Medicaid Contract Purchasing Specifications

Case Management and Care Coordination

A number of the child-related purchasing specifications contains Contractor duties relating to case management or care coordination. These provisions include language addressing qualifications of the case manager, the selection of a case manager by the enrolled child and the child's family, the case manager's responsibilities to the child, and the case manager's role in relation to utilization management. The language found in the references below reflects different models of case management, or approaches to care coordination that vary with the subpopulation of children at issue. The language is drafted to specify the interactions between the case manager, the MCO, the enrolled child and family, and other programs in the local health or social services systems in which the enrolled child is involved.

Purchasing Specification	Related Contract Language
ACCESS	§A3-2 (care coordinator services)
CD	§103(c) (home visit services) §105 (care coordination)
CW	§104 (case management)
CBHN	Chapter I (prime/prime):‡ §105 (case management services) Chapter II (prime/subprime):‡ §205 (case management services)
CSHCN	§104 (care coordination services)
CC	§108 (training of non-clinical staff)
LEAD	§001(a) (case management services defined) §003(d)(3)(G) (case management requirement)
MEDIPED	§101(v) (case management services defined)

‡The "prime/prime" arrangement has two primary contractors—the MCO and the BHO—to which the state purchaser makes capitation payments. Under this arrangement, a child is enrolled in both the MCO and the BHO. The "prime/subprime" arrangement involves one primary contractor and a subcontractor. The state purchaser contracts with and makes capitation payments to an MCO; the MCO, in turn, subcontracts with the BHO for the provision of behavioral health services.

ACCESS = Access to Services (July 2000)
CD = Child Development Services (July 2000)
CW = Child Welfare (December 2001)
CBHN = Children with Behavioral Health Needs (December 2000)
CSHCN = Children with Special Health Care Needs (August 2000)
CC = Cultural Competence (Updated, November 2001)
DENTAL = Dental and Oral Pediatric Health Services (March 2000)
IMMUN = Immunizations (May 1998)
LEAD = Childhood Lead Poisoning Services (November 1998)
MEDIPED = Medicaid Pediatric Services (September 1999)
SBHC = School-Based Health Center Services (January 2002)
SCHIP = SCHIP Pediatric Services (April 2002)