Medicaid Contract Purchasing Specifications
Treatment Guidelines
One of the Contractor duties common to the pediatric purchasing specifications
is to deliver covered items and services in a manner consistent with a
standard of care reflected in treatment guidelines. Some of these guidelines
have been developed by professional societies such as the American Academy
of Pediatrics. Other guidelines have been developed by government agencies
such as the maternal and Child Health Bureau (MCHB) of the Health Resources
and Services Administration (HRSA) and the Agency for Healthcare Research
and Quality (AHRQ). Some of the guidelines set forth in the illustrative
language are appropriate for pediatric care generally; others are specific
to certain subpopulations of children, such as children with special health
care needs. Wherever possible, multiple guidelines are listed to enable
Contractor and Purchaser to select the particular guidelines they want
to incorporate into their contract.
‡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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