Medicaid Contract Purchasing Specifications

Purchasing Specifications For Reproductive Health Services

May, 2000

Table of Contents

§201.Enrollee Access to Health Care Providers

§202. Enrollment and Disenrollment

§203. Provider Network Requirements

§204. Public Health and Other Reporting

§205. Quality Measurement and Improvement

§206. Confidentiality

§207. Information for Enrollees

PART 2. SERVICE DELIVERY AND HEALTH CARE QUALITY

§201. Enrollee Access to Health Care Providers

(a) Self-referral for Certain Covered Services ⁸⁷,⁸⁸ -- In covering services enumerated at §103 (relating to prevention, counseling and education) and at §104(a)(1) (relating to contraceptive services), Contractor shall:

(1) ensure that an enrollee may at any time seek services covered under §103 (relating to prevention, counseling and education services) and §104(a)(1) (relating to contraceptive services) that are provided in accordance with appropriate clinical guidelines⁸⁹ without prior authorization or referral from the enrollee's primary care provider, from:

(A) a network provider; or

(B) [drafter insert the name(s) of publicly-assisted provider[s] that are not network providers]

(2) reimburse a non-network provider in accordance with the same coverage and payment time-line principles that apply to providers of such services within Contractor's network at:

[Alternative A] Medicaid rates; ⁹⁰

[Alternative B] network provider rates; ⁹¹or

[Alternative C]⁹² negotiated rates;

(3) establish procedures by which a non-participating provider may refer an enrollee who tests positive for pregnancy, HIV/AIDS, sexually transmitted disease, or other reproductive health conditions diagnosed by the non-participating provider to Contractor for covered services; except that such procedures also shall provide for initiation of sexually transmitted disease treatment by the non-participating provider when indicated; and

(4) inform enrollees (including enrollees who are minors) of their right to refer themselves on a confidential basis to school health and local health agency clinics, family planning clinics and other publicly-assisted providers as defined in §112, whether or not the provider is a network provider, for prevention, counseling, education and contraceptive services covered under Part 1.

(b) Access to Reproductive Health Services for Minor Enrollees⁹³,⁹⁴ , -- In the case of an enrollee who is a minor as defined in §112, Contractor shall permit the enrollee to consent to receive reproductive health services covered under Part I to the extent permitted by federal law and regulation and by [drafter specify applicable state law and regulations].

(c) Cost-sharing Not Permitted for Certain Services ⁹⁵-- Contractor shall not impose any deductible, copayment, coinsurance payment, or other charge upon an enrollee with respect to services covered under §103 (relating to prevention, counseling and education services), §104(a) (contraceptive) or §106 (relating to perinatal services).

§202. Enrollment and Disenrollment

(a) Enrollees Receiving Reproductive Health Services at the Time of Enrollment -- In the case of an enrollee who at the time of enrollment is receiving reproductive health services, Contractor shall continue to pay for and arrange for the services until a primary care provider who is a board-certified or board-eligible specialist in obstetrics and gynecology and who participates in Contractor's provider network has:

(1) provided a medical history and examination, laboratory services or other diagnostic procedures that are indicated in the opinion of the provider and that are enumerated in Part 1; and

(2) initiated services that are indicated in the opinion of the provider and enumerated in Part 1.

(b) Enrollment of Infants Born to Enrollees ⁹⁶-- In the case of an infant born to an enrollee, the infant shall be automatically enrolled at time of birth and shall remain an enrollee until disenrolled by infant's family or caregiver.

(c) Disenrollment of Enrollees Receiving Reproductive Health Services -- In the case of an individual who ceases to be an enrollee and who, at the time of disenrollment, is receiving reproductive health services, Contractor shall:

(1) continue to provide the services to the individual until the earliest of:

(A) completion of a course of treatment;

(B) the day on which a provider or managed care plan assumes responsibility for the care of the individual; or

(C) the day on which the period for which an enrollee is covered under this Part ends; and

(2) the case of an individual who is pregnant at the time of disenrollment,

(A) cover and deliver perinatal services covered under Part 1 until sixty (60) days after birth.

(B) Contractor shall be reimbursed for post-disenrollment services at:

[Alternative A] ⁹⁷Medicaid rates;

[Alternative B] network provider rates; or

[Alternative C] negotiated rates;

(d) Transfer of Medical and Related Records -- At the request of an enrollee described in subsection (a) or (c) of this Section, Contractor shall arrange for the timely transfer of the enrollee's or former enrollee's medical record and any written plan of care as follows:

(1) in the case of a newly-enrolled enrollee, transfer shall be arranged from the enrollee's former provider(s) to the enrollee's primary care provider and to any other health care professional who is reviewing the plan; and

(2) in the case of a former enrollee, transfer shall be arranged from the enrollee's primary care network provider and case manager (if any) to the successor provider(s). Contractor shall also ensure that network providers furnishing treatment and case management services to the former enrollee at the time of disenrollment make themselves available to the successor providers for review of the former enrollee's treatment plan.

