Medicaid Contract Purchasing SpecificationsPart 3Information for New and Potential Enrolled ChildrenTable of Contents §301. Information to Potential Enrolled Children
§301. Information to Potential Enrolled Children (a) In General — Contractor shall provide to a potential enrolled child (including an adolescent) on whose behalf information is requested the following written information: (1) Items and Services — A description of: L(A) all items and services covered under Part 1;and K(B) all items and services excluded from coverage under §105 of Part 1 and information on where and how an enrolled child may obtain these benefits; (2) Items and Services Subject to Prior Authorization — An enumeration of: L(A) each covered item and service for which prior authorization is required under §103A(c) of Part 1A; and K(B) each covered item and service for which prior authorization is not required under §103A(d) of Part 1A; K(3) Provider Directory — The manner in which an enrolled child (or the child's family or caregiver) may obtain, without charge, a copy of Contractor's provider directory described in §304. K(4) Provider Selection — Procedures for selecting a primary care provider (including the right to designate a pediatric specialist as a primary care provider) and a dental care provider under Part 4; K(5) Access to Specialists — Procedures for obtaining direct access to pediatric specialists under §503 of Part 5; K(6) Self-Referrals — Information on self-referral rights for certain services under §104A of Part 1A; L(7) Complaints and Grievances — A description of Contractor's grievance and appeals process under §§1005 and 1006 of Part 10; K(8) Physician Incentive Plans — A description of any physician incentive plans under §1876(i)(8) of the Social Security Act, 42 U.S.C. §1395mm(i)(8) (made applicable to Contractor by §1903(m)(2)(A)(x) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(x)) that directly or indirectly affect a provider's compensation with respect to the treatment of an enrolled child; and L(9) Enrollee Rights and Responsibilities — A description of: (i) enrollee rights not otherwise described in paragraphs (1) - (8); and (ii) enrollee responsibilities under managed care, including the circumstances under which an enrolled child may obtain covered services through Contractor's provider network or outside of Contractor's provider network. K(b) Prior Purchaser Approval — Prior to distributing any information described in subsection (a) to any potential enrolled child, Contractor shall obtain the written approval of such information from Purchaser.
§302. Information to New Enrolled Children K(a) Comprehensive Information (1) At Time of Enrollment — Within [ ] days of being notified by Purchaser of a child's enrollment, Contractor shall mail a written enrollee handbook1 which complies with subsections (b) and (c) to the family or caregiver of the enrolled child (including an adolescent); and (2) On Request — Contractor shall upon request by the enrolled child (including an adolescent) or the child's family or caregiver: (A) make the written enrollee handbook available at its administrative offices; and (B) make the health education information described in subsection (f) available at the practice sites of primary care providers participating in Contractor's provider network. (b) Understandability — Contractor shall ensure that the enrollee handbook required under subsection (a) and the health education information required under subsection (f) are written: L(1) in a manner and format which may be easily understood by an enrolled child's (or potential enrolled child's) family or caregiver; K(2) at the [ ]th grade level; and K(3) in each language which is spoken as a primary language by at least [ ] of Contractor's enrollees. (c) Contents of Enrollee Handbook — Contractor's enrollee handbook shall contain the following information: (1) Items and Services — A description of: L(A) all items and services covered under Part 1;and K(B) all items and services excluded from coverage under §105 of Part 1 and information on where and how an enrolled child may obtain these benefits; K(2) Coverage Determination Standards and Procedures — An explanation of Contractor's coverage determination standards and procedures under §§101A and 102A of Part 1A; L(3) Emergency Services — A description of emergency services (as defined in §1401(l)) covered under [drafter insert name of purchasing document], and the procedures that an enrolled child and the child's family or caregiver should follow in the event of an emergency (including a 24-hour toll-free telephone number); (4) Items and Services Subject to Prior Authorization — An enumeration of: L(A) each covered item and service for which prior authorization is required under §103A(c) of Part 1A; K(B) each covered item and service for which prior authorization is not required under §103A(d) of Part 1A; and K(C) the procedure (including the 24-hour toll-free telephone number) by which an enrolled child and the child's family or caregiver may request prior authorization as required under §103A(b)(3); K(5) Provider Directory — The manner in which an enrolled child (or the child's family or caregiver) may obtain, without charge, a copy of Contractor's provider directory described in §304; K(6) Provider Selection — Procedures for selecting a primary care provider (including the right to designate a pediatric specialist as a primary care provider) and dental care provider under Part 4; K(7) Access to Specialists — Procedures for obtaining direct access to pediatric specialists under §503 of Part 5; K(8) Self-Referrals — Information on self-referral rights for certain services under §104A of Part 1A; K(9) Transportation — A description of transportation services covered under §101(l) of Part 1 and the procedures that an enrolled child and the child's family or caregiver should follow in obtaining such services; K(10) Service Waiting Times — Information on the requirements of §603 of Part 6 relating to waiting times for items and services with respect to emergency medical conditions, urgent medical conditions, and all other illnesses or conditions; K(11) Interpreters — A description of professional interpreter services available under §506(b)(2) of Part 5 with respect to clinical encounters and the manner in which the enrolled child and the child's family or caregiver may obtain such services; K(12) Disenrollment — A description of the circumstances under which an enrolled child may disenroll under Part 2; L(13) Complaints and Grievances — A description of Contractor's grievance and appeals process under §§1005 and 1006 of Part 10; K(14) Confidentiality — A description of the confidentiality protections for an enrolled child under §1002 of Part 