Medicaid Contract Purchasing Specifications

Part 14 Definitions

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

§1401. Definitions (Applicable to Overview and all Parts)

Commentary: The Medicaid and 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 the State Children's Health Insurance Program (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 - as defined in §014(a) of the Overview, a child whose age is 11 through 20.¹

^K(b) Anticipatory guidance - information which:

(1) is provided orally and through other methods during a periodic or interperiodic EPSDT screening encounter by an enrolled child with a provider participating in Contractor's provider network;

(2) is tailored to the physical, psychological, and social-related needs of the enrolled child (including a child with special health care needs) and the child's family or caregiver;

(3) is culturally competent (as defined in subsection (i));

(4) is designed to assist the family or caregiver of an enrolled child in understanding the course of mental and physical growth and development in infants, children, and adolescents and what to expect in the next developmental phase;

(5) encourages active involvement by family or caregiver in their child's overall development;

(6) promotes the involvement of the family or caregiver in the prevention of intentional and unintentional injuries, illnesses, and other physical and mental conditions or disturbances with respect to the enrolled child; and

(7) in the case of an enrolled adolescent, is provided in a manner consistent with the requirements of §1002(b) of Part 10 relating to confidentiality.

^K(c) Caregiver - an individual or entity, other than a family member (as defined in subsection (m)(2)) of an enrolled child, that is a foster parent, legal guardian or other individual or agency with legal authority and responsibility to care for the child.

^K(d) Child - as defined in §014(b) of the Overview, an individual under age 21.

^K(e) Child health supervision - measures that help promote physical and mental health; prevent mortality and morbidity; foster appropriate growth and development; and lead to improved health, social, educational, emotional, and developmental outcomes for children and adolescents, such as those set forth in professional guidelines enumerated in §006(a)(1) of the Overview.

^L(f) Child with special health care needs² - as defined in §1932(a)(2)(A) of the Social Security Act, 42 U.S.C. §1396u-2(a)(2)(A), a child under 19 who:

(1) is eligible for Supplemental Security Income benefits under Title XVI of the Social Security Act, 42 U.S.C. §1381 et seq.;

(2) is a child with special health care needs described in §501(a)(1)(D) of the Social Security Act, 42 U.S.C. §701(a)(1)(D);

(3) is a child described in §1902(e)(3) of the Social Security Act, 42 U.S.C. 1396a(e)(3);

(4) is a child receiving foster care maintenace maintenance payment under §472 of the Social Security Act, 42 U.S.C. §672;

(5) is a child receiving adoption assistance under §473 of the Social Security Act, 42 U.S.C. §673; or

(6) a child who is in foster care or otherwise in an out-of-home placement.

^K(g) Contractor - as defined in §014(c) of the Overview, 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(h) Covered items and services - as defined in §014(d) of the Overview, 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(i) Culturally competent³

Option 1: a health care practitioner is culturally competent (as required under §501(d) of Part 5) if he or she delivers health care items or services covered under Part 1 in an effective manner:

(1) to enrolled children from different cultures;

(2) with an understanding of, and respect for, the health-related beliefs, cultural values interpersonal styles, attitudes, and behaviors of the enrolled child and the child's family or caregiver.⁴

Option 2: health care items and services covered under Part 1 are furnished by Contractor in a culturally competent manner to enrolled children if:

(1) providers participating in Contractor's provider network possess a set of attitudes, skills, behaviors, and policies which enable Contractor and the providers to work effectively in cross-cultural situations; and

(2) Contractor and providers participating in Contractor's provider network understand the importance of acquiring and utilizing knowledge of the unique health-related beliefs, attitudes, practices, and communication patterns of enrolled children and their family or caregivers to improve services, strengthen programs, increase community participation and eliminate disparities in health status among diverse population groups.⁵

^K(j) Dental care provider - a dentist, pediatric dentist, orthodontist, periodontist, endodontist, oral and maxillofacial surgeon, dental hygienist, or [drafter insert other professional categories] licensed under state law.

