Medicaid Contract Purchasing Specifications
User Guide for Community Health Centers
Covered Benefit
Federally Qualified Health Center (FQHC) Services: §101(c)
of Part 1 identifies FQHC and RHC services as covered services under
the purchasing document.
Coverage Determinations
Evidence: §101A(b)(6) of
Part 1A relates to the use of evidence from providers such as community
health centers in connection with Contractor's coverage determinations.
Notice: §102A(c) of
Part 1A requires notice of adverse coverage determinations to publicly-supported
providers (including community health centers) referring the enrolled
child for diagnosis or treatment.
Homeless1
Access to Out-of-Network Primary Care Providers: §511(e)
of Part 5 relates to Contractor's duty under certain circumstances to
permit a homeless child (or the child's family or caregiver) to select
a primary care provider that does not participate in Contractor's provider
network.
Assignment of Non-Selecting Children:
§403(d) of Part 4 relates to Contractor's duty to assign
a homeless child who does not select a primary care provider to a network
provider with experience in serving the homeless.
Definition: §1401(n) defines
a homeless child.
Service Waiting Time: §603(c)(1)(E)
of Part 6 relates to Contractor's duty to ensure that homeless children
receive appointments with primary care providers within a specified
timeframe.
Information to Enrolled Children
Provider List: §304(a)(1)(B)
of Part 3 relates to the inclusion, in the information given to new
and potential enrollees, of the name of the community health center
with which a physician or other health professional practices.
Involuntary Disenrollment
Children Receiving Treatment: §204(b)
of Part 2 relates to Contractor's duty to ensure completion of treatment
for children receiving treatment at the time of involuntary disenrollment.
Children Not Receiving Treatment: §205
of Part 2 relates to Contractor's duty to arrange for the transfer of
the medical records of a child who is not receiving treatment at the
time of involuntary disenrollment to the successor provider assuming
responsibility for the care of the child.
Migratory or Seasonal Agricultural Worker Families
Access to Out-of-Network Primary Care Providers: §511(d)
of Part 5 relates to Contractor's duty under certain circumstances to
permit a migrant child (or the child's family or caregiver) to select
a primary care provider that does not participate in Contractor's provider
network.
Assignment of Non-Selecting Children: §403(c)
of Part 4 relates to Contractor's duty to assign a migrant child who
does not select a primary care provider to a network provider with experience
in serving migrant or seasonal agricultural worker families.
Definition:
§1401(r) defines a migratory
agricultural worker.
§1401(y) defines a seasonal
agricultural worker.
Service Waiting Time: §603(c)(1)(D)
of Part 6 relates to Contractor's duty to ensure that migratory or seasonal
farmworker children receive appointments with primary care providers
within a specified timeframe.
Network Providers
Enrollee Access to Network Providers: §501(g)
of Part 5 relates to the Contractor's duty to make the services
of any provider participating in Contractor's provider network available
to an enrolled child.
Certain Providers Identified in Federal Law: §509
of Part 5 relates to the participation of FQHCs in Contractor's
provider network and to the reimbursement of such providers.
Traditional Medicaid Provider: §508
of Part 5 relates to participation of traditional Medicaid providers,
including federally qualified health centers, in Contractor's provider
network, and to the reimbursement of such providers.
Payment: §1301(i) of Part
13 relates to the current federal law requirements regarding Medicaid
MCO payments to FQHCs.
Out-of-Network Providers
Payment
§510 of Part 5 relates to
Contractor's duty regarding payment for covered services furnished
by out-of-network providers, including those with necessary primary
care expertise.
§1201(a)(6) of Part
12 relates to Purchaser payment of out-of-network providers and Recoupment
of payments from Contractor.
Access
§005(f) of the Overview
relates to Contractor's duty with respect to payment for certain public
health services (e.g., family planning and STD diagnosis and treatment)
received by enrolled children providers such as community health centers,
whether or not such providers participate in Contractor's provider
network.
§104A of Part 1A relates
to Contractor's duty to allow self-referral by adolescent enrollees
for certain public health services (e.g., family planning and STD
diagnosis and treatment).
§103A of Part 1A relates
to Contractor's duty to exempt from prior authorization requirements
certain items and services, including immunizations, family planning
services and supplies, STD diagnosis and treatment, tuberculosis diagnosis
and treatment, and HIV diagnosis and treatment.
Referral by Contractor: §510(a)
relates to Contractor's duty to refer enrolled children to out-of-network
providers, including community health centers, under certain circumstances
and to reimburse for such referrals.
Special Supplemental Food Program for Women, Infants, and Children
(WIC)
Coordination by Participating Providers: §501(h)
of Part 5 relates to Contractor's duty to ensure that providers
in its network coordinate with WIC programs.
Memorandum of Understanding: §704(e)
of Part 7 relates to Contractor's duty regarding a memorandum of understanding
with an interested State WIC agency.
Referrals: §005(h)
of Overview and §704(b) and
(c) of Part 7 relate to Contractor's
duty regarding referrals of enrolled children under age 5 to local WIC
providers.
Endnotes
- See also CHSRP's Optional Purchasing
Specification: Medicaid Managed Care for Individuals Who Are Homeless
(forthcoming).
The sample purchasing specifications include numerous provisions addressing a wide range of issues. In the case of community health centers that own or operate an MCO, all of these provisions are obviously relevant. In the case of other centers, many of these issues directly or indirectly affect them, whether they subcontract with an MCO or not. The following provisions may be of particular interest to these centers. The provisions are listed in alphabetical order.