Medicaid Contract Purchasing Specifications

Overview of Contractor's Duties

^K§001. Purpose and Applicability

(a) Purpose — The purpose of this agreement between the State of [ ] ("Purchaser") and [ Name ] ("Contractor") is to implement the provisions of the State Medicaid Plan approved under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq. and [in states that cover targeted low-income children through Medicaid, drafter insert: the State Child Health Plan approved under Title XXI of the Social Security Act, 42 U.S.C. §1397 et seq.] relating to the furnishing of covered items and services to each enrolled child.

(b) Applicability to Contractor and Providers — The terms of [drafter insert name of purchasing document] apply to Contractor, any provider participating in Contractor's provider network, and any provider that furnishes items and services to an enrolled child upon the request or authorization of Contractor. For purposes of this section, the terms of [drafter insert name of purchasing document] include all provisions of each Part to the agreement.

(1) The provisions of federal and state law, regulation, or guidance referred to in [drafter insert name of purchasing document] apply to Contractor and providers to the same extent as other terms apply to Contractor and providers under subsection (b).

(2) In the event that a provision of federal or state law, regulation, or guidance is repealed or modified during the term of [drafter insert name of purchasing document], effective on the date the repeal or modification by its own terms takes effect:

(A) the provisions of [drafter insert name of purchasing document] shall be deemed to have been amended to incorporate the repeal or modification; and

(B) Contractor shall comply with the requirements of [drafter insert name of purchasing document] as so amended, unless Purchaser and Contractor otherwise stipulate in writing.

^K§002. Services

(a) Basic Service Duty — Contractor shall, for each enrolled child (including an adolescent), furnish, or arrange for the furnishing of, the items and services covered under Part 1 in accordance with:

(1) the coverage determination standards and procedures set forth in §101A-103A of Part 1A; and

(2) the child health supervision guidelines enumerated in §006(a)(1)¹ (and made applicable to utilization review policies and procedures under §805(a)(2) of Part 8).

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language is for your consideration.

^K§003. Enrollment and Disenrollment of Enrolled Children

(a) Enrollment and Disenrollment Procedures — Contractor shall comply with the requirements of Part 2.

(b) Information to New and Potential Enrolled Children — Contractor shall comply with the requirements of Part 3.

(c) No Appropriate Provider — Contractor shall comply with the requirements of §401(e) of Part 4 (relating to the inability to select a primary care provider).

§004. Provider Network

^K(a) General Rule — Contractor shall maintain a provider network that complies with the requirements of Part 5.

^K(b) Written Agreements with Providers — Contractor shall comply with the requirements of §501(b) of Part 5 relating to written agreements with providers participating in Contractor's provider network.

^L(c) Physician Incentive Plans² — Any physician incentive plan applicable to physicians participating in Contractor's provider network shall meet the requirements applicable to physician incentive plans under §1876(i)(8) of the Social Security Act, 42 U.S.C. §1395mm(i)(8), 42 C.F.R. §417.479.

^K(d) Vaccines for Children (VFC) Program — Contractor shall ensure that all primary care providers who participate in Contractor's provider network comply with the requirements of Part 11.

^K(e) Professional Competence — Contractor shall ensure that each provider (through which Contractor furnishes or arranges for the furnishing of an item or service covered under Part 1) meets the provider's obligation under §1156(a)(2) of the Social Security Act, 42 U.S.C. §1320c-5(a)(2), to ensure that a covered item or service provided to an enrolled child will be of a quality which meets professional recognized standards of health care.

§005. Access to Care

^K(a) General Rule regarding Initial Assessment, Travel Time, and Service Waiting Times — Contractor shall comply with the requirements of Part 6.

^K(b) Selection of a Primary Care Provider — Contractor shall comply with the requirements of Part 4 with respect to each enrolled child's selection of, or assignment to, a primary care provider.

^K(c) Access to Pediatric Specialists — Contractor shall comply with the requirements of §503 of Part 5 with respect to access to the services of pediatric specialists.

^K(d) Selection of a Dental Care Provider — Contractor shall comply with the requirements of §404 of Part 4 with respect to each enrolled child's selection of, or assignment to, a dental care provider.

