Medicaid Contract Purchasing SpecificationsEnrollee Rights and SafeguardsCommon to many of the pediatric purchasing specifications are provisions
setting forth rights and safeguards for children (and their families)
enrolled in MCOs (or in BHOs). The illustrative enrollee safeguards include
notification of rights; confidentiality of medical information and doctor-patient
communications; protections against discrimination; and procedures designed
to ensure that Medicaid-eligible children for whom covered services are
delayed or denied are able to pursue their due process rights through
the use of Contractor's grievance mechanism and the state's fair hearing
process. As discussed in "Contract Enforcement Provisions,"
enrollee safeguards also include provisions relating to third-party beneficiary
enforcement of contract requirements.
‡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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