Medicaid Contract Purchasing Specifications
Services Related
to Epilepsy
A Technical
Assistance Document
June 2002
This document sets forth illustrative language for the
purchase of epilepsy-related services from managed care organizations
(MCOs) by state agencies administering Medicaid, other state agencies,
and other managed care purchasers. It has been prepared by the George
Washington University Center for Health Services Research and Policy in
conjunction with officials from the Centers for Disease Control and Prevention
(CDC) who provided expertise, direction, and financial support for its
development.
These optional purchasing specifications were drafted
with guidance from experts in the medical specialties of epileptology,
neurology, and primary care, health care services/delivery specialists,
and patient advocates. Policy makers, managed care officials, and state
Medicaid agency representatives reviewed them. They are recommended for
consideration because they reflect good practice in the opinion of experts.
The specifications do not reflect a formal legal policy or part of a formal
practice guideline.
These optional purchasing specifications set forth a
broad menu of draft provisions relating to medical management of epilepsy.
This language may be incorporated into purchasing agreements in any of
several types of formats, including contracts, requests for proposals
(RFPs), requests for information (RFIs), and general service agreements.
The contents of this document are optional for
state policymakers. This document should be viewed as a tool
to assist managed care purchasers to identify key epilepsy-related issues
as they negotiate and draft their purchasing agreements with MCOs.
This document is not designed to stand alone. Instead,
it is designed to be incorporated, in whole or in part, into more comprehensive
purchasing agreements. Thus, this document only contains illustrative
language relating to the definition and delivery of epilepsy-related services.
It does not contain language relating to issues such as payment, resolution
of disputes between the state or other purchasers and the MCO, remedies,
termination, and other elements that would be essential to any purchasing
agreement.
This document is organized into two Parts. The first
Part contains illustrative language defining an epilepsy services benefit.
The second Part contains illustrative language articulating general MCO
duties relating to the delivery of the epilepsy services benefit set forth
in the first Part. Taken together, these two Parts reflect a consistent
set of policies that are organized to facilitate negotiation and drafting
of purchasing agreements. However, the individual elements are designed
to be portable so that they can be used independently of the rest of the
language. Italic insertions in certain provisions identify provisions
where a drafter may wish to insert relevant state laws. Explanatory Commentaries
are provided as footnotes to aid in understanding and interpretation.
Unless otherwise noted, all specifications in this document
related to medical management services and their delivery are based in
whole or in part on the best judgment and opinions of persons knowledgeable
in the treatment of epilepsy, general health care practice, health care
delivery, and health services organization and management. Of particular
note is the specification that enrollees should be reevaluated if they
do not experience an outcome free of seizures and side effects within
a period of three months. This provision underlines the fact that epilepsy
is a chronic disorder that needs to be managed on a continuing basis.
As indicated above, these optional specifications do not reflect a formal
legal policy or part of a formal practice guideline but are recommended
for consideration because they reflect good practice in the opinion of
experts.
These specifications, which are part of the Purchasing
Specifications Series, may be downloaded from www.gwhealthpolicy.org
or may be obtained in diskette form from:
Center for Health Services and Policy
Department of Health Policy
School of Public Health and Health Services
The George Washington University Medical Center
2021 K Street N.W. #800
Washington, D.C. 20006
Table of Contents
Part 1. Epilepsy-Related Service Benefits
§101. In General
— describes the general duties of contractors under this part to
cover and furnish care relating to epilepsy.
§102. Scope of Benefit
— describes in broad terms the scope of what will be considered benefits
related to epilepsy.
§103. Medical Management Services
— describes the elements of medical management of epilepsy, including
classes of covered services.
§104. Non-Medical Support Services
— describes the elements of non-medical support services for epilepsy.
§105. Diagnostic Procedures and Laboratory Services
— describes covered laboratory services and other diagnostic procedures.
§106. Pharmaceuticals and Therapeutic Devices and
Supplies — describes coverage of pharmaceuticals and therapeutic
devices and supplies.
§107. Guidelines and References — identifies
the guidelines and references that apply under this Part to the medical
management of epilepsy.
§108. Coverage Determinations — sets forth
specifications regarding the manner in which coverage determinations are
made under this Part.
§109. Definitions — sets forth definitions
used in Parts 1 and 2.
Part 2. Epilepsy-Related Service Delivery and Health Care
Quality
§201. Enrollee Access to Health Care Providers
— sets forth specifications regarding enrollee access to health care
providers for epilepsy-related services.
