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Chapter Four
Development of Successful IAAs and Promising
Practices
With the increasing cost of health care
and tighter state budgets, states are examining
ways to offer health care services with decreasing
resources. It is more important than ever to
maintain the necessary services for pregnant
women, children and adolescents by using the
expertise, creativity and resources of both
Medicaid and Title V in joint program planning
and development.
-- "Working Together – The Relationship
Between MCH Title V and Medicaid"
2005
AMCHP Factsheet
A. Summary of Key Goals and Components
B. A "Model" Interagency Agreement
C. Promising Practices and Lessons
Learned
A.
Summary of Key Goals and Components
The IAAs in the previous chapter present an
array of creative working arrangements between
State agencies that often have varying responsibilities
but ultimately the same goal: ensuring appropriate
and cost-effective services to some of their
most vulnerable populations. These IAAs represent
the work and best thinking of many individuals
across the State who have collaborated to problem-solve
issues that have arisen over the years.
Obviously, the needs and the working relationships
between agencies differ widely from State to
State; similarly, the States themselves vary
in racial, ethnic, and economic diversity. It
is not surprising, then, that each State’s
IAA is truly distinct and uniquely addresses
the concerns and needs of the local population.
As such, it is not possible to point to any
one State document and say that it could serve
as a template for other States to use as a model.
A pre-existing IAA that completely satisfies
the needs of one State and population may not
work simply transposed to another location and
group of partners and beneficiaries.
However, despite the differences found in the
IAAs, the documents do address many
of the same basic needs and goals of the Title
V and Title XIX agencies. The States themselves
speak most clearly in outlining what those goals
are: from the most overarching objective of
improving the health of women, pregnant women,
infants, children, and adolescents to detailed
plans for increasing coordination and strengthening
cooperative relationships between agencies.
With these common goals in mind, it is possible
to survey the IAAs collected and the guiding
framework provided by Medicaid regulations to
come up with a "model" document that speaks
to both goals and regulations. Despite its generalized
format, this model document cannot serve as
a simple "off-the-shelf" template for States
in amending current or developing new IAAs,
but rather can serve as a guide as to methodologies
and formats that have proven successful in real-life
settings and thus represents the best work of
Title V and Title XIX staff across the country.
B.
A "Model" Interagency Agreement
There are many caveats that must be addressed
before presenting a model document such as this.
First, this is only a general guideline of components
that have been observed to work in current IAAs.
A model template cannot address every need that
arises, but can only provide a framework into
which specific details can be placed that in
turn will address such needs. For the model
to be useful, it requires the commitment of
knowledgeable individuals to take its skeleton
and flesh it out with content relevant to their
State’s needs. As such, this model IAA
can serve as a technical assistance tool amidst
a whole toolkit of resources (many of which
are outlined in this publication) in crafting
IAAs that will serve as aids in strengthening
partnerships between Title V and Title XIX agencies.
This model follows the framework set forth
in Federal Medicaid regulations [42 CFR 431.615(c)]
as a logical way to summarize the contents of
successful IAAs. This does not imply that each
State’s IAA should also follow this structure;
the organization of each IAA must follow the
needs and priorities of the State for it to
be useful as a coordination tool.
Each section of this model generally follows
a basic structure:
• A summary of the respective
IAA components. This section explains
why each component is important and how it is
incorporated into current IAAs.
• An "additional information" section.
This section includes supplemental factors that
may be considered when drafting new IAAs.
• A "model template." This
template is a "bare bones" example of how each
section of the IAA could be written. It consists
of "fill-in-the-blank" sections (highlighted
with <<color and
angled brackets>>) that allow for
customizing the language to a specific State.
• Example(s). The
examples are taken from IAAs that can serve
as models. Some examples (and model templates)
are composites of currently successful IAAs;
the original IAA is cited when used.
The model template does not specifically treat
the overall format of a successful IAA. For
example, as noted in Chapter Two about half
of the States have developed a single IAA, while
the other half rely on a series of IAAs to address
Title V and Title XIX coordination. Because
the needs of the States – and indeed the
States themselves – are so varied, the
model presented below can only serve as a general
technical assistance tool.
Title and Author
At the most fundamental level, the IAA is a
contract between agencies or divisions within
State agencies. As such, it is a legal document
of record and should contain some basic identifying
information such as a title that details the
type of agreement and the agreeing parties.
Additional information that may be useful
to include:
- The State in which the agreement is to
take effect in (a surprising number of IAAs
lack this key piece of information, which
had to be inferred from accompanying documentation).
- The agency that initiated or issued the
document (or if it is a joint product), can
also be useful as an identifier.
(a) Model Template for Title and
Author
Title. "<<Type
of Agreement>> between <<State
Agency/Division 1>> and <<State
Agency/Division 2>>."
Author. "This document has been authored
by <<Authoring
Agency/Division>>."
or "This document has been [jointly] developed
and agreed upon by <<Agency/Division
1>> and <<Agency/Division
2>>."
