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Chapter Three
Analysis of State Title V / Title XIX
Interagency Agreements
The updated [State MCH-Medicaid Coordination
of Title V and Title XIX Interagency Agreements]
publication will provide summaries of individual
State IAA between State Medicaid and MCH programs
and will highlight programs with successful
partnerships.
-- Peter C. van Dyck, M.D., M.P.H.
Associate Administrator for MCH
From MCHB’s call for State IAAs
A. Documents Reviewed
B. Methodology: Format of the State
IAA Tables
C. Analysis and Findings
A.
Documents Reviewed
A call for State Title V/Title XIX IAAs was
issued to MCH and CSHCN directors by the Maternal
and Child Health Bureau in the spring of 2004
for the purpose of updating this publication.
Thirty-six States from across the country responded
to the request, providing a substantial body
of material to review. From these responses,
47 IAAs were collected and analyzed. Additional
material was also gathered from cover letters,
e-mails, and follow-up phone calls, mostly explanatory
in nature about the process of IAA development.
One State (Texas) provided details on the ways
its respective agencies collaborate in the absence
of a formal agreement.
This analysis, therefore, is based on the review
of IAAs and supplemental information from the
following States (Chapter Five contains
summary tables of these State IAAs):
Alabama (AL) |
Illinois (IL) |
Mississippi (MS) |
Oregon (OR) |
Arizona (AZ) |
Indiana (IN) |
Missouri (MO) |
Rhode Island (RI) |
California (CA) |
Iowa (IA) |
Nebraska (NE) |
South Carolina (SC) |
Colorado (CO) |
Kansas (KS) |
New Mexico (NM) |
South Dakota (SD) |
Connecticut (CT) |
Kentucky (KY) |
New York (NY) |
Utah (UT) |
Florida (FL) |
Louisiana (LA) |
North Carolina (NC) |
Virginia (VA) |
Georgia (GA) |
Maryland (MD) |
North Dakota (ND) |
Washington (WA) |
Hawaii (HI) |
Michigan (MI) |
Ohio (OH) |
Wisconsin (WI) |
Idaho (ID) |
Minnesota (MN) |
Oklahoma (OK) |
|
The States surveyed represent wide geographic
diversity – ranging from the East Coast
to the
Midwest to the Pacific Coast to the South –
as well as great differences in size and population
density. While not every IAA of each State in
the country was collected and analyzed, the
group
surveyed represents a wide variety of racial,
ethnic, and economic diversity among its respective
populations. Of the States surveyed, 2 were
from Region I (CT and RI), 1 from Region II
(NY),
2 from Region III (MD, VA), 7 from Region IV
(AL, FL, GA, KY, MS, NC, SC), 6 from Region
V (IL, IN, MI, MN, OH, WI), 4 from Region VI
(LA, NM, OK, TX), 4 from Region VII (IA, KS,
MO, NE), 4 from Region VIII (CO, ND, SD, UT),
3 from Region IX (AZ, CA, HI), and 3 from
Region X (ID, OR, WA).
While the documents provide a great deal of
data to review, there are certain limitations
imposed by the scope of material. First, many
of the documents did not contain specific expiration
dates, but rather stated that they would remain
in effect until mutually revised or cancelled.
There is the possibility, therefore, that these
documents may have been or soon will be superceded
by newer agreements. Further, many of the IAAs
were unsigned and/or marked “draft,”
so there remains some uncertainty about their
authority. (Despite this, it appears from the
accompanying documentation and conversations
with the States involved that most of these
documents remained the basis for coordination
among agencies.) A number of other documents
were submitted with end dates that have since
passed, so those specific IAAs may have also
been superceded. However, from documentation
accompanying these agreements, it was evident
that in most (if not all) of these cases, the
State agencies were planning on the continued
use of the IAA with only a change of end date
and slight (if any) modification of content.
This report, thus, provides an analysis of
a substantial sampling of IAAs from across the
country. There are other IAAs, either in current
use or in process, that despite continued collection
efforts could not be included in the review.
As such, the material collected does not represent
the entire range of State coordination agreements,
but rather a strong, demonstrative group to
base conclusions upon.
