Medicaid Contract Purchasing Specifications
EPSDT Services
Every Medicaid-eligible child under 21 is entitled to Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) services. Depending upon
the terms of the contract between the State Medicaid Agency and the MCO,
those children enrolled in MCOs may or may not receive all of the EPSDT
services through the MCO. Because of the breadth of the EPSDT benefit,
specificity of contract language is of particular importance for these
children. MCOs need to know exactly what services they are responsible
for covering. Enrolled children and their families need to know what services
they are entitled to receive from the MCO and what services they are entitled
to receive through the state Medicaid program. The illustrative language
in the Medicaid Pediatric Services specifications (MEDIPED) delineates
with considerable specificity what EPSDT items and services are covered
under the state's contract with the MCO, and what EPSDT items and services
(if any) are "carved out" from this contract and available through
the regular fee-for-service Medicaid program. The MEDIPED specifications
serve as the "base" benefit package for the other child-related
purchasing specifications.
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Purchasing Specification
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Related Contract Language
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CD
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- §102 (screening assessment
services)
- §103 (developmental
health promotion services)
- §104 (general developmental
interventions)
- §105 (care coordination)
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DENTAL
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- §102 (scope of benefit)
- §103 (preventive
services)
- §104 (treatment
and restorative services)
- §105 (radiographic,
lab, and other diagnostic services)
- §106 (prescription
drugs)
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IMMUN
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- §003 (immunization-related
services)
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LEAD
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- §003 (lead-related services)
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| MEDIPED |
- §101 (Medicaid items
and services)
- §102 (EPSDT)
- §101A(a)(4), (8) (EPSDT
coverage standards)
- §101A(e) (pediatric medical
necessity standard)
- §103A(d)(4) (prior authorization)
- §102B (EPSDT screening
for adolescents)
- §108B (delivery of childhood
lead poisoning services)
- §501(i) (interagency
agreements by network providers)
- §603(c)(1)(A)-(C)
(EPSDT service waiting times)
- §703(a) (interagency
agreements)
- §704(a) (cooperation
with WIC program)
- §803(a)(8) (clinical studies
of EPSDT screening services)
- §902 (EPSDT data)
- §1401(b) (definition
of anticipatory guidance)
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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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