Medicaid Contract Purchasing Specifications
Medical Necessity
Central to the concept of managed care is the control of utilization
of covered services by enrollees. This control is commonly exercised through
determinations as to whether an item or service sought on behalf of an
individual enrollee is "medically necessary." Note that many
of the child-related purchasing specifications do not use the terms "medical
necessity" or "clinical necessity;" instead, they address
"coverage determination" standards and procedures appropriate
to both MCOs and BHOs. These pediatric purchasing specifications also
speak to the scope of prior authorization controls, if any, used by Contractors
to constrain use of services by enrolled children.
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Purchasing Specification
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Related Contract Language
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ACCESS
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- §A2-9 (prior authorization)
- §A3-2(c) (prohibition
against use of care coordinator for utilization management)
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CD
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- §107(b) (qualified
personnel)
- §107(c) (exclusion
from prior authorization)
- §107(d) (coverage
determination defined)
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| CW |
- (see CBHN purchasing specifications below)
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| CBHN |
Chapter I (prime/prime):
Chapter II (prime/subprime):
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| CSHCN |
- §107(a) (standards
and procedures)
- §107(b) (role of
care coordinator in coverage determinations)
|
|
CC
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- §104 (duties relating
to translations for enrollees with limited English proficiency)
|
|
DENTAL
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- §108 (coverage
determinations)
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| IMMUN |
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LEAD
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| MEDIPED |
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| SCHIP |
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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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