§202. Enrollment and Disenrollment — sets
forth specifications regarding the enrollment and disenrollment of individuals
with epilepsy.
§203. Provider Network Requirements — sets
forth specifications relating to the composition of provider networks
for the medical management of epilepsy.
§204. Memorandum of Understanding — [Reserved]
§205. Quality Measurement and Improvement —
sets forth specifications regarding quality measurement and improvement
activities related to epilepsy.
§206. Data Collection and Reporting. — sets
forth specifications regarding information to be provided to enrollees.
§207. Information for Enrollees — sets forth
specifications regarding information to be provided to enrollees.
Part 1. Epilepsy-Related Service Benefits
§101. In General
(a) Contractor Duties — Contractor shall,
for each enrollee, cover and furnish, or arrange for the furnishing of,
epilepsy-related services enumerated in §103
in accordance with:
(1) guidelines and references enumerated in §107;
and
(2) coverage determination standards and procedures enumerated in
§108.
§102. Scope of Benefit
(a) Epilepsy-related services
— Epilepsy-related services are:
(1) services relating to medical
management of epilepsy enumerated in §103;
(2) services relating to the non-medical
support services enumated in §104;
(3) services relating to pharmaceuticals
and therapeutic devices and supplies enumerated in §105;
and
(4) services relating to pharmaceuticals
and therapeutic devices and supplies enumerated in §106.
§103. Medical Management Services
(a) Medical Management Services
— Services for the medical management (diagnosis and treatment)
of enrollees at risk for epilepsy or epilepsy-related medical complications
are the following items and services delivered in accordance with subsection
(b):
(1) neuropsychological assessments
when indicated;1
(2) laboratory tests enumerated
in §105(a);
(3) pharmaceuticals and therapeutic
devices and supplies enumerated in §106(a);
and
(4) in the case of an enrollee in
whoom epilepsy is diagnosed, epilepsy management services shall include:
(A) an individualized assessment
of the enrollee for purposes of developing a plan of assistance;
(B) a plan of assistance based
on the assessment;
(C) coordination of epilepsy-related
services that are prescribed for the enrollee and covered under
this Part; and
(D) assistance to the enrollee
in gaining access to prescribed services and in adherence to self-management
recommendations.
(b) Delivery of Medical Management Services
— In delivering the medical management services covered
under this Section, Contractor shall ensure that:
(1) an initial or preliminary diagnosis of epilepsy
made by a family physician, pediatrician, emergency department physician,
internist, urgent care center, or other health care provider is made
in accordance with applicable guidelines and references outlined in
§107and is confirmed by a neurologist2,
and in the case of any exceptions to this provision, such exceptions
must be documented with a justification for such exception; and
(2) the confirming diagnosis includes:
(A) seizure type; and
(B) epilepsy syndrome when possible;
(3) in the event a general neurologist can neither
confirm nor exclude a diagnosis of epilepsy, the neurologist may refer
the enrollee to a neurologist specializing in epilepsy or to a level
three or level four epilepsy center;
(4) for every enrollee with a diagnosis of epilepsy,
the physician confirming the diagnosis develops a detailed treatment
plan that is implemented at the most primary level of care that is
appropriate, including co-management or principal care by a specialist
where appropriate;
(5) for every enrollee with a diagnosis of epilepsy,
the physician confirming the diagnosis may refer the patient for medical
or surgical treatment when the patient has not responded to treatment
in a timely manner (e.g., is still experiencing seizures within three
months after implementation of the treatment)3;
(6) the treatment plan includes appropriate non-medical
support services described in §104;
(7) the treating physician addresses necessary
revisions to the treatment plan:
(A) in the case of an enrollee with a diagnosis
of epilepsy who has reported a seizure or treatment-related side
effects within three months after implementation of the treatment
plan, the treating physician will reevaluate and, as necessary,
revise the treatment plan, and continue to do so, until the enrollee
does not experience any seizures or treatment-related side effects
for a three-month period or the patient is referred to a more specialized
level of epilepsy care
(B) in the case of an enrollee with a diagnosis
of epilepsy who has not experienced a seizure or epilepsy-related
side effects in the preceding three months, the treating physician
periodically will review the treatment plan to determine if any
changes are necessary (at a minimum, the treating physician should