^L(e) Emergency Services and Post-Stabilization Care³ — Contractor shall comply with the requirements of §1932(b)(2)(A)⁴ of the Social Security Act, 42 U.S.C. §1396v(b)(2)(A), relating to emergency services (as defined in §1401(l)) and post-stabilization care services (as defined in §1401(t)).

^K(1) Payment to Out-of-Network Providers for Emergency Services — If an enrolled child (including an adolescent) receives emergency services or post-stabilization care from a provider other than a provider participating in Contractor's provider network, Contractor shall reimburse the treating provider:

(A) in the same amounts and on the same terms as Contractor would reimburse a provider participating in Contractor's provider network for the same service;⁵ or

(B) if Contractor reimburses participating providers on a capitated per-member per-month basis, in the amount and on the terms specified by Purchaser.

^L(2) Payment to Out-of-Network Providers for Post-Stabilization Care Services — Contractor shall comply with the requirements of 42 C.F.R. §422.100(b)(1)(iv) (relating to payment for post-stabilization care services obtained by an enrolled child from a provider not participating in Contractor's provider network).⁶

Commentary: HCFA has supported a medical home. However, some states have allowed self-referrals to providers of public health services and school-based services. A large majority of the states address family planning in these provisions. See Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, 3^rd edition, Volume 2, Part 3, Table 3.4, pgs. 3-200-3-221, www.gwu.edu/~chsrp.

^K(f) Public Health Services

(1) General Rule — Contractor agrees that an enrolled child (including an adolescent) is entitled to receive family planning services and supplies and items and services relating to diagnosis and treatment of sexually transmitted diseases covered under Part 1 from any provider of such services with a provider agreement under [drafter insert name of state Medicaid program], whether or not the provider participates in Contractor's provider network.

(2) Payment to Out-of-Network Providers — If an enrolled child receives an item or service described in paragraph (1) from a provider other than a provider participating in Contractor's provider network, Contractor shall:

(A) reimburse the treating provider in the same amounts and on the same terms as Contractor would reimburse a provider participating in Contractor's provider network for the same service;⁷ or

(B) if Contractor reimburses participating providers on a capitated per-member per-month basis, reimburse the treating provider in an amount and on terms specified by Purchaser.

^K(g) School-based Services

(1) General Rule — Contractor agrees that an enrolled child (including an adolescent) is entitled to receive items and services covered under Part 1 from any school-based health center (as defined in §507(b)(2) of Part 5), whether or not the center participates in Contractor's provider network.

(2) Payment to Out-of-Network School-based Health Centers — If an enrolled child receives such an item or service from a school-based health center that is an enrolled Medicaid fee-for-service provider other than a center participating in Contractor's provider network, Contractor shall:

(A) reimburse the treating center in the same amounts and on the same terms as Contractor would reimburse a provider participating in Contractor's provider network for the same service;⁸ or

(B) if Contractor reimburses participating providers on a capitated per-member per-month basis, reimburse the treating provider in an amount and on terms specified by Purchaser.

^K(h) Referral to WIC Agencies⁹ — Consistent with §1902(a)(11)(B) of the Social Security Act, 42 U.S.C. §1396(a)(11)(B) and 42 C.F.R. §431.635(c), Contractor shall ensure that:

(1) each enrolled pregnant, postpartum, and breastfeeding child (including an adolescent), and each enrolled child who has attained age 1 but has not attained age 5, is referred to [drafter insert name of local agency administering WIC (The Special Supplemental Nutrition Program for Women, Infants, and Children under §17 of the Child Nutrition Act of 1966, 42 U.S.C. §1786)] at the initial encounter with a provider participating in Contractor's provider network,¹⁰ unless the child has already been enrolled in WIC; and

(2) each referral made under paragraph (1) shall be documented in the medical record of the enrolled child.

§006. Delivery of Covered Items and Services

(a) In General — Contractor shall furnish or arrange for the furnishing of items and services covered under Part 1 to an enrolled child (including an adolescent) in a manner which is consistent with generally accepted principles of professional pediatric practice as reflected in the most recent version of the Guidelines enumerated in this subsection.