The IAAs differ greatly in format, length,
and level of detail. Some IAAs are boilerplate
agreements with the names of each agency and
their responsibilities written in, while others
are clearly consensus documents, the result
of many hours of focused planning and negotiation.
The documents range from 3 to over 50 pages
with many averaging around 10-12 pages. Some
documents are a simple statement that the Title
V and Title XIX agencies should work together
in ways to be mutually determined, while others
rigorously outline objectives, responsibilities,
and detailed tasks, timelines, and budgets.
There are several differing format styles that
are used in the IAAs:
- About half of the States have developed
a single IAA for outlining a full range of
activities to be coordinated between their
Title V and Title XIX agencies; the remaining
States use a series of individual IAAs to
detail activities related to specific areas
of coordination, such as EPSDT, outreach,
CSHCN, confidentiality, and record keeping.
Similarly, some of the IAAs collected are
part of a larger set of State-wide agreements
that detail activities between multiple other
agencies.
- Most (42) of the IAAs are strictly between
two agencies (almost exclusively specified
as Title V and Title XIX); however, several
documents include agreements between a larger
number of State agencies, including WIC and
local provider organizations.
- The majority of the IAAs are specifically
written for the agencies involved, highlighting
their respective responsibilities and areas
for collaboration; however, several (e.g.,
AZ) IAAs
contain only standard contract provisions.
These IAAs often include addenda that dealt
with
specific areas of focus, such as identification
of beneficiaries, lead screenings, and CSHCN.
Some of these IAAs are actually a basic Medicaid
provider agreement that can also be used
for individual providers (e.g., NM).
- Many of the IAAs highlight specific activities
that require special attention (e.g., agency
coordination, referrals, outreach, and reimbursement)
in separate sections; however, an equal number
of IAAs include such activities in an overarching
list of activities to be carried out between
agencies.
- In cases where a State’s Title V
and XIX agencies are administratively housed
within the same State agency, their corresponding
agreements are often referred to as “intra-agency
agreements.”
B.
Methodology: Format of the State IAA Tables
The summary tables (provided fully in Chapter
Four) are divided into four sections for clarity,
although each IAA itself may not conform to
this format: (I) a general description of the
document; (II) a summary of the contractual
details (Sections 1-5); (III) a summary of the
agreement components that relate to CMS requirements
outlined in 42 CFR 431.615(d) (Sections 6-18);
and (IV) a listing of general contract provisions
(Section 19). Information in the summary tables
is excerpted directly from the actual IAAs,
wherever possible.
Federal Medicaid regulations provide
a logical framework to analyze the State IAAs.
Under 42 CFR 431.615(c) State plans are required
to describe the cooperative arrangements between
the relevant agencies in order to make maximum
use of services [CFR 431.615(c)(1)]; to allow
for Medicaid to utilize services listed in the
State plan that are provided by Title V grantees
[CFR 431.615(c)(2)]; and to allow the Title
V grantees be reimbursed by the State’s
Medicaid agency [CFR 431.615(c)(4)].