(b) Example(s)
"INTERAGENCY AGREEMENT between the <<Insert
State name>> Division of
Medical Assistance and the <<Insert
State name>> Division of
Public Health, Department of Health and
Human Services. This IAA has been developed
and mutually agreed upon by the above
agencies." |
(1) Effective Date
Of the IAAs analyzed, roughly half include
a specific effective date and about half specify
that the document will take effect upon signature.
Such language sometimes occurs at the beginning
of the document and sometimes in the concluding
paragraph, immediately followed by signatures
from the agency representatives involved. To
follow the structure set in Chapter Two, the
effective date is listed here, but this convention
is strictly for consistency.
Additional information that may be useful
to include:
- An original issuance date and an amended
date, if applicable.
- An effective date of signature and a specific
date, with language such as "this document
is to become effective on whichever date occurs
first," if applicable.
(a) Model Template for Effective
Date
"This <<Document>>
will go into effect on the date
this Agreement is signed/executed/ issued
by authorized representatives of each
agency. The original date for this <<Document>>
was <<Date>>."
(b) Example(s)
"This IAA and the policies established
herein will go into effect on the date
this IAA is signed or on January 1, 2006,
whichever occurs later. The original issuance
date for this IAA was January 1, 2000,
with addenda approved on January 1, 2002
and June 30, 2003." |
(2) Duration
The duration of the IAA, when stated, is most
often linked to the effective date. The duration
may consist of a defined period (usually 1,
3, or 5 years) from a specific date or a date
range (from effective date to ending date).
Conversely, it may be set to allow the IAA to
remain effective in perpetuity or until cancelled
or modified by one or both parties.
Additional information that may be useful
to include:
- Language that requires periodic review
(see Section 16: Review): often States
specify that unless modifications are required
based on this periodic review, the IAA may
automatically renew at the end of each year.
- Language that details how agencies must
notify each other if they require modifications
to or cancellation of the IAA and the timeframe
in which they must make notification.
(a) Model Template for Duration
"This IAA is to remain in effect for
<<Duration
or Ending Date or Date Range>>
unless canceled or amended or renewed
by mutual agreement with <<Amount
of Time>> days notice by
one party to the other party."
(b) Example(s)
- "From July 1, 2004 – June 30,
2005."
- "This IAA is to remain in effect
for 1 year from the effective date of
signature or until terminated or modified.
Either party may terminate this Agreement
through written notice to the other,
at least 30 days prior to the effective
date of such termination."
- "This contract supersedes and prior
agreement between the parties and shall
continue in effect for a period of 1
year from the date hereof. It shall
remain effective for successive periods
of 1 year each thereafter unless during
any such period, this contract shall
be canceled in accordance with the terms
contained herein. This contract may
be terminated, when either party requests
termination, by giving 90 days written
notice to the other party of its intention
to terminate" (Michigan IAA).
|
(3) Type of Agreement
Most often, the type of agreement is stated
in the title with little, if any, rationale
as to why that specific method of agreement
or contract is employed. The term "interagency
agreements" typically is used to denote agreements
between separate agencies, while the term "intra-agency
agreement" is used to denote that both the Title
V and Title XIX agencies are housed within the
same agency. However, with other terms such
as Memorandum of Understanding or Agreement,
Joint Power Agreement, or Standard Business
Agreement, there does not appear to be a recognizable
pattern to the type of agreement employed. It
has been surmised that State-specific procedures
or requirements set forth the type of agreement
that must be entered into by State agencies.
However, if there are specific reasons for
one manner of agreement to be chosen over another,
it may be revealing to list those reasons in
the document itself. This, while by no means
necessary for the purposes of the agreement,
would shed further light on the working relationship
between agencies.
(4) Agencies
Involved
As a contract between agencies, it is important
to list the involved parties at the beginning.
Often this can be done in the title of the document,
but most IAAs also begin the narrative by listing
the agencies involved. While most often this
consists of the Title V and the Title XIX agencies,
other agencies such as Title XXI, WIC, and local
provider groups can also be listed.
Additional information that may be useful
to include:
- The role that each agency plays in the
State, such as whether the agency is Title
V or Title XIX.
- Abbreviations used for each agency throughout
the document.
(a) Model Template for Agencies
Involved
"This agreement has been made and entered
into by and between <<Agency
1 Name>> (<<Title
V or Title XIX Agency>>,
hereafter referred to as <<Abbreviation>>)
and <<Agency
2 Name>> (<<Title
V or Title XIX Agency>>,
hereafter referred to as <<Abbreviation>>)"…
(b) Example(s)
"This agreement has been made and entered
into this 1st day of July 2003, by and
between the NORTH DAKOTA
DEPARTMENT OF HEALTH (HEALTH), the NORTH
DAKOTA DEPARTMENT OF HUMAN SERVICES (DHS),
the PRIMARY CARE OFFICE (PCO), and the
PRIMARY CARE ASSOCIATION (PCA) to define
the responsibilities of the parties hereto…"
(North Dakota Cooperative Agreement). |
(5) Authority Cited
States can specify the relevant State and Federal
authority (both statutory and regulatory) for
entering into the IAA as well as more overarching
provisions that address services and activities
being agreed to. This documentation can then
be referenced if at any point in the future
either party needs to address disputes in activities
that may be beyond legal requirements.