^G(1) Child Health Supervision Guidelines

(A) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (National Center for Education in Maternal and Child Health, 1994), www.brightfutures.org ¹¹;

(B) Guidelines for Adolescent Preventive Services (GAPS) (American Medical Association, 1995), www.ama-assn.org/adolhlth/gapsnew;

(C) Guidelines for Health Supervision III (American Academy of Pediatrics, 1997), www.aap.org/acb2/showdetl.html?&DID=15&Product_ID=901&CATID=108;

(D) Reference Manual (American Academy of Pediatric Dentistry), Pediatric Dentistry Special Issue, 1997-98, Vol. 19:7, pp. 71-72;

(E) Bright Futures in Practice: Oral Health (National Center for Education in Maternal and Child Health, 1996), www.brightfutures.org; and

(F) [drafter insert reference to periodicity schedule or child health guidelines required by State Medicaid Plan].

^K(2) Updates or Revisions

(A) Duty of Purchaser — Purchaser shall notify Contractor whenever updates or revisions to any Guideline enumerated in paragraph (1) are issued or published.

(B) Duty of Contractor — For purposes of this subsection, the Guideline to be applied by Contractor is the most recent version of which Contractor has received notice under subparagraph (A).

^K(b) Other Requirements — Contractor shall comply with the requirements of Part 1B relating to the delivery of covered items and services.

^L(c) Most Integrated Setting — As required under 28 C.F.R. §35.130(d), in the case of an enrolled child (including an adolescent) with a disability, Contractor shall furnish or arrange for the furnishing of items and services covered under Part 1 to such enrolled child in the most integrated setting appropriate to the needs of the child.¹²

^K§007. Quality Measurement and Improvement

Contractor shall comply with the requirements of Part 8.

^K§008. Data Collection and Reporting

Contractor shall comply with the requirements of Part 9.

§009. Enrolled Child Safeguards

^K(a) In General — Contractor shall comply with the requirements of Part 10 relating to communications with providers, enrollee liability, confidentiality, discrimination, and grievances, and complaints.

(b) Entitlement to Fair Hearing — [RESERVED]

^L(c) Unnecessary Inquiries into the Existence of a Disability — Contractor and each provider participating in Contractor's provider network shall not make unnecessary inquiries into the existence of a disability with respect to an enrolled child in violation of the Americans with Disabilities Act, 42 U.S.C. §12101 et seq.¹³

^K§010. Enforcement

(a) In General — If the Contractor does not comply with a requirement of [drafter insert name of purchasing document], Purchaser may invoke one or more of the remedies enumerated in Part 12, subject to the procedural requirements set forth in such Part.

(b) Compliance Measures — In determining whether Contractor complies with the requirements of [drafter insert name of purchasing document], Purchaser shall take into account the extent to which Contractor fulfills the compliance measures enumerated in [drafter insert name of purchasing document].

^K§011. Other Applicable Federal and State Requirements

Contractor shall comply with the requirements of Part 13.

^K§012. Effect of Participation

(a) Compliance with Federal and State Law — Contractor affirms that by participating in [drafter insert name of purchasing document], it is in full compliance with all terms of [drafter insert name of purchasing document] and applicable federal and state laws and regulations with respect to each enrolled child and with respect to capitation payments received from Purchaser on behalf of such children under [drafter insert name of purchasing document].

(b) Information and Data — [RESERVED]

^K§013. Relationships with Other State and Local Agencies

Contractor shall comply with the requirements of Part 7.

§014. Definitions (Applicable to Overview and All Parts)

Commentary: The Medicaid and State Children's Health Insurance Program (CHIP) statutes have different age limits; the EPSDT benefit covers children under age 21, and the CHIP Program covers children under age 19. Note that for purposes of CHIP, states are required to report enrollment data for children under age 19 in four age categories: under 1, 1-5, 6-12, and 13-18. Letter to State Health Officials from Center on Medicaid and State Operations, HCFA, December 4, 1998, www.hcfa.gov/init/cheval.htm. HCFA has under consideration standardization of data collection according to these four categories. Purchasers and Contractors should address HCFA's efforts in their data collection requirements, and note that Medicaid-eligible enrollees between the ages of 18 through 20 will not be included in the data submitted.

^K(a) Adolescent - a child age 11 through 20.¹⁴

^K(b) Child - an individual under age 21.

^K(c) Contractor - the managed care organization doing business as [drafter insert name] that has entered into an agreement with Purchaser under [drafter insert name of purchasing document].

^K(d) Covered items and services - items and services enumerated in Part 1 that Contractor is required to furnish to an enrolled child (including an adolescent) under the coverage determination standards and procedures set forth in Part 1A.

