Medicaid Contract Purchasing Specifications
Provision of Information to Enrolled Children
Each of the purchasing specifications contains a Contractor duty to provide
information to enrolled children (and their families) as to how to obtain
covered services. The illustrative language specifies the types of information
to be made available to enrolled children, such as the benefits for which
the MCO (or BHO) is responsible; benefits that the MCO is not obligated
to provide; the names and qualifications of participating providers; and
the procedures available to appeal a failure of the MCO to cover a needed
item or service. The illustrative language also specifies the form and
languages in which the information is to be made available to enrolled
children and their families, including enrollee handbooks and health education
pamphlets.
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Purchasing Specification
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Related Contract Language
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ACCESS
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- §A3-3 (information
services)
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CD
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- §104(a) (child development
information line)
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CW
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- (see CBHN purchasing specifications)
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CBHN
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Chapter I (prime/prime):‡
- §203 (information
to enrolled children)
Chapter II (prime/subprime):‡
- §106 (information
to enrolled children)
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CSHCN
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- §202 (information
to enrolled children)
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CC
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- §102 (understandable
materials, duty to translate written materials, and posting materials)
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DENTAL
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- §203(c) (information
re: provider network)
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| IMMUN |
- §005 (information
for enrollees)
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| MEDIPED |
- §003(b) (Contractor
duty)
- §301 (information
to potential enrolled children)
- §302 (information
to new enrolled children)
- §303 (information
to enrolled adolescents)
- §304 (provider directory)
- §305 (enrollment card)
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| SCHIP |
- §003(b) (Contractor
duty)
- §301 (information
to potential enrolled children)
- §302 (information
to new enrolled children)
- §303 (information
to enrolled adolescents)
- §304 (provider
directory)
- §305 (enrollment
card)
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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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