As summarized in Chapter Two, most IAAs cite
specific legislative or regulatory Medicaid
Federal law, the most often cited being:
- SSA §1902(a)(11) and related sections.
- 42 CFR 431.615.
Additional information that may be useful
to include:
- "Whereas" statements: the authorities cited
can be included in a series of "whereas" statements,
following the example of many States (and
to mirror the style many States have adopted
for Section 7: Responsibilities).
- Specific programmatic requirements: in
addition to the specific statutory and regulatory
citation, it may also be beneficial to list
the specific programmatic requirements that
the authority speaks to. This helps provide
the IAA with a sense of purpose rather than
simply being a list of State and Federal requirements.
(a) Model Template for Authority
Cited
"Whereas, <<Federal
Authority Citation>> requires
<<Specific
Requirement(s)>> and <<State
Authority Citation>> requires
<<Specific
Requirement(s)>> and <<Local
or Program-Specific Authority Citation>>
requires <<Specific
Requirement(s)>>"…
(b) Example(s)
"Federal laws and regulations mandate
cooperation between State agencies responsible
for the administration and/or supervision
of both Title V and Title XIX of the SSA.
The following specific sections delineate
the authority and intent of this Agreement:
Legislative. Whereas (i) Title XIX of
the SSA [SSA §1902(a)(11)(A)] provides
for entering into cooperative agreements
with the State agencies responsible for
administering and/or supervising the administration
of services to ensure maximum utilization
of such services. Section 1902(a)(11)(B)
requires provision of appropriate reimbursement
to any Title funded project by Title XIX
for services and care provided to Medicaid
consumers; and (ii) Title V of the SSA
[§505(5)(F)] requires…
Regulatory. Whereas (i) 42 CFR 431.615
requires that the State Title XIX plan
include written cooperative agreements
with the State health agencies and Title
V grantees to ensure that Title V recipients
eligible for Medicaid receive services
with particular emphasis on EPSDT services…"
(Kansas IAA). |
(6) Objectives
Objectives can be anywhere along the spectrum
of extremely general to greatly detailed. Two
of the main objectives often listed in current
IAAs are (1) to define the responsibilities
of each respective party and (2) to satisfy
the statutory and regulative requirements set
forth in Section 5: Authority Cited
(see above). The more comprehensive documents
usually list one or more overarching goals followed
by more specific, measurable goals. Common objectives
are listed in Chapter Three, but can be summarized
under the following categories:
- General and Coordination.
- Programmatic and Local Relationship Building.
- Identification, Outreach, and Referral.
- Reimbursement and Financial.
- Data Sharing.
Additional information that may be useful
to include:
- Categories: States that organize their
objectives by category (such as the ones above)
carry these categories through the entire
narrative (e.g., Services Provided by Agency,
Cooperative Relationships, etc.) so that a
consistent structure is maintained.
- Activities: many States briefly list planned
activities to achieve each objective. These
activities are then discussed in detail in
the rest of the document.
- Measurable goals: some States provide measurable
goals within their objectives.
(a) Model Template for Objectives
"This IAA is entered into for the purpose
of <<Overarching
Objective>>. The implementation
of this Agreement shall be guided by the
following objectives: <<Specific
Objectives, often organized by category>>."
(b) Example(s)
- This MOU has been established "to
improve public health service delivery
and public health outcomes for low-income
populations through the sharing of available
Medicaid, HUSKY Plan Part B, HUSKY Plus
and Title V data.
More specifically, through the implementation
of the addenda to this MOU pertaining
to specific data exchanges, the purposes
are as follows:
- To increase coordination between
the Department of Public Health and
the Department of Social Services for
programs funded by the MCH Block Grant.
- To increase coordination in the administration
of programs that are designed to improve
the health of children and adults in
Connecticut.
- To increase cooperation in reviewing
and implementing fiscal policies that
affect populations served by DPH and
DSS and providers of services.
- To implement a process that allows
for joint access to critical Medicaid
and public health data without duplication
of effort.
- To promote long-range planning as
it relates to data sharing." (Connecticut
Memorandum of Understanding #2).
- "An agreement is established…
to continue to implement a State-wide
program [the Well Child Outreach Project]
designed to promote the health of children,
adolescents, and pregnant women. The
Department of Health’s goal is
to reduce the inadequate prenatal care
rate to no more than 10% by year 2000.
The Division of Medical Services’
goal is to screen 80% of all Medicaid-eligible
children each year." (Missouri IAA #2).
|
(7) Responsibilities
Defining specific agency responsibilities often
begins by identifying which agency has oversight
in administering the respective Title V, Title
XIX, and other relevant programs. A summary
of responsibilities or specific tasks can follow
to further clarify each agency’s role
in the State.
These responsibilities can be contained in
a series of "whereas" paragraphs; this format
makes this section clearly identifiable and
"sets the stage" for the rest of the agreement.