CMS continues in CFR 431.615(d) to describe
the actual content required, as appropriate,
in the State IAAs. The main component of the
Chapter Four summary tables follows this regulation
very closely. Thus, many of the table sections
directly address CMS requirements:
Summary Table Section:
(Section number) and description |
CMS Requirement Addressed: |
(6)
Objectives and (7) Responsibilities |
42
CFR 431.605(d)(1):
The mutual objectives and responsibilities
of each party to the arrangement. |
(8)
Services Provided by Agency |
42
CFR 431.605(d)(2):
The services each party offers and in
what circumstances. |
(9)
Cooperative Relationships |
42
CFR 431.605(d)(3):
The cooperative and collaborative relationships
at the State level. |
(10)
Services Provided by Local Agencies |
42
CFR 431.605(d)(4):
The kinds of services to be provided
by local agencies. |
(11)
Identification and Outreach |
42
CFR 431.605(d)(5)(i):
The methods for early identification
of individuals under 21 in need of medical
or remedial services. |
(12)
Reciprocal Referrals |
42
CFR 431.605(d)(5)(ii):
Methods for reciprocal referrals. |
(13)
Coordinating Plans |
42
CFR 431.605(d)(5)(iii):
Methods for coordinating plans for health
services provided or arranged for recipients. |
(14)
Reimbursement |
42
CFR 431.605(d)(5)(iv):
Methods for payment or reimbursement. |
(15)
Reporting Data |
42
CFR 431.605(d)(5)(v):
Methods for exchange of reports of services
furnished to recipients. |
(16)
Review |
42
CFR 431.605(d)(5)(vi):
Methods for periodic review and joint
planning for changes in the agreements. |
(17)
Liaison |
42
CFR 431.605(d)(5)(vii):
Methods for continuous liaison between
the parties, including designation of
State and local liaison staff. |
(18)
Evaluation |
42
CFR 431.605(d)(5)(viii):
Methods for joint evaluation of policies
that affect the cooperative work of the
parties. |
While the State IAAs follow this structure to
varying degrees (from an almost one-to-one correspondence
to a more general reliance on the Federal Code
for structural guidance), it nevertheless provides
a consistent benchmark to look at the documents
as a whole. In many cases, an IAA addresses
a topic that is similar to but not an exact
match to one of the summary table sections (and
its corresponding CMS requirement); in these
cases, the topic is reported in the table element
to which it is most closely related. Often an
IAA does not treat specific elements outlined
in 42 CFR 431.605(d). In such cases, “N/A”
(not addressed) is listed under that table element.
This does not mean that the document is lacking
in any way, merely that it does not address
that specific topic (which may be implicit or
treated in another document).
In many of the IAAs, specific activities are
addressed in separate sections to highlight
their importance (e.g., reimbursement is often
addressed in its own section). When this occurs,
the related requirements are described in that
specific table element. However, many IAAs summarize
all of their activities together. In this case,
specific table elements cross reference the
appropriate activity to its appropriate section
(e.g., in New York, a discussion of reimbursement
is integrated in a list of overall services.
Thus, the table element for reimbursement refers
back to the list of overall services: “See
Section 8, Service A7, B1.”)
C.
Analysis and Findings
A summary of the findings of the review of
State IAAs is presented in the following table,
followed by a more detailed analysis.
Analysis of the State
Interagency Agreements: Summary Based
on 47 Documents |
Contractual Details
|
1.
Effective Date:
• 42 specify an effective date (exceptions:
AZ, CT#2, FL, NY, SD)
• 40 specify a specific date/specific
“date of issuance or amendment”
• 2 specify a general “date of issuance
or amendment,” but no specific date |
2.
Duration
• 39 address the IAA’s duration (exceptions:
AL, AZ, CT#1, LA, NY, RI#1-2, ID)
• 16 denote a specific date (CO#1-2,
HI, IL, IA#1-4, KS, KY, MS, OH, OK, OR,
SC, WA) |
3.
Type of Agreement
• 12 “Cooperative Agreements”
• 11 “Interagency Agreements;” 1 “Intra-angency
Agreement”
• 5 “Memorandum of Agreements;” 7 “Memorandum
of Understandings”
• 2 “Intergovenmental Agreements”
• 6 miscellaneous (2 “Provider Contracts/Agreements,”
2 “Agreements;” 1 “Joint Powers Agreement,”
1 “Action Plan,” 1 “Standard Business
Agreement,” 1 “Master Agreement”) |
4.
Agencies Involved
• 39 are between two agencies (most
specified as Title V and Title XIX)
• 7 include additional agencies (CA,
CO, KY, MD, ND, OH, RI#2)
• 1 specifies only the Title V role
(RI#1) |
5.
Authority Cited
• 33 cite specific requirements on legislation,
often citing multiple sources
• 12 cite SSA§1902(a)(11) (CA, FL, HI,
ID, IN, IA#2, KS, LA, MD, NE, RI#1, SC)
• 20 cite 42 CFR 431.615 (CA, GA, IN,
IA#1-3, KS, LA, MD, MO#1,3-6, ND, OH,
OR, SC, UT, VA)
• 14 cite State legislation (CO#1-2,
CT#1, HI, IL#2, IA#1, KY, MN, MS, ND,
OK, OR, SD, WA) |
Analysis
Related to CMS Requirements |
6.
