Medicaid Contract Purchasing SpecificationsMedicaid Managed Care for Pediatric ServicesPart 1Items and ServicesTable of Contents §101. Medicaid Items and Services 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. §101. Medicaid Items and Services1 — Contractor shall, for each enrolled child (including an adolescent), cover and furnish, or arrange for the furnishing of, the items and services enumerated in this section in accordance with the coverage determination standards and procedures enumerated in Part 1A and the child health supervision guidelines enumerated in §006(a)(1) of the Overview: Commentary: This Part is intended to display illustrative language that would enable interested purchasers to ensure the elimination of potential gaps between the services state Medicaid plans must cover for children under 21 and the services included in state Medicaid contracts with MCOs. This illustrative language represents a comprehensive listing of all potential benefits categories for which federal Medicaid matching funds are available under §1905(a) of the Social Security Act, 42 U.S.C. §1396d(a). In order to bring their contracts into conformity with standard commercial offerings, the contracts reviewed in the three editions of Negotiating the New Health System indicate that states include in their contracts significantly fewer than all the services covered under their state Medicaid plans. Thus, some states may elect not to include certain classes of services at all (e.g., FQHC services, private duty nursing care). Others may carve out required services (e.g., mental health and substance services). Still other states may place limits on the amount or duration of services their MCO contractors must furnish (e.g., limiting outpatient mental health visits to 26 in a year or permitting MCOs to maintain formularies that are more restrictive than those maintained by the state under its Medicaid plan). Accordingly, the illustrative language is drafted to enable state purchasers to cover fewer benefits in their MCO contracts than are covered under §1905(a). A separate section (e.g., §105) would then set forth benefits categories not covered under the purchasing agreement. Note, however, a state Medicaid program retains responsibility for items and services included in the state's Medicaid plan that are omitted from a purchasing agreement with an MCO but continue to represent an individual entitlement to the MCO's Medicaid-eligible enrollees. Furthermore, in the case of children eligible for EPSDT services, the state Medicaid program is required to cover all medically necessary services under §1905(a), whether or not such services are covered under the state Medicaid plan. State Medicaid agencies would retain residual responsibility with respect to MCO enrollees for the provision of any such items or services not covered under the purchasing agreement with the MCO and required under EPSDT. (a) Inpatient hospital services as defined in 42 C.F.R. §440.10; (b) Outpatient hospital services as defined in 42 C.F.R. §440.20; (c) (1) Federally qualified health center services as defined in §1905(l)(2)(B) of the Social Security Act, 42 U.S.C. §1396d(l)(2)(B), and any other ambulatory services offered by a Federally qualified health center and which are otherwise included under [drafter insert reference to State Medicaid Plan]; and (2) rural health clinic services as defined in §1861(aa)(1) of the Social Security Act, 42 U.S.C. §1395x(aa)(1), and as referenced in §1905(l)(1) of the Social Security Act, 42 U.S.C. §1396d(l)(1), and any other ambulatory services which are offered by a rural health clinic and which are otherwise included under [drafter insert reference to State Medicaid Plan]; (d) Laboratory and x-ray services as defined in 42 C.F.R. §440.30; (e) Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) items and services as defined in 42 C.F.R.§440.40(b) and §102; (f) Physician services and medical and surgical services of a dentist as defined in 42 C.F.R. §440.50; (g) Family planning services and supplies under §1905(a)(4)(C) of the Social Security Act, 42 U.S.C. §1396d(a)(4)(C) and §104; (h) Home health services as defined in 42 C.F.R. §440.70; (i) Services furnished by a nurse-midwife as defined in 42 C.F.R. §440.165; (j) Services furnished by a certified pediatric nurse practitioner or certified family nurse practitioner as defined in 42 C.F.R. §440.166; (k) Prescribed drugs as defined in 42 C.F.R. §440.120(a) and §103; (l) Transportation services as defined in 42 C.F.R. §440.170; (m) Skilled nursing facility services for individuals under age 21 as defined in 42 C.F.R. §440.170(d); (n) Medical and other remedial care recognized under state law furnished by licensed practitioners as defined in 42 C.F.R. §440.60; (o) Private duty nursing services as described in 42 C.F.R. §440.80; (p) Clinic services as defined in 42 C.F.R. §440.90; (q) Physical therapy, occupational therapy and services for individuals with speech, hearing, and language disorders as described in 42 C.F.R. §440.110; (r) Other diagnostic