Sometimes, this format is carry forwarded from
Section 5: Authority Cited (see above). While
this is often an editorial decision, it can
help to provide a strong rationale and introduction
to the rest of the document.
Responsibilities can be broken down into
categories, such as:
- The Title V agency’s responsibilities.
- The Title XIX agency’s responsibilities.
- Other agencies’ responsibilities.
- Joint or shared responsibilities.
Additional information that may be useful to
include:
- A summary sentence that follows the listing
of agency responsibilities and serves to introduce
the discussion of services to be provided
in support of these responsibilities.
- A specific contact or position within each
agency who is responsible for making sure
that responsibilities are being met.
(a) Model Template for Responsibilities
"Whereas <<Agency
1>> is the State agency responsible
for administering <<Program
1>> and has further responsibility
for <<Agency
1’s Specific Responsibilities>>;
<<Agency 2>>
is the State agency responsible for administering
<<Program
2>> and has further responsibility
for <<Agency
2’s Specific Responsibilities>>;
etc….
Now, therefore, be it resolved that <<Agency
1, Agency 2, etc.>> agree
to perform the following in connection
with this agreement"…
(b) Example(s)
"Whereas the Department of Health is
responsible for administering the Title
V program and has further responsibility
for the following services: child health
services; family planning services; dental
health; genetic services; WIC services…
And whereas the Department of Human Services
is responsible for administering the Title
XIX program and has further responsibility
for all health planning issues in the
State…
And whereas the Title V and XIX agencies
are jointly charged with direct responsibility
to achieve…
Now, therefore, be it resolved that the
Department of Health and the Department
of Human Services agree to the following
services in order to fulfill their responsibilities
as set forth above." |
(8) Services
Provided by Agency
There can be no single model that details services
to be provided by each agency (Title V, Title
XIX, and other relevant agencies and programs)
in the IAA, since there is such wide variety
of format and range of activities in current
agreements. Overall, States have divided tasks
to address their specific needs and working
arrangements; some States provide great detail
in documenting their respective services and
responsibilities while other States summarize
their division of responsibilities in a couple
of paragraphs. However, there are several examples
of services provided by agency that have appeared
in IAAs across the country. These may be useful
in drafting future agreements.
Model 1
In the most basic approach to delineating services,
each agency’s services are listed separately
and are followed by a list of joint responsibilities
(see below). This is the approach that most
States currently use in their IAAs.
Model 2
An alternate approach to this straight-forward
model would be to organize services according
to type, similar to those presented in Section
6: Objectives. In this way, the services
can be traced back directly to the objective
that they are to support. The categories could
still be as follows:
- General and Coordination.
- Programmatic and Local Relationship Building.
- Identification, Outreach, and Referral.
- Reimbursement and Financial.
- Data Sharing.
Other categories such as administration and
policy, confidentiality, contract monitoring,
training and technical assistance, etc. could
be used to fit the specific needs of the State.
Model 3
A third approach, currently in use by some States,
would be to organize services by the State program
under which they fall. While many of the activities
under each program have a tendency to be repetitive,
this model can provide a high degree of detail
for each program.
Model 4
Finally, many States currently issue separate
IAAs for specific programs or sets of activities.
By focusing individual documents on such specific
topics, it may be easier to go into greater
detail and delineation of responsibility than
if one single IAA were to be issued.
Obviously, there are additional methods of
organizing agency responsibilities; these are
initial suggestions to generate thought when
drafting new documents. The diversity among
the activities themselves is even greater. States
assign roles to agencies as the needs of their
population demand. However, a listing of specific
activities that appear repeatedly in current
IAAs is presented in Chapter Three.
(a) Model Templates for Services
Provided by Agency
Model 1 "The agency that administers
Title V has the responsibility to:
- <<Responsibility
1>>
- <<Responsibility
2>>
The agency that administers Title XIX has
the responsibility to:
- <<Responsibility
1>>
- <<Responsibility
2>>
Other/local agencies have the responsibility
to:
- <<Responsibility
1>>
- <<Responsibility
2>>"
Model 2
"The agency that administers Title V has
the responsibility to:
General and Coordination.
- <<Responsibility
1>>
- <<Responsibility
2>>
Programmatic and Local Relationship
Building.
- <<Responsibility
1>>
- <<Responsibility
2>>
Identification, Outreach, and Referral.
- <<Responsibility
1>>
- <<Responsibility
2>>
Reimbursement and Financial.
- <<Responsibility
1>>
- <<Responsibility
2>>
Data Sharing.
- <<Responsibility
1>>
- <<Responsibility
2>>
The agency that administers Title XIX
has the responsibility to…"
Model 3
"Program 1: <<Program
Name>>
- The agency that administers Title
V has the responsibility to…
- The agency that administers Title
XIX has the responsibility to…
Program 2: <<Program
Name>>
- The agency that administers Title
V has the responsibility to…
- The agency that administers Title
XIX has the responsibility to…"
Model 4
If a State chooses to use separate IAAs
for specific programs or activities, such
IAAs can be organized by any of the models
above. The decision to issue separate
agreements can give the State the flexibility
to provide more detail about each program
without any one document becoming overly
long.
