Medicaid Contract Purchasing Specifications
Purchasing Specifications
For Medicaid Pediatric Dental And Oral Health Services
March, 2000
Introduction
This document sets forth illustrative language for the purchase
of pediatric dental and oral health services for Medicaid beneficiaries
enrolled in managed care organizations (MCOs). The specifications
are intended for use in health care service purchasing agreements
with managed care organizations (MCOs) that either for a preset
fee (i.e., a premium) or under an administrative services agreement
(ASO) arrange for the delivery of comprehensive health care, including
pediatric dental and oral health services, through a network of
participating providers. In the case that pediatric dental and
oral health services are excluded from comprehensive managed care
service agreements, the specifications may be used in purchasing
pediatric dental and oral health services under separate purchasing
agreements with MCOs that specialize in these services.
The specifications have been developed for use by state agencies
purchasing health care services for Medicaid-eligible and other
low-income children, who are at significantly higher risk of untreated
dental caries than children in higher-income families.1
The specifications were drafted by the Center for Health Services
Research and Policy (CHSRP, formerly Center for Health Policy
Research) of the George Washington University Medical Center,
School of Public Health and Health Services under the direction
of experts in the field of pediatric dental and oral health services.
The Centers for Disease Control and Prevention (CDC) provided
guidance on clinical and policy issues addressed in the sample
specifications and financial support for their development. The
specifications were reviewed in draft form by representatives
of the Health Care Financing Administration, the Health Resources
and Services Administration, state Medicaid agencies, consumers,
health care providers, and managed care organizations.
As a publication of CHSRP, the specifications do not represent
agency policy, guidance or other official act by any public agency.
The contents of this document are optional for state policymakers.
These sample specifications are illustrative. They are designed
to function as one of many tools that Purchasers employ to develop
and oversee managed dental and oral health care services for Medicaid
beneficiaries who are children and adolescents. The specifications
may be used in their entirety or on an item-by-item basis, depending
on the range of issues that a Purchaser wishes to address. Individual
specifications may be added to appropriate sections in a purchasing
agreement or a package of specifications may be added to an agreement
as a dental and oral health services appendix or attachment.
Because of variations in Purchasers' financing options, policy
preferences and legal duties, there is no single correct method
for covering and delivering pediatric dental and oral health services.
An important variable in purchasers' decisions would be the risk
of pediatric dental caries in the Medicaid population(s) to be
enrolled by a managed care Contractor, taking into consideration
the fluoride level(s) of the water supply(ies) where the population(s)
live and the higher risk of dental caries in all low-income children
and youth.2 Given these variables,
it is nevertheless possible to identify the critical decision
points that purchasers may face and to suggest approaches to each.
The specifications offer illustrative options for purchasing including
key issues in coverage, access, delivery and quality of care.
The specifications have been drafted to be consistent with federal
legal requirements pertaining to dental and oral health services
for children and adolescents enrolled in Medicaid. Drafters may
wish also to incorporate a state's medical assistance (Medicaid)
plan, which includes, for example, the state's periodicity schedules
for dental and oral health assessments ("screens") under the Medicaid
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
benefit. For purchasers who wish to use this drafting strategy,
the document includes suggestions for incorporating the state's
medical assistance plan by inserting citations to it.
A Purchaser may elect to remain silent with respect to a particular
matter for which illustrative language has been prepared. In such
a case, rules of contract construction would mean that the purchaser
would effectively elect to defer resolution of the particular
issue to contractor discretion.
The specifications are accompanied by Commentaries(shown as endnotes)
to aid in reading and interpretation. All specifications will
be hyperlinked to numerous related government and private agency
website addresses. The specifications are part of a series of
sample purchasing specifications that, beginning in 1998, are
being posted at CHSRP's website address.3
The specifications are designed to be used in conjunction with
other specialized CHSRP sample specifications, which relate to
comprehensive health care services for children and adolescents
enrolled in Medicaid and in state Child Health Insurance Programs
(CHIP) that extend Medicaid coverage to CHIP-eligible children
and adolescents. The current version of the comprehensive document
includes general provisions relating to dental and oral health
services; the document also includes a section reserved for insertion
of these more detailed pediatric dental and oral health services
specifications. The comprehensive specifications are identified
in Commentaries by references to MEDICAIDSPECS, which refers to
Sample Medicaid Pediatric Purchasing Specifications: A Technical
Assistance Document.4
The dental and oral health services and other sample purchasing
specifications in the series may be obtained in diskette form
from:
Center for Health Services Research and Policy
(formerly Center for Health Policy Research)
School of Public Health and Health Services
The George Washington University Medical Center
2021 K Street N.W. #800
Washington, D.C. 20006
Endnotes
- Commentary: Vargas CM, Crall
JJ, Schneider DA. Sociodemographic distribution of pediatric
dental caries: NHANES III, 1998-1994. JADA 1998;129:1229-36.
- Commentary: Information on
the risk of caries and on fluoride levels in community water
supplies may be available from state or county public health
agencies.
- Commentary: The Center website
address is: http://www.gwu.edu/~chsrp. At the time this draft
was prepared, specifications had been posted for vaccine preventable
diseases, childhood lead poisoning and pediatric (adolescent
and child) Medicaid specifications. In addition to the pediatric
MEDICAID specifications cross-referenced in this document, other
CHSRP specifications projects were: access to health care; care
for children in the child welfare system; child development
services and services for children with special health care
needs; cultural competence; data and information collection
and reporting; HIV/AIDS; information and reporting; memoranda
of understanding between managed care organizations and state
and local health and other agencies; mental illness and addiction
disorders services for children and adults; pharmacy services;
services for homeless individuals; sexually transmitted disease
services; and tuberculosis services. In addition to CDC, support
for these specifications projects comes from the Health Resources
and Services Administration (HRSA); the Substance Abuse and
Mental Health Services Administration (SAMHSA); the National
Committee on Vital and Health Statistics; the David and Lucille
Packard Foundation, Center on the Future of Children; The Commonwealth
Fund; and Glaxo Wellcome Inc.
- Commentary:The Center website
address is: http://www.gwu.edu/~chsrp.