^L(k) Emergency medical condition - as provided under §1932(b)(2)(C) of the Social Security Act, 42 U.S.C. §1396u-2(b)(2)(C), a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent or caregiver of an enrolled child), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(1) the placement of the child's health (or with respect to a pregnant adolescent, the health of the adolescent or her unborn child) in serious jeopardy;

(2) serious impairment of the child's bodily functions; or

(3) serious dysfunction of any bodily organ or part.

^L(l) Emergency services - inpatient and outpatient care and services which are:

(1) covered under §1905 of the Social Security Act, 42 U.S.C. §1396d(a);

(2) needed to evaluate or stabilize an emergency medical condition (as defined in subsection (k)); and

(3) furnished by a provider qualified to furnish such services.

^K(m)

(1) Enrolled child - as defined in §014(e) of the Overview, a child (or adolescent) with respect to whom Contractor assumes financial responsibility for furnishing or arranging for the furnishing of items and services covered under Part 1.

(2) Enrolled child's family or caregiver⁶ - a natural or adoptive parent of a child, a grandparent or stepparent with whom the child lives, or a caregiver (as defined in subsection (c)).

^K(n) Homeless - as described in §1902(a)(48) of the Social Security Act, 42 U.S.C. §1396a(a)(48), and §330(h)(4)(A) of the Public Health Service Act, 42 U.S.C. §254b(h)(4)(A), a child who:

(1) does not reside in a permanent dwelling;

(2) who does not have a fixed home or mailing address;

(3) whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations; or

(4) who is a resident in transitional housing.

^L(o) Individualized educational program (IEP)⁷ - a plan of services developed by an educational agency pursuant to the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. §1401(11), 34 C.F.R. §§300.15, 300.347, which sets forth the special education and related services required by a child.

^L(p) Individualized family services plan (IFSP)⁸ - a plan of services developed by an early intervention agency pursuant to the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. §1401(12), 34 C.F.R. §§303.17, 303.344, which sets forth the early intervention services required by a child and the child's family or caregiver.

^K(q) Medically necessary - as defined in §101A(e) of Part 1A, with respect to an enrolled child, an item or service enumerated under Part 1 is necessary to:

(1) prevent, correct, or ameliorate a condition, disability, illness or injury;

(2) prevent, correct, or ameliorate a developmental disability or delay; or

(3) maintain functioning.⁹

^K(r) Migratory agricultural worker - as described in §330(g)(3)(A) of the Public Health Service Act, 42 U.S.C. §254b(g)(3)(A), an individual:

(1) whose principal employment is in agriculture on a seasonal basis;

(2) who has been so employed within the last 24 months; and

(3) who establishes for purposes of such employment a temporary abode.

^K(s) Pediatric specialist - a provider (as defined in subsection (v)) who is a physician, child psychiatrist, child psychologist, or other health care practitioner, children's hospital, or other entity that with respect to the diagnosis, treatment, or management of a child's (or adolescent's) illness, injury or condition has specialized expertise (as evidenced by certification or licensure, or other means of formal recognition) relating to the particular illness, injury, or condition of the child.¹⁰

^L(t) Post-stabilization care services - as defined in §1852(d)(2) of the Social Security Act, 42 U.S.C. §1395w-22(d)(2), and 63 Fed. Reg. 34986 (June 26, 1998), post-stabilization care services are medically necessary, non-emergency services needed to ensure that an enrolled child remains stabilized from the time that the treating hospital requests authorization from Contractor until:

(1) the enrolled child is discharged;

(2) a physician participating in Contractor's provider network arrives and assumes responsibility for the enrolled child's care; or

(3) the treating physician and Contractor agree to another arrangement.

^K(u) Primary care provider - a provider (as defined in subsection (v)) that meets the requirements of §502(c) of Part 5.

^K(v) Provider - as defined in §014(f) of the Overview, 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(w) Provider network - as defined in §014(g) of the Overview, 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(x) Purchaser - as defined in §014(h) of the Overview, [drafter insert name of state purchasing agency].