(b) Example(s)
Model 1
See the Virginia IAA for services organized
by agency.
Model 2
See the Indiana MOU for services organized
by topic.
See the Iowa Cooperative Agreement #2
for services organized by objective.
Model 3
See the Kansas Cooperative Agreement and
the Colorado IAA #1 for services organized
by program.
Model 4
See the six Missouri Cooperative Agreements
for separate agreements based on program
and/or service. |
(9) Cooperative
Relationships
Defining on paper the cooperative relationships
between agencies is a very tricky process, since
often the aspects that make up the relationships
are mainly visible through the activities in
which they participate. In writing an IAA, it
becomes important to include language emphasizing
cooperation and collaboration into each agency’s
required activities. By specifying that the
agencies need to work collaboratively on activities
the IAA forces the process of cooperation to
occur if the activities are to be completed.
The importance of establishing and maintaining
cooperative relationships between agencies can
also be emphasized in other parts of the IAA,
including Section 13: Coordinating Plans
and Section 17: Liaison (both described
below). Consideration should be given to having
the IAAs include a provision encouraging the
State Medicaid agency to involve the Title V
agency in the planning, development and implementation
of Medicaid changes made via State Plan Amendments
and waivers.
(10) Services Provided
by Local Agencies
In the IAAs collected, the trend is to list
information that needs to be shared with local
agencies, such as data relative to children
enrolled in Medicaid and information on the
services that Medicaid offers. Similarly, it
is important to set forth the training and technical
assistance to be provided to local health agencies
by Title V and/or Title XIX staff.
If not included as part of the overall services
provided by agency, it may be beneficial to
include a section on local coordination and
services as part of new IAAs.
(a) Model Template for Services
Provided by Local Agencies
"Local Coordination and Services:
Collaboration with local agencies:
- Data and information sharing: <<List
Data>>
- Training: <<List
Training>>
- etc.
<<Local Agency Name>> has
the responsibility to:
- <<Responsibility
1>>
- <<Responsibility
2>>
(b) Example(s)
Excerpted examples of collaboration with
local agencies from the Wisconsin MOU:
"A. Encourage State, regional, and local
health department staff to participate
in any Medicaid managed care advisory
groups.
B. Provide local health departments and
WIC projects with essential information
on how the Medicaid managed care system
works, current information on Medicaid
quality of care indicators, and the current
Medicaid reimbursement.
C. Provide HMOs with information on local
health departments and WIC projects and
the services they provide.
D. Promote coordination and collaboration
between local health departments WIC Projects,
HMOs, and other Title XIX managed care
programs." |
(11) Identification
and Outreach
Identification of individuals who are potential
beneficiaries or who are not receiving Medicaid
services and outreach to these groups needs
to occur before appropriate referrals and/or
services can be provided. The structure of how
these activities will be accomplished can be
included in Section 8: Services Provided
by Agency or highlighted as a separate section
of the IAA.
Additional information that may be useful
to include:
- Follow up information on providing referrals
and/or services to individuals once identified.
- Use of proper diagnosis codes to identify
high-risk children.
- Reporting of data on outreach activities
conducted in the State.
(a) Model Template for Identification
and Outreach
"<<Agency
Name>> shall identify infants,
children, adolescents, and women who are
potentially eligible for Medicaid and/or
who have not received appropriate screenings
or services. Once identified, the agency
shall:
- Assist them in applying for such
benefits.
- Provide the appropriate referral
and/or services.
- Conduct outreach to inform the individuals
about services for which they are qualified.
<<Agency
Name>> shall also provide
additional outreach activities by:
- Informing families about Medicaid
benefits, especially EPSDT services
through a combination of oral and written
formats at venues such as health fairs,
immunization clinics, community health
services offices, physician and public
health offices, and hospitals.
- Conducting outreach (such as scheduling
appointments and reminding families
when exams are due) to ensure that families
are benefiting from Medicaid services.
- Developing brochures and other materials
for informing recipients about Medicaid
services.
- Maintaining a toll-free number that
women and families can contact and receive
information from appropriately trained
personnel who provide information and
referrals for prenatal care, family
planning, and well-child services."
(b) Example(s)
- See Kansas’ Cooperative Agreement
for an example of activities related
to identification.
- See Iowa’s IAA for an example
of a specific agreement focused on outreach.
|
(12) Reciprocal Referrals
As with identification and outreach, reciprocal
referrals are most often covered in Section
8: Services Provided by Agency. One of the challenges
is to ensure that the importance for referrals
does not become lost among a long list of activities.
(a) Model Template for Reciprocal
Referrals
"<<Agency
Name>> will establish a system
of referrals for those services not directly
rendered by the agency, but are essential
to meet the individual’s need. To
the degree possible, these referrals will
be made at the time of client contact.
Programs such as <<List
Programs>> will fall into
this category." (Adapted from Kansas’
Cooperative Agreement).
