Medicaid Contract Purchasing SpecificationsIntroductionSince 1995, the George Washington University Center for Health Services Research and Policy (CHSRP) has conducted intensive examinations of contracts between state Medicaid agencies and managed care organizations (MCOs) for the delivery of services to Medicaid-eligible children enrolled in the MCOs. This analytic work produced four editions of a comprehensive study of contract provisions. The fourth edition of Rosenbaum, S. et al, Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts (2001) is available on CHSRP’s website, http://www.gwhealthpolicy.org/. Negotiating the New Health System is part of a broader set of analytic studies and technical assistance efforts relating to Medicaid managed care. These projects have been financed by numerous public and private funders. The public funders are the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). Private funders include the David and Lucile Packard Foundation, the Commonwealth Fund, the Center for Health Care Strategies, Inc., the Pew Charitable Trusts, and the Annie E. Casey Foundation. Extensive analytical work derived from Negotiating the New Health System consists of a series of briefs and reports prepared by CHSRP on specific issues relating to children's health and managed care. These reports and analyses explore in more detail contracting and other issues that purchasers of pediatric health care may wish to consider in drafting contractual language for children enrolled in Medicaid or SCHIP1. The analytic work that produced Negotiating the New Health System also produced sample purchasing specifications for use by state Medicaid agencies and other public and private purchasers2. A number of these specifications, all of which are posted at CHSRP’s website, www.gwhealthpolicy.org/, relate directly or indirectly to the purchase of managed care services for children:
The purpose of this User Guide is to assist interested purchasers and others in locating provisions in the 12 pediatric-related purchasing specifications that address the same general issue but vary in their policy content3. By comparing different approaches to the same issue, state officials, MCOs and BHOs, providers, consumers, and other interested parties will gain a better understanding of the policy options available to them. Interested purchasers, in particular, will be able to draw from and, as appropriate, integrate the different texts in order to develop language that precisely reflects their own policy preferences. Because the 12 purchasing specifications listed above all address one or more groups of Medicaid-eligible children in managed care, there is considerable overlap among them. Most of these specifications have provisions relating to case management, provider networks, and treatment guidelines, among others. However, the content of these provisions will often vary, reflecting policies specific to the subpopulation of children in question. For example, the purchasing specifications for both Children with Behavioral Health Needs (CBHN) and Children with Special Health Care Needs (CSHCN) contain provisions on case management (CBHN §105; CSHCN §104). However, the text in each provision differs because the models of case management for each population differ. Similarly, the guidelines for delivery of care enumerated in the purchasing specifications for Dental and Oral Pediatric Health Services (DENTAL §107) differ from those enumerated in Lead Poisoning Services for Children (LEAD §003) specifications. Endnotes1. For analyses of Medicaid and SCHIP contracting issues, see Rosenbaum, S, Sonosky, C, Shaw, K, and Zakheim, M. Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, 3rd Edition,Volume 1 (1999); Rosenbaum, S, and Sonosky, C. Federal EPSDT Coverage Policy: An Analysis of State Medicaid Plans and State Medicaid Managed Care Contracts (December 2000) ; and Rosenbaum, S., Shaw, K., and Sonosky, C. SCHIP Policy Brief #3: Managed Care Purchasing Under SCHIP: A Nationwide Analysis of Freestanding SCHIP Contracts (December 2001). For additional information on Medicaid and SCHIP, see Rosenbaum, S, Proser, M, Schneider, A, and Sonosky, C. Room to Grow: Promoting Child Development Through Medicaid and CHIP. The Commonwealth Fund.(July 2001); Rosenbaum, S, Markus, A, Sonosky, C, and Repasch, L. SCHIP Policy Brief #2: State Benefit Design Choices under SCHIP: Implications for Pediatric Health Care (May 2001); Rosenbaum, S, and Smith, B. SCHIP Policy Brief #1: State SCHIP Design and the Right to Coverage (March 2001); Rosenbaum, S, Markus, and Roby, D. An Analysis of Implementation Issues Relating to CHIP Cost-Sharing Provisions for Certain Targeted Low Income Children (1999); and Wehr, E, Rosenbaum, S, Shaw, K, and Valencia, K. Managing Child Welfare: An Analysis of Contracts for Child Welfare Service Systems. (1999). 2. As of May 2002, a total of 21 purchasing specifications have been posted on the CHSRP website, www.gwhealthpolicy.org/. An additional 4 are under development. The specifications fall into four broad groupings: (1) population-based (e.g., children); (2) service-related (e.g., child development services); (3) public health conditions (e.g., HIV/AIDS); and (4) MCO operational issues (e.g., cultural competence). 3. See also Purchasing Specifications Relating to Managed Behavioral Health Care Services: A User's Guide (December 2001), available at www.gwhealthpolicy.org/. |
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