10; K(15) Liability Protections — A description of the liability protections for an enrolled child and the enrolled child's family or caregiver under §1003 of Part 10; K(16) Physician Incentive Plans — A description of any physician incentive plans under §1876(i)(8) of the Social Security Act, 42 U.S.C. §1395mm(i)(8) (made applicable to Contractor by §1903(m)(2)(A)(x) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(x)) that directly or indirectly affect a provider's compensation with respect to the treatment of an enrolled child; L(17) Applicable Cost-Sharing — Cost-sharing requirements, if any, applicable to an enrolled child under §1003(c) of Part 10; K(18) Coordination of Benefits — A description of the manner in which coverage under [drafter insert name of purchasing document] is coordinated with other third party coverage or with IEPs or IFSPs as required under §105A of Part 1A; and L(19) Enrollee Rights and Responsibilities — A description of: (i) enrollee rights not otherwise enumerated in paragraphs (1) - (18) that are set forth in [drafter insert reference to patient protections provisions in state managed care law]; and (ii) enrollee responsibilities under managed care, including the circumstances under which an enrolled child may obtain covered services through Contractor's provider network or outside of Contractor's provider network. K(d) Periodic Update — Contractor shall ensure at least [ ] that the contents of the enrollee handbook enumerated in subsection (c) are current. K(e) Prior Purchaser Approval — Prior to distributing any enrollee handbook (or periodic update thereof) to any enrolled child, Contractor shall obtain the written approval of such handbook (or periodic update thereof) from Purchaser. K(f) Health Education Information2 — Consistent with subsection (a)(2)(B), Contractor shall ensure that health education information is made available at the practice sites of primary care providers participating in Contractor's provider network to an enrolled child (including an adolescent) and to the child's family or caregiver with respect to the following priority illnesses or conditions: (1) SIDS — Information on Sudden Infant Death Syndrome and Other Sudden and Unexpected Infant Death and strategies for reducing the risk of infant death; (2) HIV/AIDS — Information on the risk factors associated with the transmission of Human Immunodeficiency Virus, reducing the risk of transmission, including perinatal transmission, the availability of HIV testing and prevention services, and treatments for HIV and Acquired Immune Deficiency Syndrome; and (3) Injury Prevention — Information on the types of injuries that most frequently affect enrolled children (including adolescents), the risk factors associated with such injuries, and strategies for reducing the risk of injuries; (4) [drafter insert reference to other illnesses and conditions that represent priority to State public health department].
K§303. Information to Enrolled Adolescents3 (a) Enrolled Adolescent Pamphlet — Contractor shall provide to each enrolled adolescent and to each enrolled child on the child's 11th4 birthday a pamphlet5 that meets the understandability requirements of §302(b) that includes the following information: (1) Confidentiality — a description of the confidentiality protections for an enrolled adolescent under §1002(b) of Part 10; (2) Adolescent Health Providers — the identity, location, qualifications, and availability of each provider participating in Contractor's provider network with an expertise in the care of adolescents; (3) Self-Referrals — a description of an enrolled adolescent's right to self-refer for certain services under §104A of Part 1A; (4) Emergency Services (A) a description of emergency services (as defined in §1401(l)) covered under [drafter insert name of purchasing document]; and (B) the procedures that an enrolled adolescent should follow in the event of an emergency (including a 24-hour toll-free telephone number); (5) Treatment for Abuse — a description of the services available to abused enrolled adolescents, including the right to examination for physical or sexual abuse without prior authorization under §103A(d)(13) of Part 1A; and (6) Minor Consent Laws — a description (furnished to Contractor by Purchaser) of the State's minor consent laws.
§304. Provider Directory (a) In General — Contractor shall, upon request, make available to each potential or new enrolled child (and the child's family or caregiver) without charge, on a [ ] basis, an accurate written list of all providers participating in Contractor's provider network under Part 5 that specifies: L(1) Identity K(A) the name, mailing address and telephone number (including the 24-hour toll-free telephone number) of each provider; and K(B) in the case of a physician or other health professional who practices at a location that is a federally qualified health center, or rural health clinic, the information described in clause (i) and the name of the center or clinic (or the name by which it is known in the community) at which the physician or professional practices; L(2) Location K(A) the location of each practice site of each provider; and K(B) the bus or subway routes through Contractor's service area; L(3) Qualifications K(A) specialty and board certification of each provider; and K(B) languages other than English in which the provider is fluent; L(4) Availability6 K(A) the hours that each provider is actually available at the provider's practice site; and K(B) accommodations made by each provider for an enrolled child with special health care needs in accordance with §505 of Part 5.
K§305. Enrollment Card — Within [ ] days of being notified by Purchaser of a child's enrollment, Contractor shall issue to the child and the child's family or caregiver an enrollment card that contains Contractor's name and a 24-hour toll-free telephone number for use in the event of an emergency.7
Endnotes
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Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under §1932(a)(5) of the Social Security Act, 42 U.S.C. 1396u-2(a)(5) relating to the provision of information by Medicaid MCOs to enrollees and potential enrollees.
HCFA has published a letter to State Medicaid Directors dated February 28, 1998 (www.hcfa.gov/medicaid/bba2208b.htm) which provides:
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 information for new and potential enrolled children 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 the provision of information to enrollees used by state agency purchasers in contracting with Medicaid MCOs. These options may be found at Table 1.5, Vol. 2, Part 1, pages 1-258 through 1-366, and Table 1.6, Vol. 2, Part 1, pages 1-368 through 1-418, www.gwu.edu/~chsrp.