^K(y) Seasonal agricultural worker - as described §330(g)(3)(B) of the Public Health Service Act, 42 U.S.C. §254b(g)(3)(B), an individual:

(1) whose principal employment is in agriculture on a seasonal basis; and

(2) who is not a migratory agricultural worker.

^K(z) Urgent care - inpatient and outpatient care and services which are:

(1) covered under §1905(a) of the Social Security Act , 42 U.S.C. §1396d(a);

(2) needed to evaluate or treat an urgent medical condition (as defined in subsection (aa)); and

(3) furnished by a provider qualified to furnish such services.

^K(aa) Urgent medical condition - a condition in a child manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson (including the family or caregiver of an enrolled child), who possesses an average knowledge of health and medicine, could reasonably expect the absence of same day medical attention to result in:

(1) placement of the child's health (or with respect to a pregnant adolescent, the health of the adolescent or her unborn child) in serious jeopardy;

(2) serious impairment of a child's bodily functions; or

(3) serious dysfunction of a child's bodily organ or part.

Endnotes

An alternative option would be to define an adolescent as a child age 12 through age 20.
An alternative option would be to add one or more of the following categories of children within which there is a high prevalence of chronic conditions: (1) recipients of family preservation and support services from a state child welfare agency pursuant to 42 U.S.C. ï¿½629 et seq.; (2) homeless (as defined in subsection (n)) or at risk of being homeless; or (3) a member of family of a migratory agricultural worker (as defined in subsection (r)) or a seasonal agricultural worker (as defined in subsection (y)); (4) is under age 3 and is eligible for early intervention services under the Individuals with Disabilities Education Act, 20 U.S.C. ï¿½ï¿½1400 et seq., 34 C.F.R. ï¿½ï¿½303.16, 303.300; or (5) is age 3 or over and is eligible for special education and related services under the Individuals with Disabilities Education Act, 20 U.S.C. ï¿½ï¿½1400 et seq., 34 C.F.R. ï¿½300.7.
Another alternative option would be: a child under 21 who has a chronic physical, developmental, or behavioral condition, and requires health and related services of a type or amount beyond that which is required by children generally. See Merle McPherson et al., "A New Definition of Children with Special Health Care Needs," 102 Pediatrics No. 1, July 1998, p. 137.
See also Table 3 of "Cultural Competence in Medicaid Managed Purchasing: General and Behavioral Health Services for Persons with Mental and Addiction-Related Illnesses and Disorders," Issue Brief #4, Managed Behavioral Health Care Issue Brief Series, GW Center for Health Services Research and Policy, June, 1999, www.samhsa.gov.
This definition is derived from Health Resources and Services Administration, Health Care Rx: Access for All, The Presidentï¿½s Initiative on Race.
This definition of cultural competency was developed by HCFA for purposes of interpreting the final Medicare + Choice regulations, which require that each M+C organization receiving federal Medicare dollars "ensure that services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities." 42 C.F.R. ï¿½422.112(a)(9). This definition focuses on the organization; in contrast the definition in Option #1 focuses on individual providers participating in Contractorï¿½s provider network.
An alternative option would be to define "parent" and "foster parent" as the terms are defined for purposes of an IEP at 34 C.F.R. ï¿½300.20 or for purposes of an IFSP at 34 C.F.R. ï¿½303.l9.
For additional regulatory requirements relating to an IEP, see 34 C.F.R. ï¿½ï¿½300.340 - 300.361.
For additional regulatory requirements relating to an IFSP, see 34 C.F.R. ï¿½ï¿½303.340 - 303.345.
See footnote 6 in Part 1A.
An alternative option is to enumerate as "other entities" one or more of the following: (1) hospitals with the highest level of designation of advanced newborn intensive care capacity; (2) hospitals with a pediatric intensive care unit; (3) hospitals offering pediatric psychiatric care; (4) centers of excellence; and (5) specialty providers of multidisciplinary care in a single integrated unit.