screening, preventive, and rehabilitative services as defined in 42 C.F.R. §440.130; (s) Inpatient psychiatric hospital services as defined in 42 C.F.R. §440.160; (t) Hospice benefits as defined in §1905(o) of the Social Security Act, 42 U.S.C. §1396d(o); (u) Durable medical equipment and prosthetic devices as defined in 42 C.F.R. §440.120(c); (v) Case management services as defined in §1905(a)(19) of the Social Security Act, 42 U.S.C. §1396d(a)(19); (w) Tuberculosis-related services as defined in §1905(a)(19) of the Social Security Act, 42 U.S.C. §1396d(a)(19) and covered under §108; (x) Respiratory care services as defined in 42 C.F.R. §440.185; (y) Personal care services as defined in 42 C.F.R. §440.167; and (z) Home- and community-based services as described in 42 C.F.R. §440.180.2 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 on EPSDT is for your consideration. §102. EPSDT Commentary: Most commercial managed care products do not include a benefit that corresponds to the Medicaid EPSDT benefit, which is mandatory for children under 21. The purpose of the language suggested in the following section is to clearly articulate the elements of the EPSDT coverage requirement for the benefit of MCOs (and affiliated providers) that may be unfamiliar with it. As discussed in the commentary to §101, Purchasers that elect not to require an MCO to cover the entire EPSDT benefit will remain responsible for directly covering the remaining items and services. (a) In General (1) Contractor shall, for each enrolled child (including an adolescent), cover and furnish, or arrange for the furnishing of, the EPSDT items and services enumerated in this section in accordance with: L(A) section 1905(r) of the Social Security Act, 42 U.S.C. §1396d(r), as implemented by 42 C.F.R. §§440.40(b), 441.50 et seq., and §§5150, 5123.2, 5240, and 5310 of the State Medicaid Manual; K(B) the coverage determination standards and procedures enumerated in §§101A - 103A of Part 1A and child health supervision guidelines enumerated in §006(a)(1) of the Overview; and L(C) the requirement of §101B(a) relating to non-group screening. K(2) Contractor shall implement paragraph (1) in coordination with [drafter insert name of State Title V Maternal and Child Health Agency] consistent with §505(a)(5)(F)(i) of the Social Security Act, 42 U.S.C. §705(a)(5)(F)(i) and the memorandum of understanding described in §703(c) of Part 7. L(3) Periodic and Interperiodic Screening Services (A) Periodic EPSDT Screening Services are preventive health exams described in subsection (b) furnished in accordance with [drafter insert reference to the schedules (determined by Purchaser after consultation with recognized medical and dental organizations involved in child health care) under the approved State Medicaid Plan for preventive physical and mental health, dental, vision, developmental, and hearing screening services]. (B) Interperiodic EPSDT Screening Services are physical, mental, dental, vision or hearing screens described in subsection (b) that, in furtherance of the preventive purpose of the EPSDT benefit: (i) occur at a time other than the applicable periodic EPSDT screening services referenced in subparagraph (A); and (ii) are requested by an enrolled child's family or caregiver or by an individual who comes into regular contact with the child and who suspects the existence of a physical, mental or developmental health problem (or possible worsening of a preexisting physical, mental or developmental health condition). L(b) Scope of Benefit —EPSDT items and services include: (1) Periodic and Interperiodic Screening Services — Periodic EPSDT screening services (as defined in subparagraph (a)(3)(A)) and interperiodic EPSDT screening services (as defined in subparagraph (a)(3)(B)) shall, at a minimum, include: (A) a comprehensive health and developmental history (including assessment of both physical and mental health development); (B) a comprehensive unclothed physical exam; (C) appropriate immunizations in accordance with §104B; (D) laboratory tests (including lead blood level assessment appropriate for age and risk factors) in accordance with §108B; (E) health education, including anticipatory guidance as defined in §1401(b). (2) Vision Services — Vision services (whether as part of a periodic EPSDT screening service as defined in subparagraph (a)(3)(A) or an interperiodic EPSDT screening service as defined in subparagraph (a)(3)(B)) to determine the existence of suspected vision-related illnesses or conditions shall include: (A) diagnosis and treatment for vision-related defects or conditions, including eyeglasses. (3) Dental Services — Dental services (whether as part of a periodic EPSDT screening service as defined in subparagraph (a)(3)(A) or an interperiodic EPSDT screening service as defined in subparagraph (a)(3)(B)) to determine the existence of a suspected dental related illness or condition shall be furnished in accordance with §103B and shall include: (A) relief of pain and infections; (B) restoration of teeth; and (C) maintenance of dental health. (4) Hearing