(e) Individual Enrollment Cards or Other Evidence of Coverage -- In issuing enrollment cards or other evidence of coverage at the time of enrollment, Contractor shall furnish individual cards or copies of such evidence for each individual (including minor individuals⁹⁸ as defined in §112) who qualifies for services under Part 1.

§203. Provider Network Requirements

(a) Providers of Reproductive Health Services in Contractor's Provider Network -- Except as provided at subsection(B), Contractor shall include as participating network providers (for direct and referral services) the following classes of providers:

(1) primary care providers who are:

(A) board-certified or board-eligible physicians in the following areas:

(i) family practice;

(ii) internal medicine;

(iii) pediatrics; and

(iv) obstetrics and gynecology; and

(B) health care professionals who are certified or licensed under state law to practice as: ⁹⁹

(i) nurse practitioners;

(ii) nurse midwives; or

(iii) physician assistants.

(2) health care professionals, who may be primary care providers enumerated in paragraph (1), who are trained in provision of contraceptive services counseling;

(3) health care professionals, who may be nurses, social workers or other classes of health care professionals, who are trained and experienced in pregnancy-related case management;

(4) board-certified or board-eligible specialist and subspecialist physicians in the following areas:

(A) maternal and fetal medicine;

(B) genetic disorders;

(C) infertility;

(D) perinatal services;

(E) neonatology; and

(F) adolescent health;

(5) board-certified or board-eligible specialist and subspecialist physicians with demonstrated experience in the management of complex reproductive health conditions including ¹⁰⁰

(A) pregnancy and HIV infection;

(B) pediatric HIV infection;

(C) pregnancy and addiction disorder; and

(D) pregnancy and diabetes;

(6) genetic disorders clinics, centers or services that provide:

(A) skilled, high-resolution ultrasound, amniocentesis and other perinatal tests and procedures; and

(B) pre-and post-test counseling by genetics counselors who are licensed or certified under state law to provide such counseling;

(7) regional perinatal centers or other tertiary health care facilities that offer perinatal and neonatology services for women at risk of poor pregnancy outcome as defined in §112 and their infants as:

(A) inpatient services (including intensive care); and

(B) outpatient services;

(8) providers of infertility services;

(9) registered dietitians or other clinical nutrition providers that are licensed or accredited under state law; and

(10) providers of lactation services.

(b) Consultation Agreements with Specialist and Subspecialist Physicians: -- In lieu of including one or more of the classes of specialist and subspecialist physicians enumerated in subsections (a)(4) or (a)(5), Contractor shall enter into written Agreements with such physicians, which Agreements shall specify their obligation to make consultation services available to network providers.

(c) Inclusion of Publicly-Assisted Providers in Contractor Network -- Contractor shall make reasonable efforts to enter into subcontracts with publicly -assisted providers as defined in §112 for provision of, at a minimum, the preventive and contraceptive services described in Part 1.

(d) Inclusion of Birthing Centers in Contractor Network -- Contractor may include as participating network providers (for direct, consultative and referral services) birthing centers that are accredited under state law and that offer perinatal services in accordance with appropriate clinical guidelines¹⁰¹ that are appropriate for women at low risk of poor pregnancy outcome and their infants.

(e) Selection of Primary Care Pediatric Provider by Pregnant Enrollees -- In the case of an enrollee who is pregnant, Contractor shall offer the enrollee an opportunity during the last trimester of her pregnancy to:

(1) select a primary care pediatric provider for her newborn; and

(2) meet with the selected primary care pediatric provider.

(f) Criteria for Provider Credentialing and Compensation ¹⁰²-- In developing and managing a provider network for services covered under Part 1, Contractor shall not take any actions enumerated at paragraph(1) against a provider participating in Contractor's network solely on the basis of any factors enumerated at paragraph (2) of this subsection:

(1) the actions prohibited under this subsection are:

(A) exclusion of a provider from Contractor's network; ¹⁰³

(B) reduction or withholding of financial compensation or other financial penalty;

(2) unless adjusted for the acuity of conditions of enrollees under the care of a network provider, the factors that may not be the sole basis of actions against participating providers under this subsection are:

(A) the frequency or duration of enrollee visits for reproductive health services;

(B) the number or type of laboratory services, mammograms or prescription drugs and biologicals for contraceptive indications that are provided or ordered by the provider;

(C) the number or type of drugs, devices or supplies for contraceptive indications that are prescribed or delivered by the provider; or

(D) the number or type of referrals or consultations related to reproductive health services that are ordered by the provider.

