Items and Services

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The sample Medicaid Pediatric Purchasing Specifications are divided into an Overview of Contractor’s Duties and 14 accompanying Parts that provide greater detail on specific subject areas. The Overview sets forth the basic duties owed by Contractor and providers to comply with the requirements in the various Parts.

Part 1: Items and Services

This Part enumerates an option for the benefit package for an enrolled child. These specifications have been drafted to be co-extensive with the full Medicaid program. The specifications offer sample language for virtually all Medicaid covered services for children under age 21 in accordance with federal Medicaid coverage and medical necessity standards. §101 represents a comprehensive listing under §1905(a) of the Social Security Act of all potential benefits categories for which federal Medicaid matching funds are available without a demonstration waiver. All federal service definitions found in federal regulations are incorporated by reference. §102 articulates the elements of the EPSDT coverage requirements in the Medicaid statute. A separate section, §105, sets forth benefit categories not covered under the purchasing agreement, if any. Purchasers that wish to include fewer than all items and services covered under their State Medicaid plans in agreements with MCOs retain direct responsibility under federal Medicaid law for the provision of remaining items and services to eligible children. This Part includes other sections for Purchasers interested in elements of particular items or services, such as prescription drugs and public health services.

Part 1A: Coverage Determination Standards and Procedures

This Part sets forth possible coverage determination standards and procedures to be followed by MCOs as well as permissible prior authorization and self-referral procedures. The coverage determination standards articulated in §101A reflect the federal Medicaid statute and regulations. These standards are broader in scope than the standards typically found in commercial MCO contracts. Insurers generally limit coverage to certain treatment which is medically necessary to restore functioning following an illness or injury. This traditional rule of insurance is designed to limit financial risk exposure and to prevent “moral hazard,” an industry term used to describe the problem which arises when individuals with costly long-term and chronic health conditions seek coverage. Traditional insurance principles therefore may result in coverage for only a subset of all procedures that Medicaid may cover. See Negotiating the New Health System (2nd Ed.), Vol. 1, p.18.

  • 101A speaks to standards for coverage determination, which is a decision by the Contractor as to whether to furnish (or pay for) an item or service that is covered under the purchasing agreement (in Part 1) with respect to an individual child. Subsection (e) defines “coverage determination.” Subsection (a) lists the standards that the Contractor is to apply in making such determinations. Subsection (b) lists the types of evidence the Contractor must consider in making such determinations. Subsection (c) lists the reasons for which a Contractor may not make a coverage determination that results in the denial of a covered item or service to an individual child. Finally, subsection (d) sets forth a special rule for coverage determinations in the case of enrolled children with reportable conditions or diseases. The process by which coverage determinations are to be made is set forth in §102A.

Part 1B: Delivery of Covered Items and Services

The provisions in this Part address ways in which providers may deliver items and services to enrolled children. This Part was designed to enable Purchasers to specify, at their option, criteria and guidelines for the delivery of health care services to specific populations of children, or for specific illnesses or conditions. For example, §101B(b) specifies the use of Bright Futures: Encounter Forms for Health Professionals (1998) for an initial assessment of an enrolled child by a provider.

Part 2: Enrollment and Disenrollment Procedures

This Part sets forth Contractor’s possible duties related to enrollment and disenrollment procedures. Specifically, in accordance with the overwhelming majority of state contracts and RFPs, §201 clarifies that children born to women who are enrolled with a contractor shall be treated as enrolled with the contractor and shall remain enrolled until the newborn is determined ineligible for Medicaid by the State Medicaid Agency or disenrolled by the family or caregiver. The other sections in this Part concern the possible duties related to children receiving treatment at the time of enrollment, and at the time of disenrollment. In addition, possible grounds for disenrollment of an enrolled child are enumerated.

Part 3: Information for New and Potential Enrolled Children

This Part enumerates possible information to be given to enrolled children prior to enrollment, and once enrolled. The contents of and requirements for an enrollee handbook are spelled out. The Part also specifies what information should be included in health education materials for enrolled children and in a pamphlet for enrolled adolescents. In addition, the Part provides language that would require Contractor to issue an enrollment card with Contractor’s name and 24-hour toll-free phone number to the family of each enrolled child.