Services — Hearing services (whether as part of a periodic EPSDT screening service as defined in subparagraph (a)(3)(A) or an interperiodic EPSDT screening service as defined in subparagraph (a)(3)(B)) to determine the existence of a suspected illness or condition shall include: (A) diagnosis and treatment of defects in hearing, including hearing aids. (5) Other Necessary Services — Such other medically necessary health care, diagnostic services, treatment, and other items and services described in §1905(a) of the Social Security Act, 42 U.S.C. §1396d(a), to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the periodic or interperiodic screening services described in this section, whether or not such items or services are covered under [drafter insert reference to State Medicaid Plan]. 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 on prescription drugs is for your consideration. K§103. Prescription Drugs (a) In General — As required by §101(k), Contractor shall cover and furnish, or arrange for the furnishing of, a drug or biological product described in 42 C.F.R. §440.120(a) or §1927(k)(2) of the Social Security Act, 42 U.S.C. §1396r-8(k)(2), and prescribed for an enrolled child by a provider that participates in Contractor's provider network or through which Contractor has otherwise arranged for the furnishing of items or services.3 (b) Limitations on Coverage — Any limitations imposed by Contractor on drugs or biological products covered under subsection (a) shall be consistent with subsections (c) and (d), §104(c) (relating to contraceptive drugs and devices), §§101A, 102A, and 103A(e) (relating to coverage standards and procedures). (c) Formularies — Contractor may limit the coverage of prescription drugs to those listed on a formulary if the formulary is not more restrictive than the formulary that [drafter insert name of State Medicaid Agency] is authorized to establish under §1927(d)(4) of the Social Security Act, 42 U.S.C. §1396r-8(d)(4).4 (d) Substitution — If Contractor limits the coverage of prescription drugs to those listed on a formulary that provides for the substitution of therapeutically equivalent drugs, Contractor shall make such a substitution only with the written authorization of the enrolled child's treating provider.
§104. Family Planning Services and Supplies Commentary: The illustrative language in the following section parallels language used by some states in their contracts with Medicaid MCOs.5 States have chosen to articulate the elements of covered family planning services and supplies because there are no applicable federal regulations. Note that the federal Medicaid statute, §1902(a)(23)(B), 42 U.S.C. §1396a(a)(23)(B), entitles all Medicaid beneficiaries who are enrolled in MCOs to obtain family planning services and supplies from the provider of their choice, whether or not that provider participates in the MCO's provider network or otherwise has an arrangement with the MCO. Family planning services and supplies are a required benefit under federal Medicaid law (subject to a 90 percent federal matching payment), but States have the option of "carving out" this benefit from any risk contracts with MCOs and paying for the benefit on a fee-for-service basis. L(a) In General — As required under §101(g) andsubsection (b), Contractor shall cover and furnish, or arrange for the furnishing of, family planning services and supplies under §1905(a)(4)(C) of the Social Security Act, 42 U.S.C. §1396d(a)(4)(C), for an enrolled adolescent consistent with §104A of Part 1A (relating to self-referral for certain services). K(b) Scope of Benefits — Family planning services and supplies covered under §101(g) are: (1) Health education and counseling consistent with the GAPS Guidelines enumerated under §006(a)(1)(B) of the Overview; (2) Health history, physical examination, and risk assessment consistent with the GAPS Guidelines enumerated under §006(a)(1)(B) of the Overview; (3) Pregnancy testing and counseling consistent with the GAPS Guidelines enumerated under §006(a)(1)(B) of the Overview; (4) Laboratory tests;6 (5) Testing for, diagnosis of, and treatment of, sexually transmitted diseases (STDs) in accordance with §106; (6) Testing and counseling for individuals at risk of infection with the Human Immunodeficiency Virus (HIV), and referral for treatment in accordance with §107; (7) Contraceptive items and services, including male and female condoms;7 (8) Insertion and removal of implantable contraceptives; (9) Prescription drugs and devices enumerated under subsection (c); (10) Tubal ligation and vasectomy (consistent with 42 C.F.R. §§441.250 - 441.259 relating to informed consent regarding sterilization); and (11) Treatment of complications associated with the use of contraceptive items and services.8 K(c) Prescription Drugs and Devices — Contractor shall cover and furnish, or arrange for the furnishing of, any prescription drug or device for contraceptive use that is approved by the Food and Drug Administration (whether or not the drug or device is labeled for adolescent use).