(g) Provider and Subcontractor Compliance -- Contractor shall ensure that the providers and subcontractors furnishing medical, health, administrative and other services enumerated in Parts 1 and 2 comply with Contractor's duties with regard to these services.

§204. Public Health and Other Reporting

(a) Public Health and Other Reporting ¹⁰⁴-- Contractor shall comply with:

(1) public health-related data and reporting requirements set forth in [drafter insert relevant state law or regulation]; and

(2) sexual abuse and domestic violence reporting requirements set forth in [drafter insert relevant state law or regulation].¹⁰⁵

§205. Quality Measurement and Improvement

(a) Development and Dissemination of Practice Guidelines - Contractor shall develop or adopt and disseminate to network providers and subcontractors practice guidelines for reproductive health services based on the guidelines enumerated in §107 of Part 1.

(b) Focused Quality Review ¹⁰⁶-- In assessing the quality of the reproductive health services and related procedures enumerated in Parts 1 and 2, Contractor shall conduct or arrange for the [drafter specify frequency of the following studies] conduct of:

(1) medical and administrative records reviews and audits to measure the timeliness, appropriateness and accessibility of services enumerated in Part 1. At a minimum, such reviews and audits shall address:

(A) the percentage of enrollees who received reproductive risk assessments and counseling that were appropriate to individual enrollee ages¹⁰⁷ and reproductive goals;

(B) the percentage of pregnant enrollees who received prenatal care in the first trimester of pregnancy; and

(C) the percentage of pregnant enrollees who receive the appropriate number of prenatal visits in accordance with appropriate guidelines;¹⁰⁸ and

(2) in the case of an enrollee survey of the quality of covered services, measurement of the percentage of enrollees of childbearing age who received specific information on contraceptive services.

(c) Performance Reporting -- Contractor shall report to Purchaser [drafter insert frequency of reports] the data resulting from the quality measurement and improvement activities described in this Section.

§206. Confidentiality¹⁰⁹

(a) Maintenance of Confidentiality of Information Relating to Enrollee Reproductive Health Status and Receipt of Reproductive Health Services -- In delivering the services covered under Part 1, Contractor shall comply and ensure provider, employee and subcontractor compliance with:

(1) [drafter insert state laws and regulations that protect the privacy of medical information relating to individuals including individuals who are minors]; and

(2) requirements described in subsections (b) and (c) of this Section.

(b) Omission of Information from Communications Relating to Enrollee Reproductive Health Status and Receipt of Reproductive Health Services -- Contractor, upon written prior request of an enrollee, shall omit from written, oral or electronic communications with an enrollee (or, in the case of an enrollee who is a minor, with the parent or caregiver of the enrollee) information that would enable, directly or indirectly, a third party to determine the enrollee's reproductive health status or receipt of reproductive health services covered under Part 1. ¹¹⁰

(c) Informing Enrollees Regarding Confidentiality Protections -- Contractor shall include the following information in enrollee risk-assessment, counseling and information services enumerated in Part 1 and in member handbooks:

(1) medical information relating to an individual enrollee's (including a minor enrollee) reproductive health status and receipt of reproductive health services is confidential except that:

(A) under [drafter insert applicable State law or regulation] such information may be disclosed only to public health authorities that are responsible for control of communicable diseases and recording births, deaths and other vital statistics; and

(B) under [drafter insert applicable State law or regulation], information about the age of an enrollee's sexual partner may be disclosed to authorities with responsibility for investigation and prosecution of sexual abuse, statutory rape or other criminal acts.

§207. Information for Enrollees ¹¹¹

(a) Enrollee Information -- Contractor shall make the following information available to enrollees (including enrollees who are minors) before and at the time of enrollment and thereafter when there are material changes in the information:

(1) the reproductive health services that are covered under Part 1.

(2) the availability of certain covered reproductive health services on a self-referral basis as described in §201(a).

(3) availability of certain covered reproductive health services without cost-sharing as described in §201(c);

(4) Contractor's network primary care, specialty and subspecialty, and other providers including providers that offer special language and physical access services and special cultural competency arrangements; and

(5) confidentiality standards under this agreement as described in §206.