Objectives
• 46 contain readily identifieable objectives
• 24 list increased coordination, strengthened
relationships, and/or establishing strong
cooperative relationships (CA, CT#1-2,
IA#1-3, ID, IL#2, IN, KS, LA, MD, MN,
ND, NE, NY, OH, OK, RI#1, SC, SD, UT,
WA, WI) |
7.
Responsibilities
• 30 provide a summary of each agency’s
programmatic/administrative accountabilities(CA,
CO#1, CT#1, FL, GA, IA#1-2, ID, IL#2,
KS, KY, LA, MD, MN, MO#1,3-6, MS, ND,
NE, NY, OK, OR, RI#1-2, SD, WA, WI)
• 17 only included information on which
agency is identified as Title V and Title
XIX(AL, AZ, CO#2, CT#2, HI, IA#3-4, IL#1,
IN, MI, MO#2, NC, NM, OH, SC, UT, VA)
|
8.
Services Provided by Agency
• All 47 provide a breakdown of services
provided by agency
• 39 provide specific services provided
by each agency, and/or mutual services
(CO#1-2, CT#1-2, FL, GA, HI, ID, IL#1-2,
IN, IA#2-4, KS, KY, LA, MD, MI, MN, MO#1-6,
NE, NM, NY, NC, ND, OH, OK, RI#2, SC,
SD, UT, VA, WA)
• 5 break down services by topic/objective
(CA, MS, ND, RI#1, WI) exclusively or
in addition to services provided by agency |
9.
Cooperative Relationships
• 27 address cooperation between agencies
(CA, CO#1-2, GA, IA#1-2, ID, IL#1, IN,
KS, LA, MD, MI, MN, MO#1,4, NC, ND, NY,
OH, OK, RI#1, SD, UT, VA, WA, WI)
o 17 of these 27 address cooperation/coordination
as part of Section 8 or elsewhere
(CA, CT#2, GA, IL#1, IN, MD, MI, MO#4,
ND, NY, OH, OK, RI#1, SD, UT, VA, WA)
o 10 of these 27 address cooperation/coordination
as an indivudual section (CO#1, IA#1-2,
ID, KS, LA, MN, MO#1, NC, WI) |
10.
Services Provided by Local Agencies
• 13 address collaboration with local
agencies and services to be provided (CA,
IA#3, IL#1, KS, MI, NC, ND, NE, NY, OH,
VA, WI)
• 12 integrate engagement of local agencies
into overall division of services (Section
8), stating that plans for coordination
and services are often developed in conjunction
with community partners (CA, IA#3, IL#1,
IN, KS, MI, ND, NE, NY, OH, VA, WI) |
11.
Identification and Outreach
• 34 address outreach to various degrees
(AL, AZ, CA, CO#1, CT#2, FL, HI, IA#1-4,
ID, IL#1-2, KS, MD, MI, MN, MO#3-6, MS,
NC, NE, NM, NY, OH, RI#1, SD, UT, VA,
WA, WI)
• 17 address outreach as part of overall
division of services (AL, AZ, CT#2, FL,
HI, IA#3, IL#2, MI, MO#4-5, NM, NY, OH,
RI#1, SD, UT, WI)
• 1 focuses entirely on outreach (IA#4)
|
12.
Reciprocal Referrals
• 28 address referrals (AL, CA, CO#1,
CT#2, FL, HI, IA#1-2,4, ID, IL#2, KS,
KY, MD, MI, MN, MO#1,3, 5-6, NC, ND, NE,
NY, OH, SD, WA, WI)
• 16 incorporate referrals as part of
overall division of services (AL, CA,
CO#1, CT#2, IA#4, IL#2, KY, MD, MI, MN,
MO#5, NC, NY, OH, SD, WA) |
13.
Coordinating Plans
• 30 include plans for coordination
(CA, CO#1, CT#2, GA, IA#1-2,4, ID, IL#1,
IN, KS, KY, MD, MI, MN, MO#1-4, MS, NC,
ND, NY, OK, RI#1, SD, UT, VA, WA, WI)
|
14.