review the treatment plan once a year);
(8) in the event a treating physician deviates
from an established treatment guideline in the treatment of an enrollee
with a diagnosis of epilepsy, the medical reason for such a deviation
is documented; and
(9) Federal Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) services are met for children under age 21 with
a diagnosis of epilepsy.4
§104. Non-Medical Support Services
(a) Non-Medical Support Services —
In delivering the non-medical support services that are covered under
§102(a)(2), Contractor shall ensure that:
(1) the treating physician, in coordination with
a case manager, develops a psychosocial support services plan for
enrollees with a diagnosis of epilepsy;
(2) a case manager is provided for enrollees
with complicated epilepsy, e.g., enrollees with treatment-resistant
epilepsy or enrollees with epilepsy who have physical or mental disabilities
that adversely affect their educational or vocational performance,
their social participation, or their activities of daily living;
(A) For purposes of this section, a case manager
is someone other than the enrollee’s Medicaid social worker
or Medicaid case manager, and someone other than a managed care
plan’s utilization case manager5;
(3) enrollees with a diagnosis of epilepsy receive
medical case management services outlined in §103(a)(4)
and the psychosocial support services plan described in paragraph
(a)(1) outlined in this section; and
(4) enrollees with a diagnosis of epilepsy receive
education about the condition and available support services;
(5) enrollees with a diagnosis of epilepsy receive
any necessary vocational counseling;
(6) enrollees with a diagnosis of epilepsy receive
any necessary occupational, physical, and speech therapy with clearly
stated goals; and
(7) special education needs are met for children
of school-age with a diagnosis of epilepsy.6
§105. Diagnostic Procedures and Laboratory Services
(a) Laboratory Services — Laboratory
services that are covered under §103(a)(2)
are the following tests delivered in accordance with subsection (b)
of this Section:
Epilepsy requires a two-part diagnostic procedure that focuses on two
questions: Does the patient have seizures? If so, is there an identifiable
cause?
Laboratory tests are to be used to address both of these questions
and to monitor treatment.
(1) In the case of an enrollee for whom an assessment
indicates the possible diagnosis of epilepsy, the following shall
be performed:
(A) All hematologic, hepatic,
renal, metabolic, endocrine, and other tests of help in general
medicine;
(B) Routine electroencephalography (EEG) performed
with a minimum of 16 channels, asleep and awake with photic stimulation
and hyperventilation;
(C) Magnetic resonance imaging (MRI) of high
resolution with appropriate sequences prescribed by the treating
physician to detect subtle brain lesions; and
(D) Full, prolonged neuropsychological battery
to assess intelligence, focal brain damage, and memory.
(2) If the enrollee has the diagnosis of epilepsy,
additional tests may be needed:
(A) Antiepilepsy medication blood levels including
unbound levels;
(B) Routine hemograms, liver function tests
and renal tests for monitoring of possible toxicity. Serum electrolytes
and bone density determinations are required in selected cases;
(C) Repeat MRI with high-resolution fields
and special angles to assess mesial temporal sclerosis and migration
disorders;
(D) Prolonged video EEG monitoring (often
for several days) with or without sphenoidal electrodes;
(E) Positron emission tomography
(PET), interictal and ictal single photon emission computed tomography
(SPECT), functional MRI, magnetoencephalography (MEG) and other
neuro-imaging tests may be needed if surgery is being considered;
and
(F) Intracarotid sodium amytal test (Wada
test) in preparation for surgery.
(b) Delivery of Laboratory Tests — In
delivering the laboratory tests covered under this Part, Contractor
shall ensure that the tests are provided in accordance with the guidelines
and references enumerated in §107.
§106. Pharmaceuticals and Therapeutic Devices and
Supplies
(a) Pharmaceuticals and Therapeutic Devices
and Supplies — Pharmaceuticals and
therapeutic devices and supplies that are covered under §103(a)(3)
are the following, delivered in accordance with subsection (b):
(1) Pharmaceuticals: Contractor shall cover all
drugs currently approved by the U.S. Food and Drug Administration
for the treatment of epilepsy; and
(2) Therapeutic devices: Contractor shall cover
implantation of vagus nerve stimulators.
(b) Delivery of Pharmaceuticals and Therapeutic
Devices and Supplies — In delivering the therapeutic devices
and supplies covered under subsection (a), Contractor shall ensure that
the devices and supplies are provided in accordance with the guidelines
and references enumerated in §107.