Endnotes:

Commentary: Experts in reproductive health consider that minimizing barriers to family planning services is important in prevention of unintended pregnancy and in early diagnosis and treatment of sexually transmitted disease, HIV and other communicable diseases. Under Section 1915(b) of the Social Security Act (42 U.S.C. '1396n(b)), a Medicaid beneficiary enrolled on a mandatory basis in managed care must be allowed to seek family planning services from any Medicaid provider of these services, whether or not the provider is a member of Contractor's provider network. Contractors may wish to include publicly-assisted family planning providers in their networks or to make alternative arrangements for services that such providers furnish to Contractor's enrollees. Medicaid Purchasers may wish to consider sample specifications for self-referral for adolescent Medicaid enrollees for family planning, sexually transmitted disease and HIV/AIDS services at MEDICAIDSPECS ' 005(f); self-referral for certain HIV/AIDS services at HIV/AIDSSPECS §201(a),(f) and for certain sexually transmitted disease services at STDSPECS §201(a) (www.gwu.edu/~chsrp).
Commentary: In certain states, direct enrollee access to specialists in obstetrics and gynecology (without prior authorization or referral by the enrollee's primary care provider) is required under state law for enrollees in state-regulated managed care organizations. Drafter may also wish to determine the status of the Health Care Financing Administration's (HCFA) proposed rule relating to womens' direct access in Medicaid managed care to "women's health" specialists. At the time these specifications were drafted, the HCFA proposed rule for the 1997 Balanced Budget Act specified that a women enrolled in a Medicaid managed care plan regulated under the proposed rule be entitled to direct access to a "women's health specialist" participating in the MCO's provider network, without prior authorization from the enrollee's primary care provider. Medicaid Program; Medicaid Managed Care; Proposed Rule 63 Fed Reg 52022 (1998) (to be codified at 42 C.F.R. ï¿½438.306. (This proposal was drafted to be consistent with the Consumer Bill of Rights and Responsibillities, published in November, 1997 by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 63 Fed.Reg. 52023.)
Commentary: For applicable guidelines see '110(a)-(d).
Commentary: This alternative is provided for consideration by Medicaid Purchasers.
Commentary: This alternative is provided for consideration by non-Medicaid and Medicaid Purchasers.
Commentary: This alternative is provided for consideration by non-Medicaid and Medicaid Purchasers.
Commentary: Twenty-three states and the District of Columbia by law specifically permit minors to consent to contraceptive services. Twenty-seven states and the District of Columbia by law specifically permit minors to consent to prenatal care and delivery services without parental consent or notification. The District of Columbia and 49 states permit minors to consent to diagnosis and treatment of a sexually transmitted disease; however, not all states deem HIV to be a sexually transmitted disease. At least 13 states by law specifically permit minors to consent to HIV testing and seven states also by statute expressly permit minors to consent to HIV treatment. Although certain states permit minors to consent to medical or surgical care generally, just two states and the District of Columbia allow minors to consent to termination of a pregnancy. As of February, 2000, 31 states enforced laws requiring parental consent or notification regarding a minor seeking to terminate a pregnancy. The U.S. Supreme court has found that in order to protect a minor's right to privacy, such laws must permit a minor to obtain authorization for pregnancy termination from a judge without informing her parents. Alan Guttmacher Institute .http://www.agi-usa.org/pubs/ib21.html , Teenagers' Right to Consent to Reproductive Health Care (.http://agi-usa.org/pubs/ib21.html); Alan Guttmacher Institute, Facts in Brief: Induced Abortion (http://www.agi-usa.org/pubs/fb_induced_abort.html); K Hein, Annotation: adolescent HIV testing -- who says who signs? AJPH 1997; 87:1277-1278
Commentary: Purchasers may wish to consider similar sample purchasing specifications relating to access of minors to certain HIV/AIDS services at HIV/AIDSSPECS §202(g) and to sexually transmitted disease services at STDSPECS §201(b) (www.gwu.edu/~chsrp). Medicaid Purchasers may wish to consider similar sample specifications relating to access by adolescents to family planning services, diagnosis and treatment of sexually transmitted disease and HIV counseling and testing at MEDICAIDSPECS '005(f) (www.gwu.edu/~chsrp)
Commentary: Federal Medicaid law prohibits co-payment or other beneficiary cost-sharing for covered services for beneficiaries who are under age 18 or who are pregnant, or for family planning or emergency services; however, nothing precludes a Medicaid Purchaser from exempting additional types of care from beneficiary cost-sharing. 42 U.S.C. §1396a(a)(14), 1396o.
Commentary: Medicaid Purchasers may wish to consider similar sample specifications relating to automatic enrollment of enrollees' newborns at MEDICAIDSPECS §201(b) (www.gwu.edu/~chsrp).
Commentary: This alternative is provided for consideration by Medicaid Purchasers.
