Medicaid Contract Purchasing Specifications
Enrollment and Disenrollment Procedures
Most of the child-related purchasing specifications contains provisions
addressing enrollment and disenrollment issues affecting children (and
their families). Enrollment issues include provision of enrollee information;
assessment of new enrollee health needs; selection of primary care providers
and case managers; and the effective date of coverage. Disenrollment issues
include procedures for voluntary disenrollment; criteria for involuntary
disenrollment; the date of termination of coverage; and the Contractor's
responsibility for continuation of services to enrolled children receiving
treatment at the time of disenrollment, whether voluntary and involuntary.
For guidance to provisions concerning assessment, see the table above
on Assessment and Identification of Enrolled Children.
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Purchasing Specification
|
Related Contract Language
|
|
ACCESS
|
- §A2-8 (first appointments
for new enrollees)
|
|
CD
|
- §101(e)
(other contractor duties)
|
|
CW
|
- §102 (identification
and enrollment)
|
| CBHN |
Chapter I (prime/prime):
Chapter II (prime/subprime):
- §105 (enrollment and
disenrollment)
- §106 (information)
|
| CSHCN |
- §201 (enrollment
and disenrollment)
- §202 (information)
|
|
DENTAL
|
- §202 (enrollment
and disenrollment)
|
|
LEAD
|
- §004 (enrollment and
disenrollment standards)
|
| MEDIPED |
- §003 (Contractor duty)
- Part 2 (enrollment and disenrollment
procedures)
- Part 3 (information for new
and potential enrolled children)
|
| SCHIP |
- §003 (Contractor
duty)
- Part 2 (enrollment
and disenrollment procedures)
- Part 3 (information
for new and potential enrolled children)
|
‡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)
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LEAD = Childhood Lead
Poisoning Services (November 1998)
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MEDIPED = Medicaid Pediatric
Services (September 1999)
-
SBHC = School-Based Health
Center Services (January 2002)
-
SCHIP = SCHIP Pediatric
Services (April 2002)
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