States used to rely on government regulations to define Medicaid programs. Under Medicaid managed care, however, contracts with managed care organizations have replaced many regulations. Now the states must insure that Medicaid entitlements are preserved in its contracts.

It is essential to develop relationships with Medicaid administrators and staff, especially those who will develop the contracts. In most states, the Medicaid agency issues a request for proposal (RFP) to managed care organizations before negotiating the contract. Some states arrange a public comment period while developing the RFP. Other states prefer to develop the RFP without public comment. In this case, you must work with Medicaid officials, including members of the Medicaid Advisory Committee, as they write contracts.

The contract between the state and managed care organizations must include adequate information. Review the checklist for key pediatric issues to consider when reviewing an RFP or contract. In addition to the categories given, consider the unique circumstances of your state.

Category	OK	n/a or inade- quate	More info needed
I. Covered Groups The RFP/contract should:
Specify whether participation in managed care is voluntary or mandatory.
Specify which groups of individuals (e.g. children with special health care needs), if any, are “carved-out” or exempt from inclusion.
Specify whether there is any minimum period of eligibility (e.g. a 12-month “lock-in”).
II. Marketing The RFP/contract should:
Describe who will conduct marketing (managed care plan, independent contractor, Medicaid agency).
Ensure that marketing materials are accurate.
Ensure that marketing materials have been reviewed for appropriate literacy levels.
Ensure that marketing materials are available in languages other than English if appropriate.
Describe required elements of marketing materials and how often they should be updated. These elements may include:
description of covered benefits;
accurate list of primary care providers and specialists, their locations and office hours.
Describe clear, graduated sanctions for violations of marketing guidelines and how they will be enforced.
III. Enrollment/Selection of Primary Care Provider The RFP/contract should:
Describe who will enroll participants.
Ensure adequate time for participants to respond to request to select a plan and to select a primary care provider.
Ensure that participants receive an accurate list of primary care providers.
Ensure that pediatricians are included as primary care providers.
Ensure that every effort is made to allow beneficiaries to be able to choose a health plan.
When participants must be assigned to a plan, describe the process for assigning participants who do not select a plan, including the criteria that will be used. These criteria should include:
current and previous relationships with primary care providers;
assignment of other family or household members;
location of providers;
capability of managed care organization to provide special care or services appropriate for the individual.
Ensure that if enrollees lose their eligibility and than regain it at a later time, that they are able to re-enroll in the same plan.
IV. Initiation of Medical Services to New Enrollee The RFP/contract should:
Ensure that there is an appropriate timeline for the provision of information to the new enrollee.
Describe the format(s) in which a new enrollee receives information, such as face-to-face encounters in conjunction with written materials, or solely through written materials.
Describe the required timeline for an initial appointment.
Ensure that providers can verify eligibility 24 hour a day and designate which entity is to be contacted for this information: the state or the plan.
Ensure that enrollees are provided with a way of obtaining information on their eligibility and plan enrollment, such as a 24 hour toll free number.
V. Medical Services to New Enrollees with Special Health Care Needs The RFP/contract should:
Provide a comprehensive definition to identify “children with special health care needs” (e.g. Maternal and Child Health Bureau defines children with special health care needs as “those who have or are at elevated risk for chronic physical, development, behavioral, or emotional conditions and who also require health and related services of a type or amount not usually required by children.
Allow children with special health care needs to select pediatric specialists or a team of specialists as their primary care providers.
Describe any services that are “carved out.”
Require plans to specify coordination arrangements with other providers of care and publicly financed systems. (e.g. Title V programs for Children with Special Health Care Needs, Social Security Income services, education, and Early Childhood Intervention programs for children with special health care needs.
Require that each plan’s care coordination program be monitored by the state.
Allow children with special health care needs to access out of network providers, if no providers within the network are able to meet their special needs.
VI. Covered Services The RFP/contract should:
Clearly describe the requirements of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program including:
clearly listing it as a required service;
requiring plans to furnish periodic screens and identify all screening components;
defining “medically necessary” for the purposes of EPSDT;
include language describing the Academy’s periodicity schedule.