(c) Prohibited Substitutions —
In the case that the treating physician considers such substitutions
contraindicated, neither Contractor nor its network providers or subcontractors
may use any procedure, including a formulary, as a substitute for indicated
pharmaceuticals or therapeutic devices or supplies.
§107. Guidelines and References
(a) Guidelines
(1) National Association of Epilepsy Centers
(www.naecepilepsy.org),&#r147;"Guidelines
for Essential Services, Personnel, and Facilities in Specialized Epilepsy
Centers in the United States,” Epilepsia 42(6): 804-814,
2001.
(2) Commission on European Affairs of the International
League Against Epilepsy, “Commission on European Affairs: Appropriate
Standards of Epilepsy Care Across Europe,” Epilepsia 38(1):
1245-1250, 1997.
(3) American Academy of Neurology (www.aan.com):
(A) The Use of Felbamate in the Treatment
of Patients with Intractable Epilepsy (May 1999) (http://www.aan.com/
public/practiceguidelines/felb.PDF)
(B) Management Issues for Women with Epilepsy
(Oct. 1998) (http://www.aan.com/public/practiceguidelines/wwe.pdf)
(C) EEG/Video Monitoring for Epilepsy (Aug.
1999) (http://www.aan.com/public/practiceguidelines/00000059.pdf)
(D) Vagus Nerve Stimulation for Epilepsy
(July 1997) (http://www.aan.com/public/practiceguidelines/00000076.pdf)
(E) Reassessment: Vagus Nerve Stimulation
for Epilepsy (Sept. 1999) (http://www.aan.com/public/practiceguidelines/VNS.pdf)
(4) European Federation of Neurological Societies
Task Force, “Pre-surgical Evaluation for Epilepsy Surgery –
European Standards,” European Journal of Neurology 7(1):119-122
(2000).
(5) The Clinical Standards Advisory Group,
Services for Patients with Epilepsy (Report for the United Kingdom
Health Ministers and National Health Service) (1999).
(b) References
(1) Federal Early Periodic Screening
Diagnosis and Treatment (EPSDT) requirements for children with a diagnosis
of epilepsy, § 1905(r) of the Social Security Act, 42 U.S.C.
§1396d(r).
(2)Agency for Health Care Research and Quality,
Management of Newly Diagnosed Patients with Epilepsy: A Systematic
Review of the Literature, Technical Assessment No. 39 (2001). A summary
of the report is available online at http://www.ahcpr.gov/clinic/epcsums/epilepsum.htm.
§108. Coverage Determinations
(a) Evidence Used in Making Coverage Determination
— In making coverage determinations (as defined in §109(a))
with respect to an enrollee at risk or with a diagnosis of epilepsy,
Contractor shall base such determinations on the following evidence:
(1) appropriate clinical guidelines and references
enumerated in §107;
(2) the enrollee's health status including
pregnancy, psychosocial factors and other factors that could adversely
affect or complicate successful medical management of epilepsy in
the enrollee;
(3) clinical evidence of the condition for
which approval of services is requested; and
(4) the opinion of the treating physician
and the provider confirming a diagnosis
of epilepsy.
(b) Prohibited Substitutions — If
substitutions are contraindicated under appropriate guidelines and references
enumerated in §107, neither Contractor
nor Contractor's provider network or subcontractors may use any procedure,
including a formulary, to substitute pharmaceuticals, therapeutic devices
or supplies, or lab tests unless directed to do so by the treating physician.
§109. Definitions
(a) Coverage Determination — 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 enrollee, an item or service enumerated under §102
is necessary to:
(1) prevent, correct or ameliorate a condition,
disability, illness or injury; or
(2) maintain functioning.
(b) Epilepsy — a central nervous system disorder
that is characterized by unprovoked, recurrent seizures that disrupt
communication among brain cells.
(c) Successor Provider — a provider who assumes responsibility
for furnishing medical services to a former enrollee of Contractor's
plan.
Part 2. Epilepsy-Related Service
Delivery and Health Care Quality
§201. Enrollee Access to Health Care Providers
(a) Timelines for Certain Epilepsy-related
Services — In administering services covered under Part
1, Contractor shall comply with the following timelines:
(1) provider visits for enrollees with epilepsy
shall be scheduled to occur in accordance with timelines recommended
in appropriate guidelines and references enumerated in §107;
and
(2) enrollees should have ready access to
consultation and continuing care by generalist and specialist providers.