K§105. Medicaid Items and Services Not Covered [Drafter insert list of items and services covered under State Medicaid Plan but excluded from coverage under this purchasing agreement] §106. STD Services [To be supplied upon completion of benefits provisions in sample purchasing specifications for sexually transmitted disease services] §107. HIV Services [To be supplied upon completion of benefits provisions in sample purchasing specifications for services for HIV and HIV-related conditions] §108. TB Services [To be supplied upon completion of benefits provisions in sample purchasing specifications for tuberculosis services] §109. Diabetes Services [To be supplied upon completion of benefits provisions in sample purchasing specifications for diabetes services] Endnotes
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Clarity and specificity are of particular importance with respect to benefits and coverage. In this regard, the illustrative language in this Part is intended to be consistent with HCFA's letter to State Medicaid Directors regarding the requirement of the Balanced Budget Act that each risk contract between a purchaser and a managed care entity specify the benefits which the entity is responsible for providing or arranging As explained in the December, 1997 letter, the BBA provision is:
intended to protect beneficiaries by ensuring there is no ambiguity concerning the range of Medicaid-covered services that will be available to them under the contract. To achieve this result, each contract must include a description of benefits that identifies and defines all Medicaid services to be made available by the managed care entity. The contract terminology should be drafted with sufficient precision so that the managed care entity will be responsible for providing these Medicaid services to the same degree as the services are covered under [the state Medicaid] plan. At a minimum, this means that service definitions should comply with all Federal and State plan requirements. For each Medicaid service, the contract should specify the amount, duration, and scope of services that the managed care organization must offer. It is important for the contract to be very specific about the exact services which the managed care entity must provide, since [the purchaser] is responsible for all benefits in the state plan not offered by the managed care entity. Finally, the contract must include provisions that address the responsibility of the managed care entity to furnish care and services when medically necessary in sufficient detail to ensure that beneficiaries receive needed services to which they are entitled under the contract www.hcfa.gov/medicaid/bba4704.htm.
CHSRP is also developing sample purchasing specifications relating to a number of public health issues that involve benefits. Among these are sample specifications for the purchase of services relating to sexually transmitted diseases (STDs), HIV infection and HIV-related conditions, tuberculosis, and diabetes. Upon completion of these sample public health purchasing specifications, the relevant sections of these specifications will be incorporated into this Part.
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 on Medicaid items and services is for your consideration. Purchasers may also find it useful to review Negotiating the New Health System (3rd Ed.) which provides other options relating to benefit packages used by state agency purchasers in contracting with Medicaid MCOs. These options may be found at Table 2.1, Vol. 2, Part 2, pages, 2-40 through 2-386, Table 2.2, Vol. 2, Part 2, pages 2-388 through 2-600; Table 2.4, Vol. 2, Part 2, pages 2-696 through 2-805; Table 3.9, Vol. 2, Part 3, pages 3-474 through 3-492, www.gwu.edu/~chsrp.