(b) Example(s)
See Nebraska’s IAA for a rationale
in establishing a system of reciprocal
referrals. |
(13) Coordinating
Plans
A discussion of the activities to coordinate
agency plans to provide appropriate Medicaid
services helps support the clear need for the
IAA in the first place. Without coordination
between agencies, there can be no successful
maintenance of the system that provides such
services. Therefore, it is important to stress
the ongoing need to have coordinated plans between
agencies. The discussion of coordination can
take place in Section 8: Services Provided by
Agency, integrated as a specific activity under
each category; likewise, coordination may also
assume its own section in the IAA or a separate
category of related activities.
Additional information that may be useful to
include:
The benefits of coordinating plans, such as:
- Preventing duplication of effort among
agency programs.
- Improving the cost effectiveness of the
health care delivery system.
- Improving the availability of services.
- Focusing services on specific population
groups or geographic areas.
- Maximizing effectiveness of service delivery.
(a) Model Template for Coordinating
Plans
"In order to secure the following benefits:
<<List Benefits>>,
<<Agency 1>>
and <<Agency
2>> jointly agree to work
collaboratively and coordinate program
activities in the following areas: …"
(b) Example(s)
"The scope of services covered under
Title XIX may impact Title V’s program
plans and budgets. Similarly, actions
of Title V may affect Medicaid provider
service requirements and the cost of services.
Therefore, each agency hereby states its
intention to coordinate plans…"
(Virginia’s IAA). |
(14) Reimbursement
The requirements set forth by States for reimbursement
are so varied and often so detailed, that it
is not logical to present a model template for
this section. However, there are many common
elements that should be considered in drafting
an IAA:
- The rate and/or total amount of reimbursement.
- Often at the current Medicaid reimbursement
rate or at the State match/share of costs
based on a fee schedule.
- Not to exceed the cost of providing
the service.
- The activities (administrative and services
provided) that are to be reimbursed.
- The documentation needed to ensure reimbursement.
- The mechanism and periodicity for filing
reimbursement claims.
- The assignment of first and primary sources
for payment and third party reimbursement.
For examples of how specific States treat reimbursement,
see Chapter Two: C(14) or the individual summary
tables in Chapter Four.
(15) Reporting Data
As with many of these sections, details of
data reporting may take the form of specific
activities to be performed by each agency or
they may be explained in a separate section
of the IAA. Since the mechanisms for reporting
data can be extremely detailed and confusing,
it may be beneficial to begin the IAA’s
section on data by explaining what the overall
goals for the process are (e.g., to improve
program administration and outcomes; develop
performance measures that rely on linked data;
gaining a better understanding of the needs
of the Medicaid population). Data can be reported
and shared through a variety of mechanisms,
including:
- Monthly, quarterly, and/or annual reports
(programmatic, agency summaries).
- Electronic access to reports through State-wide
data systems that collect programmatic information
(e.g., number of beneficiaries, number of
services provided).
- Program procedural manuals.
Issues that need to be considered in reporting
of data include:
• Security and confidentiality.
- Use of data only for specified purposes.
- Mechanisms for review and audit.
- Maintenance of records.
Additional information that may be useful
to include:
- A reminder that financial reimbursement
is tied to accurate documentation and reporting
of data.
- What activities the data will be used for
(e.g., needs assessment activities, program
planning, evaluation, determination of barriers
to enrollment and application assistance).
- The assignment of a key contact whose responsibility
is to ensure secure, accurate, and timely
transfer of data.
(a) Model Template for Reimbursement
This model is adapted from Indiana’s
MOU:
"Reporting Data:
A. Mutual Services.
- Work together to improve the State’s
capacity to integrate data, link data
files, and to utilize program data to
improve program administration and outcomes.
- Work collaboratively in the development
of performance measures that rely on
linked data as a means of better understanding
the needs of vulnerable populations
and targeting resources to them more
effectively.
- Collaborate among programs to guide
the permissible sharing and dissemination
of data for program administration,
policy development, and to carry out
the responsibilities listed in this
Agreement.
- Implement processes to ensure data
sharing requests are in compliance with
HIPAA and applicable State and federal
statutes, regulations, and guidelines.
- Assign specific program designees
to accept and coordinate all data request
from each respective agency in accordance
with individual program procedures and
protocols.
- Provide specific agreed upon program
data necessary for program monitoring
and evaluation.
B. Title V.
- Work collaboratively by providing,
in compliance with HIPAA regulations,
the necessary client data files and
vital records data to facilitate client
care administration and to permit matching
of population-based and other programmatic
data files for evaluation purposes.
- Cross-match computerized participant
files to generate lists of newly enrolled
members who are not participating in
all potential services to increase service
coordination efforts.
- Provide data through standard reports
about population-based health care assessments.
- Collaborate with Title XIX to determine
joint outcome indicators and objectives
to be
evaluated regularly.
C. Title XIX
- Work collaboratively by providing,
in compliance with HIPAA regulations,
the necessary client data files and
vital records data to facilitate client
care administration and to permit matching
of population-based and other programmatic
data files for evaluation purposes.