§202. Enrollment and Disenrollment
(a) Enrollment of an Individual Receiving
Medical Management Services for Epilepsy — In the case
that Contractor enrolls an individual who, at the time of enrollment,
is receiving medical management services for epilepsy, Contractor shall
furnish such medical management services covered under Part
1 until the enrollee has been medically evaluated and medical management
services have been prescribed by the enrollee’s treating physician
and, if indicated in the opinion of the treating physician, by one or
more specialist or subspecialist providers enumerated in §203(a).
(b) Disenrollment of an Individual Receiving
Medical Management Services for Epilepsy — In the case
of an individual who ceases to be an enrollee and who, at the time of
disenrollment, is receiving medical management services for epilepsy
under §103, Contractor shall:
(1) continue to furnish such services until
the earlier of:
(A) notice to Contractor that the enrollee
is under the care of a successor provider as defined in §109(c);
or
(B) the end of the period for
which a premium has been paid to Contractor for coverage of the
individual; and
(2) at the request of an enrollee:
(A) arrange for timely transfer
of all medical records to the individual's successor provider [drafter
insert time frame]; and
(B) ensure that network providers furnishing
epilepsy-related medical management services to the individual at
the time of disenrollment make themselves available to the successor
provider for review of the individual's treatment plan.
§203. Provider Network Requirements
(a) Network Requirements — Contractor’s
provider network shall include the following classes of providers:
(1) generalist providers whose practice includes
treatment of individuals with epilepsy;
(2) specialist providers who are board-certified
or board-eligible in neurology and subspecialist providers who are
board-certified or board-eligible in neurology with additional training
in epileptology;
(3) comprehensive epilepsy center9
(either through direct network participation or through a contractual
or referral relationship);
(4) referral relationship with a pediatric
neurologist;
(5) a medical case manager who has background
or training as a registered nurse or social worker;
(6) providers trained to meet the special
education needs of school-age children;
(7) epilepsy educators as part of an epilepsy
education program;
(8) laboratories that are certified under
the Clinical Laboratory Improvements Act of 198810
and provide the services listed under §105;
(9) providers of behavioral health services
who may be in one or more of the following classes of providers: clinical
psychologists, board-certified or board-eligible psychiatrists, or
social workers with Master’s degrees;
(10) speech, occupational, vocational, and
physical therapists; and
(11) registered pharmacists.11
(b) Network Selection Practices —
Contractor's provider selection practices shall ensure the inclusion
of providers that demonstrate a high level of performance in furnishing
epilepsy-related services, including a referral relationship contract
with an epilepsy center.
(c) Criteria for Provider Network Participation
and Compensation12
— In calculating a network provider’s penalty
or incentive payment, Contractor shall not, solely on the grounds of
the amount, scope or duration of epilepsy related services covered under
§102:
(1) exclude13
the provider from participation in Contractor’s provider network;
or
(2) reduce or withhold compensation from,
or otherwise impose financial penalties upon a provider participating
in Contractor’s provider network.
(d) Payment for Certain Services Furnished
by Non-network Providers14
— In the event that an enrollee receives treatment for epilepsy
on an emergency basis from a provider who is not a network provider,
such provider shall be reimbursed for such service at:
(1) [Alternative A]15
Medicaid rates; or
(2) [Alternative B] network
provider rates; or
(3) [Alternative C] negotiated
rates.
§204. Memorandum of Understanding [reserved]
§205. Quality Measurement and Improvement
(a) Quality Measurement — Contractor shall
measure the quality of care for enrollees with a diagnosis of epilepsy
against the following standard: enrollees should experience an outcome
in which they have no seizures or treatment-related side effects within
a period of three (3) months. If such a standard is not met, providers
shall revise an enrollee’s treatment plan in accordance with §103(b)(7)(A).
(b) Dissemination of Standards, Guidelines,
and other Materials — Contractor shall make available
to all network providers participating in Contractor’s provider
network:
(1) a full description of all epilepsy-related
services and service duties set forth in this Part;
(2) any practice guidelines and other materials
that Contractor uses to evaluate provider performance; and
(3) any clinical protocols that Contractor
uses to monitor provider performance.
(c) Collection of Epilepsy Quality Improvement
Project Data — At least [drafter insert frequency
of data collection], Contractor shall collect data on epilepsy-related
services to assess the quality of epilepsy-related care provided for
enrollees.