Commentary: Issuance of individual enrollment cards or other evidence of coverage has been recommended by certain local public health agencies that wish to be reimbursed for sexually transmitted disease and certain other services that they furnish for Medicaid and non-Medicaid managed care enrollees.
Commentary: Inclusion of these practitioners as primary care providers is required only to the extent that state licensure and certification laws permit these practitioners to assume primary clinical responsibility for an individual.
Commentary: Experience in the management of complex reproductive health conditions may be demonstrated by maintenance of an active practice providing continuous and direct medical care to individuals with the complex reproductive health conditions, either in regular practice or as part of a supervised post-gradute training program, or completion of a minimum number of continuing medical education (CME) hours annually, as specified by Purchaser. The definition of such experienced providers may vary from community to community, depending on the types of providers within a community's health care delivery system.
Commentary: For applicable guidelines, see '110(a).
Commentary: This section is intended to minimize disincentives for providers to furnish certain services for which barriers should be minimized, in the view of experts in reproductive health. The section does not prohibit a Contractor from evaluating provider performance for purposes of quality assurance or other activities that are not related to performance penalties.
Commentary: "Exclusion" includes both initial Contractor determinations with regard to inclusion of a provider from Contractor's network and period Contractor redeterminations ("recredentialing") with regard to retaining or excluding a network provider.
Commentary: Medicaid Purchasers may wish to consider similar sample public health reporting specifications addressing documentation of family-planning encounters by enrolled adolescents (whether or not self-referred) at MEDICAIDSPECS '005(f) and reporting incidence of certain conditions including sexually transmitted disease and genetic or metabolic conditions, at MEDICAIDSPECS '702(a). Purchasers may also wish to consider forthcoming sample specifications on data and information collection and reporting. (www.gwu.edu/~chsrp )
Commentary: These reporting requirements include births, fetal deaths, abortions, certain congenital conditions in newborns and other "vital statistics" as well as reporting requirements relating to certain communicable diseases (e.g., gonorrhea, HIV).
Commentary: Purchasers may wish to consider additional sample specifications addressing quality assurance of HIV/AIDS services, at HIV/AIDSSPECS §207(A)(1), (6), and (7) (www.gwu.edu/~chsrp ). These sample specifications address clinical performance studies to assess performance of: HIV testing of all pregnant enrollees no later than second prenatal encounter; assessment of adolescents for HIV risk and assessment of adult enrollees for HIV risk factors. Medicaid Purchasers may wish to consider additional sample specifications addressing quality assurance relating to studies of provision of family planning services to enrolled adolescents, at MEDICAIDSPECS '803(a) (www.gwu.edu/~chsrp ).
Commentary: Reproductive health experts recommend that counseling protocols that are developed specifically for adolescents be used with these enrollees.
Commentary: For applicable guidelines, see '110(a).
Commentary: Medicaid Purchasers may wish to consider sample specifications relating to confidentiality of EPSDT services for adolescent Medicaid enrollees at MEDICAIDSPECS ''102(c), '1002(b) and generally applicable sample specifications relating to confidentiality protections at MEDICAIDSPECS '1002(www.gwu.edu/~chsrp)
110. Commentary: In order to protect the confidentiality of sensitive reproductive health information from, for example, an abusive partner, an "explanation of benefits" sent to an enrollee would not specifically identify the type of services provided to the enrollee.
Commentary: Medicaid Purchasers may wish to use specifications in this section to supplement the information requirements for potential enrollees and enrollees of Medicaid managed care organizations established by the 1997 Balanced Budget Act. Under the Act, the state, a Medicaid managed care enrollment broker or a managed care organization must make available to enrollees and potential, on request, information in an easily understood form on the MCO's providers (identity, locations, qualifications, and availability of health care providers) and information on all items and services available to enrollees under the managed care contract. 42 U.S.C. ï¿½1936u-2(a)(5)(A), (B)(i),(iv). Also, before or when a beneficiary enrolls in managed care, the state must itself or through managed care organizations inform the beneficiary of Medicaid benefits that are not available under the managed care contract, including where and how to get such benefits. 42 U.S.C. ï¿½1396u-2(a)(5)(D). Medicaid Purchasers may wish to consider similar sample specifications addressing enrollee information generally and for adolescents at MEDICAIDSPECS ''302, 303 and forthcoming CHSRP specifications on access to health care services, which will include specifications addressing reading level, other aspects of enrollee information. www.gwu.edu/~chsrp