A full listing of these specifications is set forth in the following Table; the dated specifications are posted on CHSRP's website. Table 1.
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