Reimbursement
• Only 8 do not cover reimbursement
topics (AZ, CO#2, CT#1-2, MN, MO#6, RI#1,
SC)
• 18 incorporate reimbursement into
overall division of services (FL, ID,
IL#1, IN, MI, MO#1-5, ND, NM, NY, OH,
OK, RI#2, SD, UT) |
15.
Reporting Data
• Only 3 do not cover data reporting
(OR, RI#1, MO#6)
• 22 address data as part of the division
of services (AL, FL, HI, IA#3-4, IL#1-2,
IN, KY, MI, MO#1-5, NM, NY, OH, OK, SD,
UT, WA) |
16.
Review
• 19 detail a plan for periodic review
of the IAA (CA, IA#2, IL#1-2, IN, KS,
KY, LA, MN, MO#1,3-5, NC, ND, OH, RI#1,
UT, WI)
• 8 incoporate a review into other sections
of the IAA (IA#2, IN, KS, KY, MO#4-5,
OH, WI) |
17.
Liaison
• 32 establish a method or individual
for liaison (CA, CO#1-2, FL, GA, IA#1-3,
ID, IL#1, IN, KS, KY, LA, MI, MN, MO#1-5,
NC, ND, NY, OH, OK, RI#2, SD, UT, VA,
WA, WI) |
18.
Evaluation
• 23 establish a system for evaluating
the effectiveness of the programs and/or
IAA (CA, IA#2, ID, IL#1-2, IN, KS, KY,
LA, MN, MO#1-6, NC, ND, OH, RI#1-2, UT,
WI)
• 12 discuss evauation as a separate
topic, outside the general division of
services (CA, IA#2, ID, IL#1, KY, LA,
MO#3-6, ND, RI#1) |
General
|
19.
General Contract Provisions
• Only 7 do not contain general contract
provisions (AL, CT#2, ID, LA, NY, RI#1-2)
• 37 contain termination of agreement
clauses, 29 lay out procedures for amendment,
26 define standards of confidentiality
in record keeping. |
Detailed Analysis
A detailed analysis of the manner in which
the State IAAs correspond to the review components
are presented in the following section. Most
often, a common trend emerges as to how States
approach each topic. These common trends are
explained and examples of States that either
greatly differ from or reflect the norm are
given.
General Document
Description
Title and Author
Many of the documents collected contain an
easy to find title, most often consisting of
the type of agreement, followed by the agencies
involved, and concluding with the scope of the
agreement. However, most of the documents do
not provide an easily identifiable author or
originating agency, which has to be inferred
by the contractual language. Many States also
do not include the State name in the title or
opening pages of the document, making it initially
difficult to identify what State is being discussed.
Document Date, Number
of Pages, and Document URL
This information has been taken from a physical
review of each document. The Web site address
for each document is given; the full electronic
text of every document surveyed is available
from http://www.mchlibrary.info/IAA.
Contractual Details
(1) Effective
Date
Of the 47 IAAs collected, only 5 do not contain
any language related to an effective date (AZ,
CT#2, FL, NY, and SD). Most of the documents
list specific dates or state that they would
take effect upon signature (e.g., MD, OH) or
upon the date of issuance (e.g., GA). In the
case where the effective date depends upon the
date of signature, the summary table lists that
date in brackets (e.g., for WA, [January 1,
2000]). Several of the IAAs list both an issuance
date and an effective date of amendment (e.g.,
AL, MI).
(2) Duration
Sixteen of the 47 IAAs collected denote specific
dates of duration (CO#1-2, HI, IL, IA#1-4, KS,
KY, MS, OH, OK, OR, SC, and WA), while 8 (AL,
AZ, CT#1, LA, NY, RI#1-2, and ID) identify no
period of duration. However, for all of these
IAAs, supporting documentation reveals that
the IAAs are currently in effect. Several of
the documents indicate that they will remain
in effect for a period of 1, 3, or 5 years from
an unspecified effective date.
