Medicaid Contract Purchasing Specifications
User Guide for State Title V Maternal and Child Health
Agencies
Bright Futures
Coverage Determinations: §101A(a)(7)
of Part 1A relates to the application of Bright Futures: Guidelines
for Health Supervision of Infants, Children, and Adolescents in
the making of coverage determinations with respect to an individual
enrolled child.
Guidelines: §006(a)(1)(A)
of the Overview specifies Bright Futures as one of the guidelines
Purchasers may wish Contractor to follow in delivering covered items
and services to enrolled children.
Quality Measurement and Improvement Program: §802(b)(2)(C)
of Part 8 relates to the use of Bright Futures in the conduct
of compliance reviews.
Utilization Review: §805(a)(2)
of Part 8 relates to the use of Bright Futures in Contractor's
utilization review policies and procedures.
Case Management: §101(v) of
Part 1 identifies case management services as a covered item or service
under this purchasing document.
Children with Special Health Care Needs
Definitions
§1401(f) of Part 14 defines
children with special health care needs.
§1401(s) of Part 14 defines
pediatric specialist.
Network Providers: §505
of Part 5 relates to Contractor's duty regarding accessibility of providers
in its network.
Pediatric Specialists as Primary Care Providers: §402
of Part 4 relates to the selection of a primary care provider for an
enrolled child with special health care needs, including the choice
to select a pediatric specialist as a primary care provider.
Pediatric Specialists as Participating Providers: §503
of Part 5 relates to Contractor's duty regarding sufficiency of the
number of participating pediatric specialists and the role of such specialists.
Prior Authorization: §103A(d)(14)
of Part 1A relates to the exclusion of services for a chronic condition
from Contractor's prior authorization restrictions.
Quality Measurement and Improvement Program
Clinical Study: §803(a)(6)
of Part 8 and §905(b)
of Part 9 relates to Contractor's duty to conduct study to assess
quality of clinical care furnished to children with special health
care needs.
Standards: §802(b)(1)(C)
of Part 8 sets forth an access standard specific to children with
special health care needs.
Coordination of Benefits: §105A
of Part 1A sets forth obligations of Contractor relating to enrolled
children with third party coverage.
Coverage Determinations
Evidence: §101A(b)(6)
of Part 1A relates to the use of evidence from Title V agency professionals
in connection with Contractor's coverage determinations.
Grounds for Denial or Exclusion: §101A(c)(4)
of Part 1A would prohibit the use by Contractor or an enrolled child's
receipt of Title V services as a ground for denial or exclusion of services.
Notice: §102A(c) of
Part 1A requires notice of adverse coverage determination to Title V
agency or grantee referring the enrolled child.
Disenrolled Children: §703(b)
relates to Contractor's duty to notify disenrolled children of availability
of services from Title V agency or grantees.
EPSDT: §102(a)(2) of Part
1 relates to coordination with Title V agencies in the delivery of early
and periodic screening, diagnostic, and treatment services to enrolled
children.
Health Education Information: §302(f)
of Part 3 relates to priority illnesses or conditions about which Contractor
could be required to inform enrolled children.
Memorandum of Understanding: §703(c)
of Part 7 relates to the memorandum of understanding between Contractor
and an interested Title V agency.
Network Providers
Traditional Medicaid Provider: §508(b)(6)
of Part 5 relates to participation in Contractor's provider network
by Title V maternal and child health clinics.
Interagency Agreement: §501(i)
of Part 5 and §703(a) of Part
7 relate to Contractor's duty to ensure that providers in Contractor's
provider network comply with Title V/Medicaid interagency agreement.
Out-of Network Providers
Payment
§510 of Part 5 relates to
Contractor's duty regarding payment for services furnished by out-of-network
providers.
§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 public
health services received by enrolled children from out-of-network providers.
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 the WIC program.
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 WIC referrals.
Vaccines for Children (VFC) Program: Part
11 relate to duties of Contractor and providers in Contractor's
network relating to participation in VFC program.
The sample purchasing specifications include numerous provisions addressing a wide range of issues. Although many of these issues directly or indirectly affect state Title V agencies and their grantees, the following provisions may be of particular interest to Title V Agencies. The provisions are listed in alphabetical order.