§206. Data Collection and Reporting
(a) Quality Assurance Reporting — At least [drafter
insert frequency of reporting], Contractor shall report epilepsy
quality improvement indicators.
(b) Availability to Purchaser of Certain Documents — Upon
request, Contractor shall make available to Purchaser the most recent
version of each of the following documents:
(1) Contractor’s provider manual and any other directives,
guidelines or protocols transmitted in writing or electronically by
Contractor to providers participating in Contractor’s provider
network relating to the provision or coverage of items and services
covered under §102;
(c) standards and procedures for Contractor’s coverage determinations
under §108; and
(d) sufficient data collection and monitoring to comply with applicable
state laws regarding epilepsy reporting.
§207. Information for Enrollees
(a) Information on Covered Services16
— Contractor shall make available information on epilepsy-related
services covered under §102 before and at the time of enrollment
and when there are material changes in epilepsy-related coverage.
Endnotes
See Agency
for Healthcare Research and Quality, Management of Newly Diagnosed Patients
with Epilepsy: A Systematic Review of the Literature, Technical Assessment
No. 39. A summary of the report is available online at http://www.ahcpr.gov/clinic/epcsums/epilepsum.htm.
Commentary: Exceptions
to the need for a neurologist’s confirmation of a diagnosis of epilepsy
may be justified when the primary care pediatrician, family practitioner,
or internist has extensive training and experience diagnosing and treating
epilepsy and when the condition is uncomplicated and responds fully to
initial treatment.
Commentary:
Three months is suggested as a practical interval within which a patient’s
treatment for epilepsy can be implemented, evaluated, and – where
necessary – modified. However, the determination of a timely response
to treatment should take into account individual circumstances such as
the time required to effect changes in medication regiments and the frequency
of subsequent seizures (if any). A high frequency of subsequent seizures
may indicate that patient referral is more urgent.
See §
1905(r) of the Social Security Act, 42 U.S.C. § 1396d(r). For additional
information on purchasing EPSDT services from MCOs, see Part 1 of Medicaid
Pediatric Purchasing Specifications (Sept. 1999), available at www.gwhealthpolicy.org.
Commentary.
The role of the case manager is to expand access to care and services
for enrollees with a diagnosis of epilepsy. Therefore, the case manager
in this section is specifically distinguished from a managed care plan’s
utilization case manager or a Medicaid social worker. The need for a case
manager may be stronger for children at lower levels of care.
For additional
information about special education needs of children, see Children
with Special Health Care Needs (Aug. 2000), available at www.gwhealthpolicy.org.
For additional
information on purchasing pharmaceuticals, see Purchasing Specifications
for Pharmaceutical and Pharmaceutical Services (Dec. 2001), available
at www.gwhealthpolicy.org.
See
Access to Services Purchasing Specifications, Center for Health
Services Research and Policy (June 2000), www.gwhealthpolicy.org.
Commentary:
The National Association of Epilepsy Centers have established criteria
for what constitutes a “comprehensive” epilepsy center. See
www.naecepilepsy.org
Commentary:
§353 of the Public Health Service Act, 42 U.S.C. §263a.
Commentary:
In the case of a Medicaid purchaser that has elected to “carve out”
pharmaceutical services from a purchasing agreement and to continue providing
such services on a fee for service basis, this specification would not
be applicable.
Commentary:
This provision addresses a specific use of data on the enumerated
services. It does not prohibit a Contractor from collecting the data or
from using it for other purposes such as quality measurement and improvement.
Commentary:
“Exclusion” refers to a) initial Contractor determinations
with regard to including a provider in the Contractor’s network and
b) Contractor determinations with regard to retaining a provider in Contractor’s
network.
Commentary:
For Medicaid purchasers, the Balanced Budget Act of 1997 requires Medicaid
managed care contracts to provide “for coverage for emergency services
[as defined in the Act] without regard to prior authorization or the emergency
care provider’s contractual relationship with the organization [or
primary care case manager].” §1932(b)(1)(A)(i) of the Social
Security Act, 42 U.S.C. §1396u-2(b)(1)(A)(i).
Commentary:
Several alternative reimbursement-related specifications are provided
for consideration by Medicaid and non-Medicaid purchasers.
Commentary:
This optional specification is consistent with the requirement in Medicaid
law that potential enrollees and enrollees be provided with information
about services covered under the state Medicaid agency’s managed
care contract. §1932(a)(5) of the Social Security Act, 42 U.S.C.
§1396u-2(a)(5).