- Provide specified demographic data
summaries regarding populations served
by Title V programs needed to fulfill
Title V Federal reporting requirements
and to track MCH-related Healthy People
2010 Objectives.
- Make available each month to other
State agencies the names of newly certified
Medicaid beneficiaries to be used for
eligibility determination."
(b) Example(s)
- California’s IAA devotes an
entire objective to "develop and implement
data collection and reporting systems
that support assessment, surveillance,
and evaluation with respect to health
status indicators and health outcomes
among the populations served by both
programs." See the full document for
details.
- Louisiana’s Intra-Departmental
Agreement details its data requirements
in a section called "Methods of Exchange
of Information."
- South Carolina’s MOA deals
exclusively with the maintenance and
transfer of data files.
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(16) Review
While the majority of IAAs currently do not
build in an automatic process for review, the
addition of this requirement would help ensure
the document remains current and adequately
addresses the needs of the Medicaid beneficiaries.
Because it was noted that many of the IAAs were
non-specific, out-of-date, or not signed, there
should be a periodic review from each agency
to help alleviate these issues.
(a) Model Template for Review
"This agreement shall be reviewed at
least <<Periodicity
of Review>> or at the request
of either party by <<Established
Committee or Representatives of Each Agency>>
and, if necessary, amended upon mutual
agreement of the agencies involved. Amendments
shall be in writing and signed by the
authorized representative of each party
and will comprise an official component
of the document from that time forward.
This agreement may also be terminated
at this time upon notification of either
party."
(b) Example(s)
Illinois’ IAA requires both an
annual review of the entire agreement
and a periodic review of sections at the
request of either agency. |
(17) Liaison
A successful IAA needs a defined mechanism
to ensure that coordination between agencies
is maintained and that the requirements of the
agreement itself are being met. Establishing
an official liaison(s) between agencies can
help accomplish these goals.
Activities for the liaison(s) may include meeting
with the corresponding agency on a regular basis
for a variety of purposes that may include:
- Ensuring that the activities outlined in
the IAA are met.
- Continuous communication between agencies.
- Coordinating areas of shared responsibility
between agencies.
- Updating each agency on developments as
they arise.
The assignment of a liaison is often discussed
in the context of overall program coordination
(see Section 13) and establishing cooperative
relationships between agencies (see Section
9). The role of the liaison can be defined in
either of these sections or as a separate section.
(a) Model Template for Liaison
"Meetings between agencies will take
place at least <<Periodicity
of Meeting>> to review progress
toward meeting mutual objectives. <<Position
or Name of Liaison Staff>>
from <<Agency
1>> and the <<Position
or Name of Liaison Staff>>
from <<Agency
2>> shall jointly be responsible
for serving as agency liaison for the
purposes of implementing this agreement
and ensuring that ongoing communication
and coordination take place between the
represented agencies.
(b) Example(s)
- Idaho’s Cooperative Agreement
summarizes the role of liaison in general
terms.
- Georgia’s Interagency Master
Agreement assigns the role of liaison
in terms of an overarching committee
for review of progress in the implementation
of the agreement.
|
(18) Evaluation
The evaluation of the effectiveness of the
agreement and the corresponding collaboration
between agencies should be integrated into the
IAA itself along with measures of review and
liaison. Most often, this evaluation can take
place by committee that includes the designated
liaisons from Section 17.
(a) Model Template for Evaluation
"The agencies that administer Title V
and Title XIX will jointly establish an
advisory committee for the following purposes:
- To monitor implementation of this
Agreement.
- To coordinate services offered.
- To review and update its provisions
as necessary.
- To ensure that all Medicaid-eligible
persons in need of Medicaid services
receive them.
- To ensure that appropriate fiscal
documentation is ongoing.
- To ensure that collaboration between
agencies and coordination of joint activities
is ongoing.
- <<Additional
Goals>>.
The committee will meet every <<Periodicity
of Meeting>> when either
agency requests that a formal meeting
be conducted. The committee will be comprised
of <<List
Committee Members>>.
(b) Example(s)
Kansas’ Cooperative Agreement and
Missouri’s IAAs are extremely detailed
in regards to evaluation and form the
basis for the model template above. |
(19) General Contract Provisions
The general contract provisions are usually
formulaic and based on both State and Federal
regulations. As stated in Chapter Two, these
provisions may consist of the following:
- Amendment/modification of agreement.
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- Provisions for lack of funds.
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- Confidentiality/HIPAA compliance.
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- Systems for maintenance of records.
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- Nondiscrimination clauses.
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- Dispute resolution mechanisms.
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- Drug-free workplace provisions.
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- Regulations regarding subcontracts.
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- Failure to satisfy scope of work (SOW).
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- Indemnification/liability clauses.
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- Grounds for termination of agreement.
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Additional information that may be useful
to include:
A section on definitions/terms and acronyms
used in the document. Many of the IAAs collected
(CO, HI, MO, NC, OH, and UT) contained a glossary
of terms. This information proved valuable in
wading through the abundance of agency names,
State programs, etc. often encountered in such
documents.
