Medicaid Contract Purchasing Specifications
Provider Network Requirements
The adequacy of an MCO's (or BHO's) provider network largely determines
whether enrolled children actually receive needed services for which a
Purchaser has contracted. Each of the pediatric purchasing specifications
addresses provider network issues of concern to enrolled children and
their families. Illustrative language is provided to specify the composition
of the provider network (including bilingual capacity); the qualifications
and cultural competence of providers participating in the network; the
training of participating providers in the assessment and treatment of
children; the content of written agreements between the MCO (or BHO) and
participating providers; and arrangements between the MCO (or BHO) and
out-of-network providers.
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Purchasing Specification
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Related Contract Language
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ACCESS
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- §A2-1 (provider
network requirements)
- §A2-2 (primary care
providers)
- §A2-3 (specialists)
- §A2-4 (out-of-network
providers)
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CD
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CW |
- §105 (assignment
to primary care provider)
- §107 (provider
network)
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CBHN |
Chapter I (prime/prime):‡
- §204 (multidisciplinary
team)
- §205 (provider network
requirements)
Chapter II (prime/subprime):‡
- §209 (multidisciplinary
team)
- §210 (provider network
requirements)
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CSHCN |
- §203 (provider selection
and assignment)
- §204 (provider network
requirements)
- §204A (medical home)
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CC
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DENTAL
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- §203 (provider network
requirements)
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IMMUN |
- §004 (provider participation
in VFC)
- §006 (services by
out-of-network providers)
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LEAD
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- §005 (network provider
qualifications)
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MEDIPED |
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SBHC |
- §101A (Purchaser
payment to out-of-network SBHC)
- §101B (MCO payment
to out-of-network SBHC)
- §101C (requirement
to subcontract with SBHC)
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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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