Medicaid Contract Purchasing Specifications
Contract Enforcement Provisions
Most of the child-related purchasing specifications contain language
setting forth remedies available to both the state purchasing agency and
enrolled children (and their families) if the contracting MCO does not
comply with the requirements of its contract with the state agency. The
different specifications reflect different approaches through which the
state purchaser can monitor and ensure contract compliance, ranging from
the use of performance measures to the imposition of financial penalties.
In addition, the provisions in most of the specifications would give enrolled
children and their families a way to enforce the terms of the contract
that are designed for their benefit (e.g., standards for accessibility
of services). The legal doctrine of "third party beneficiary"
holds that an individual who is not a party to a contract may, under certain
circumstances, enforce the performance of duties in the contract because
the individual is an intended beneficiary of those duties. While varying
from state to state, this doctrine is reflected in both state court decisions
and state laws, and applies to both private and public contracts.
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Related Contract Language
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CD
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CBHN
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Chapter I (prime/prime):
- §211 (remedies
for noncompliance)
Chapter II (prime/subprime):
- §111 (remedies for
noncompliance)
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CSHCN
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- §210 (remedies for
noncompliance)
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DENTAL
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- §110 (compliance
measures)
- §206 (compliance
measures)
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IMMUN
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MEDIPED
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- §010 (enforcement)
- §1201 (remedies
for noncompliance)
- §1202 (remedies
re: covered items and services)
- §1203 (remedies
re: enrollment and disenrollment)
- §1204 (remedies
re: quality improvement)
- §1205 (remedies
re: data collection and reporting)
- §1206 (remedies
re: enrolled child safeguards)
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SCHIP
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- §010 (enforcement)
- §1201 (remedies
for noncompliance)
- §1202 (remedies
re: covered items and services)
- §1203 (remedies
re: enrollment and disenrollment)
- §1204 (remedies
re: quality improvement)
- §1205 (remedies
re: data collection and reporting)
- §1206 (remedies
re: enrolled child safeguards)
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‡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.
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ACCESS = Access to
Services (July 2000)
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CD = Child Development
Services (July 2000)
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CW = Child Welfare
(December 2001)
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CBHN = Children with
Behavioral Health Needs (December 2000)
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CSHCN = Children with
Special Health Care Needs (August 2000)
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CC = Cultural Competence
(Updated, November 2001)
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DENTAL = Dental and
Oral Pediatric Health Services (March 2000)
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IMMUN = Immunizations
(May 1998)
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LEAD = Childhood Lead
Poisoning Services (November 1998)
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MEDIPED = Medicaid Pediatric
Services (September 1999)
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SBHC = School-Based Health
Center Services (January 2002)
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SCHIP = SCHIP Pediatric
Services (April 2002)
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