Georgia’s Interagency Master Agreement,
Ohio’s IAA, and Kansas’ Cooperative
Agreement all contain detailed sections on general
contract provisions that can be used as models.
C.
Promising Practices and Lessons Learned
As can be seen, the amount and variety of information
within the State IAAs is staggering. The ways
that States have developed and use these documents
is likewise as varied as their individual needs.
However, one fact cuts across all the information
presented above: States find their IAAs to be
most successful when these documents are developed
together and clearly delineate each agency’s
responsibilities in a measurable manner and
in a stated time frame. After contacting many
of the States who provided IAAs for this study,
several other "promising practices" become clear.
First, in all cases where States feel that
they have IAAs that address each agency’s
needs, there is a great willingness to work
together on a personal level. Staff from each
agency have long-standing relationships with
their counterparts across the table. In each
case, there is a personal dedication to making
sure that the IAAs are in place and that the
agencies are well aware of their details. Often
the process of writing or updating the IAAs
together serves as good practice in bringing
staff from agencies together. When the documents
become a shared project, the activities that
they outline often flow out of a sense of partnership.
For the documents to be useful, staff have
to know about them and have easy access to current
versions. In cases where States feel that their
IAAs are not sufficient, one of the major barriers
is simply in obtaining a current signed copy
that everyone could agree upon. This is particularly
true when there is large staff turnover. States
that felt that there could be room for improved
coordination of activities often had agency
positions that had been vacant for long periods
of time. These positions, if consistently filled,
could provide the liaison between agencies vital
to the success of the IAAs. Another issue for
staff is the simple ability to find the IAAs
in a centralized location. Some staff interviewed
said that they have multiple copies of their
State IAAs in their desk, but were not exactly
sure which one is most recent.
The need to be well acquainted with the IAAs
also becomes evident. In States that are pleased
with coordination between agencies, staff seem
familiar with the purpose and details of their
IAAs and how they serve to provide an outline
for working together. Conversely, staff who
feel that coordination between agencies could
be improved often had only a cursory understanding
of their State’s IAA. Of course, IAAs
that are clear and engaging and that address
specific issues and responsibilities have a
greater chance of being read and referred to.
One State employee said that she never read
the IAA because it was "too legal to be understood."
Overall, whether the Title V and Title XIX
agencies are housed within the same State department
or division (and whether their IAAs are thus
interagency or intra-agency agreements), seems
to have little impact on how agency staff feel
they coordinate activities together. What becomes
evident is that the IAAs that present detailed
lists of services and responsibilities are the
ones that seem to be most successful. While
some States simply list mutually agreed upon
activities in a long list while others link
these activities to objectives and/or activity
type, the most important factor is that the
activities are spelled out so that there is
no question as to responsibility. With the basics
mapped out, staff are able to focus on innovative
ways to collaborate.
Successful IAAs most often present each agency’s
responsibilities separately and then their shared
responsibilities. These documents likewise present
the services to be provided by each agency in
a similar fashion. Whether a State has a single
IAA to address coordinated activities broadly
or several smaller IAAs that focus on specific
programs, again the important message is that
the documents are clear and specific. One Title
XIX contact, while reading the IAA over the
phone, said that he didn’t realize all
the services that his State Title V office actually
offered.
There seems to be a fine line between the right
amount of detail in the various IAAs and "just
too much information." Many States have found
that while a large amount of detail regarding
specific issues (e.g., documentation and reimbursement)
is necessary, a long "laundry list" actually
is counter productive in facilitating meaningful
collaboration. There is a balance that constantly
has to be met between making the IAAs detailed
enough to be useful but not making them so detailed
that no one can agree upon them to begin with
and then no one is familiar with them enough
that they are useful. There is a sense that
for IAAs to be successful, they need to be specific
to State Title V and Medicaid offices rather
than just a modified basic provider agreement.
A common concern among State agencies is ensuring
that the agreed upon responsibilities in the
IAAs actually get carried out consistently throughout
the State. Often the list of activities, specifically
those to be carried out locally, is ambitious;
however, it sometimes is difficult to track
that the activities are indeed carried out at
this level. Many States feel that their IAAs
would benefit from more specific processes to
interact with local health departments or other
Title V grantees and better ongoing communication
with the "front line."
The counter balance to this desire is the constant
fear of developing too many processes and reporting
mechanisms that simply serve to "bog down" already
busy agency staff. The fear of too much paperwork
was evident in conversations with States. Successful
IAAs, thus, need to find the right balance of
communication and reporting required in order
to remain useful tools for the agencies that
developed them.
The driving point of State IAAs that cannot
be emphasized enough is that they are more than
just dusty legal documents providing standard
contract language of roles and responsibilities.
The time spent developing and refining these
documents is well worth the time and effort.
The linkages that they can facilitate have the
potential to provide a more comprehensive system
of services to those who need them the most.
At their best – having been well conceived,
written, and agreed upon – and in the
hands of agency staff who understand their true
value, the IAAs can serve as an essential road
map to successful coordination.
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