^K(e) Enrolled child - a child (including an adolescent) for whom the Contractor assumes financial responsibility for furnishing or arranging for the furnishing of items and services covered under Part 1.

^K(f) Provider - a health care practitioner, clinic, hospital, school, or other entity enrolled by the State to furnish medical, dental, mental health, or other health care services.

^K(g) Provider Network - the set of providers that have entered into enforceable written agreements with Contractor which comply with the requirements of [drafter insert name of purchasing document] to furnish, or arrange for the furnishing of, items and services covered under Part 1 to enrolled children (including adolescents).

^K(h) Purchaser - [drafter insert name of state purchasing agency].

Endnotes

An alternative option would be to delete paragraph (2) and any reference to child health supervision guidelines. Under this option, the contractor would have a duty only to furnish covered services in accordance with specified coverage determination standards and procedures. Note that, in the case of EPSDT services, federal Medicaid law requires that states consult with recognized medical and dental organizations involved in child health care in establishing periodicity schedules for screening, vision, dental, and hearing services, ï¿½1905(r) of the Social Security Act, 42 U.S.C. ï¿½1396d(r). This consultation, which is not optional, is reflected in ï¿½102 of Part 1.
See also DHHS OIG letter (dated August 19, 1999) (www.hhs.gov/progorg/oig). The letter states that "Congress intended that physician incentive arrangements related to Medicare risk-based managed care contracts and similar Medicaid contracts be subject to regulation by the Secretary pursuant to ï¿½1876(i)(8) and ï¿½1903(m)(2)(A)(x) in lieu of being subject to ï¿½ï¿½1128A(b)(1) and (2)."
Purchasers and Contractors should note that each hospital participating in Contractor's provider network must comply with the requirements of ï¿½1867 of the Social Security Act, 42 U.S.C. ï¿½1395dd, relating to the examination and treatment for emergency medical conditions and women in labor.
See Letter to State Medicaid Directors requiring that "emergency services must be covered without regard to prior authorization or the emergency care provider's contractual relationship with the [MCO]ï¿½to enable a Medicaid enrollee to immediately obtain emergency services at the nearest provider when and where the need arises," www.hcfa.gov/medicaid/bba2208c.htm.
An alternative option would be to require Contractor to reimburse the out-of-network emergency care provider at the same rate that the State's Medicaid program would pay the provider for the item or service on a fee-for-service basis.
See Letter to State Medicaid Directors requiring States to comply with the the Medicare+Choice regulation referenced in this paragraph, www.hcfa.gov/medicaid/bba8598.htm.
An alternative option would be to require Contractor to reimburse the out-of-network provider of public health services at the same rate that the State's Medicaid program would pay the provider for the item or service on a fee-for-service basis.
An alternative option would be to require Contractor to reimburse the out-of-network school-based health center at the same rate that the State's Medicaid program would pay the provider for the item or service on a fee-for-service basis.
This requirement is a statutory obligation of State Medicaid Agencies that, under this illustrative language, would be delegated to the Contractor through the purchasing agreement between the Contractor and State Medicaid Agency.
An alternative option would be to require that the WIC referral occur at the initial assessment under ï¿½601(b) of Part 6, whether or not that assessment represents the enrolled child's initial encounter with a provider participating in Contractor's provider network.
As discussed in footnote 1, an alternative option would be to delete subsection (a) altogether. Another alternative option would be to retain subsection (a) (and the corresponding ï¿½002(a)(2)) and one or two of the sets of guidelines referenced.
In Olmstead v. L.C., —- U.S. —- (1999), the Supreme Court held that the Americans with Disabilities Act of 1990 prohibits the unnecessary institutionalization of individuals who can be integrated into community settings with reasonable accommodation taking into account the resources available to the State and the needs of others with mental disabilities. See http://supct.law.cornell.edu/supct/html/98-536.ZS.html.
HCFA's Key Approaches to the Use of Managed Care Systems for Persons with Special Health Care Needs (October 1998), www.hcfa.gov/medicaid/smd-snpf.htm, provides that states should consider that "[c]ommunications with MCO enrollees must be consistent with the ADA prohibition on unnecessary inquiries into the existence of a disability."
An alternative option would be to define an adolescent as a child age 12 through age 20