Chapter Four
Development of Successful IAAs and Promising Practices

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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.

• 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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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:

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.