Describe how immunizations will be provided, including who will provide them and how they will be reimbursed. Include language that addresses how reimbursement will be handled when a new immunization is developed.
Provide a definition for medically necessary that
is appropriate for the age and health status of the enrollee;
will prevent or ameliorate the effects of a condition, illness, injury, or disorder;
will aid the overall physical and mental growth and development of the enrollee;
and will assist in achieving or maintaining maximum functional capacity in performing daily activities.
Provide a definition of emergency and urgent care that takes into consideration the age and needs of children as well as the level of knowledge of the care provider.
Outline a process to appeal denials of care based on medically necessary determinations.
Describe treatment of coverage exclusions.
Describe drug formularies and the process for allowing providers to prescribe outside the formulary.
Describe process for coverage of services furnished by non-network providers.
Describe enabling services including transportation and translation.
Describe ancillary services including:
physical therapy;
occupational therapy;
speech therapy;
nutritional counseling.
Allow primary care pediatricians to refer patients to pediatric specialists and hospitals within the plan promptly and efficiently when the provider deems such care is medically indicated.
VII. Provider Network The RFP/contract should:
Require managed care organizations to demonstrate adequate networks to ensure access based on the following:
access to inpatient institutions;
provider hours and location
telephone access
provider/patient ratios
pediatric medical specialty
pediatric surgical subspecialty provider panels.
Require managed care organizations to include as primary care providers pediatricians that are accepting new patients and to provide a directory of providers so that patients may choose one.
Include language on physician qualifications, including board certification and residency completion.
Assure that providers and patients have a range of referral options within reasonable proximity to their location (e.g. 30 mile radius).
Give special consideration to the inclusion of historical Medicaid providers.
VIII. Financing and Reimbursement The RFP/contract should:
Describe any risk adjustments to the plan. Describe what can or must be passed on to the provider e.g. performance incentives for providing preventive care.
Ensure that physicians are reimbursed in a timely fashion.
Describe the mechanism for reimbursing the time and effort expended by primary care providers or case managers in providing care coordination services for children with special health care needs.
Describe who has responsibility for collecting co-payments and/or premiums, the provider or the health plan.
IX. Consumer Information The RFP/ contract should:
Specify steps managed care organization should take to help members make informed decisions about their health care by providing them with appropriate information (e.g. language translation services, new member orientation/education, guidance/telephone assistance to determine when to use the emergency room.)
Establish a consumer “report card” that will allow individuals to compare ratings of consumer satisfaction and quality of care for Managed Care Plans available to Enrollees of the State Medical Assistance Program. The report card should include information concerning each plan’s rate of success in:
meeting childhood immunization schedules;
providing pediatric and prenatal preventive care;
other measures of treatment for chronic and acute medical conditions in pregnancy and childhood;
timely access to appropriate care by Enrollees of the State Medical Assistance Program.
X. Quality Assurance The RFP/contract should:
Specify measures that assess how well the care delivered by the managed care plans to Medicaid patients is achieving the results that it should (i.e. that the health plan responds to the needs of those who are ill and those who are well).
Specify how managed care organizations can assess whether care is available to Medicaid members when they need it and in a timely and convenient manner.
Require managed care organizations to establish and describe formal and informal complaints/grievance procedures for patients and providers.
Encourage managed care organizations to seek accreditation by National Commission on Quality Assurance (NCQA).
Require plans to conduct satisfaction surveys that will provide information about whether a health plan is able to satisfy the diverse needs of its members, including a disenrollment survey.
Describe data collection and reporting requirements of managed care plans. These should include, but not be limited to:
number of visits to pediatricians, family physicians, and other health care providers as a way to assess general access to care for Medicaid children
number of children receiving EPSDT screens
immunization rates.
Specify how providers will be evaluated (e.g. outcomes of care, immunization rates) and how plan will educate provider accordingly.

Sources:
National Association of Child Advocates, Medicaid Managed Care: An Advocate’s Guide for Protecting Children. 1996. Washington, DC: National Association of Child Advocates.

George Washington University Center for Health Policy Research. Negotiating the New Health Care System: A Nationwide Study of Medicaid Managed Care Contracts, 1997.