Thirty Questions to Ask About Managed Care and EPSDT

Executive Summary

This document lists thirty questions detailing essential elements related to EPSDT that should be included in contracts and Requests for Proposals (RFPs) between the state Medicaid agency and managed care plans. In reviewing any contract, child health advocates should look for a ?yes? to all of these questions. This list can be used in conjunction with two related question lists: Medicaid Managed Care: 20 Questions to Ask Your State and Behavioral Health: Medicaid, Managed Care and Children — More Questions to Ask.)

The following thirty questions address elements that should be included in contracts and Requests for Proposals (RFPs) between the state Medicaid agency and managed care plans. In reviewing the contract, child health advocates should look for a ?yes? to all of these questions. 
Outreach and the Provision of Information
1. Do the RFP and contract specify the responsibilities of the managed care plan, contracting providers, and the state agency for conducting outreach and informing?
2. Will each enrollee be provided information, in writing and orally, about the need for preventive care? 
3. Will each enrollee be provided information, in writing and orally, about EPSDT services? 
4. Will each enrollee be provided information, in writing and orally, about the availability of help scheduling appointments and providing transportation? 
5. Will plans be required to document when enrollees decline EPSDT services and to deem the rejection as specific to that particular service at that time (so that outreach and informing for future EPSDT services persists)? 
6. Will ?high-risk? enrollees (e.g., pregnant women and adolescents, foster children, non-users) receive targeted outreach and informing regarding EPSDT? 
7. Will the state Medicaid agency, plans and providers use appropriate means to communicate to persons who do not speak English, do not read, or who are hearing impaired or vision impaired? 
8. Do the RFP and contract clarify who has responsibility for informing enrollees of transportation assistance and arranging for or providing non-emergency transportation? 
Screening Services
9. Do the RFP and contract specify separate screening schedules for medical, vision, hearing, and dental screens and allocate responsibility for each of these screens? 

10. Do the RFP and contract specify that a medical screen must include a comprehensive physical/mental health examination and developmental history? 
11. Do the RFP and contract specify that a medical screen must include a comprehensive unclothed physical exam? 
12. Do the RFP and contract specify that a medical screen must include immunizations, as set by the CDC? 
13. Do the RFP and contract specify that a medical screen must include all necessary laboratory tests, including lead blood tests (not simply verbal risk assessment) at 12 and 24 months? 
14. Do the RFP and contract specify that a medical screen must include health education, including anticipatory guidance to the child and family? 
15. Are plans prohibited from imposing prior authorization for periodic and interperiodic screens? 
16. Are plans and providers required to make referrals for necessary follow-up treatment, to assure the timely receipt of services, and to maintain accurate health records for all screening components? 
17. Is the plan required to meet and exceed 80 percent EPSDT participation? 
18. Do the RFP and contract explain what specific steps will be taken if the plan fails to meet 80 percent EPSDT participation? 
Treatment and Provider Participation
19. Do the RFP and contract list all of the services included in 42 U.S.C. 1396d(a) and specify which services are to be provided by the plan, the state, or other contracting organizations? 
20. Are plans prohibited from placing caps on the number of services a child can receive (e.g., two psychology visits per month)? 
21. Are plans required to use the EPSDT standard (42 U.S.C. 1396d(r)(5)) for determining which services must be covered (i.e., services necessary to correct or ameliorate physical or mental conditions)? 
22. Do the RFP and contract specify that the plan must provide ?case management? services (to facilitate needed medical, education, social, and other services)? 
23. Will enrollees be informed of the availability of family planning services offered by the plan and outside of the plan? 
24. Are adolescents assured of the confidentiality of their services, to the extent permitted by law? 
25. Do the RFP and contract address the ability of minors to consent for treatment without parental consent or notification? 

26. Are payment rates adequate to enlist enough obstetrical providers, pediatric providers, and adolescent specialists so that services are available to Medicaid enrollees at least to the extent services are available to the general population in the geographic area? 
27. Are plans required to coordinate services and activities with other agencies, e.g., WIC, Title V, Head Start, school-based clinics, Federally Qualified Health Centers? 
28. Do the RFP and contract require the plan to meet national professional standards of care as articulated by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, the American College of Obstetricians and Gynecologists, the American Medical Association Guidelines for Adolescent Preventive Screening, and the American Academy of Child and Adolescent Psychiatry?s Work Group on Quality Issues? 
Reporting Requirements
29. Will plans and providers be required to report uniform, EPSDT-specific encounter data sufficient to complete the HCFA Form-416? 
30. Will information on EPSDT performance be made publicly available? 

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