Many of the IAAs specify that they will remain
in effect in perpetuity (e.g., NE) or until
cancelled (e.g., MO, NM) or modified (e.g.,
CA) by one or both parties. Several IAAs require
periodic review and unless modifications are
required, they are set to automatically renew
at the
end of each year unless written notice is provided
to request amendment or nullification of the
agreement (e.g., IN, MI).
(3) Type of Agreement
There are many permutations of the type of
agreement entered into by the various State
Title V and Title XIX agencies. Agreements between
separate State agencies are often described
as “interagency agreements” (e.g.,
CA, CO), while those housed within the same
division or department often describe themselves
as “intra-agency agreements” (e.g.,
LA). On the whole, terms used to describe the
contract vary widely from “Action Plan”
to “(Cooperative) Agreement” to
“Memorandum of Agreement/Understanding”
(MOA or MOU). In such instances, there does
not seem to be a direct correlation between
the type of agreement and the nature of the
relationship between agencies. It is likely
that the types of agreement are stock titles
used in legal agreements across the various
States or similarly that specific State regulations
require a specific form of agreement to be entered
into between parties. In a few states such as
AL and NM, the format of the IAA is specified
as a “Provider Contract” or a “Provider
Participation Agreement” that the Title
XIX agency obviously uses with other provider
contracts as well as with Title V agencies.
(4) Agencies Involved
Thirty-nine of the 47 IAAs surveyed are between
two agencies, most specified as the agencies
that administer Title V and Title XIX. Many
of the agreements, however, stated only the
agency title without clearly specifying what
its exact role is (either Title V or Title XIX).
However, in the majority of these cases, it
is fairly evident as to each agency’s
respective identity, roles, and responsibilities.
One of the documents (RI#1) lists only the participation
of the agency that administers Title V without
specifying the corresponding Title XIX agency’s
responsibilities. Several other States (CA,
CO, KY, MD, ND, OH, and RI#2) also include other
agencies (e.g., Title XXI, WIC, and local provider
organizations), assigning each specific responsibilities.
(5) Authority Cited
From the 47 documents collected, there are
a variety of sources relied upon for authority
in delineating each agency’s respective
roles and responsibilities. While each State
cites the authority that is most relevant to
their specific IAA, there are some overall trends:
- Legislative
or Regulatory Medicaid Federal Law.
Most States (33 total) cite specific
requirements in legislative or regulatory
Medicaid Federal law [either exclusively (13)
or in combination with another authority (20)].
Most often, the IAAs cite:
- SSA §1902(a)(11) or related sections
(CA, FL, HI, ID, IN, IA#2, KS, LA, MD,
NE, RI#1, and SC) and/or
- 42 CFR 431.615 (CA, GA, IN, IA#1-3,
KS, LA, MD, MO#1,3-6, ND, OH, OR, SC,
UT, and VA).
- State
Requirements.
Fourteen IAAs cite State authority
for establishing their agreements (CO#1-2,
CT#1, HI, IL#2, IA#1, KY, MN, MS, ND, OK,
OR, SD, and WA), including both State legislature
and other/previous IAAs.
- Multiple
Authorities Cited. Many
IAAs thoroughly cite a combination of Federal,
State, and other (program-specific) authorities
for the establishment of their agreements.
Only 12 of the IAAs do not refer to any overarching
authority as the basis for establishing their
agreements (AL, AZ, CT#2, IL#1, IA#3, IA#4,
MI, MO#2, NM, NY, NC, and RI#2); two (ID, RI)
cite the SSA in general, but do not give a specific
reference. One (WI) does not cite an authority
for the statutory basis for its IAA, but instead
refers to authority for specific programs such
as EPSDT and WIC.
Analysis Related
to CMS Requirements
(6) Objectives
Overall, States are highly conscientious in
providing clear sets of objectives for their
IAAs. Forty-six of the 47 documents surveyed
contain readily identifiable objectives at the
beginning of their narratives. The objectives
range in descriptiveness, from extremely direct
(Florida’s IAA states its objective “to
better serve the needs of Florida’s pregnant
women and children at risk for poor birth and
health outcomes”) to highly detailed (Ohio’s
IAA lists 13 separate objectives, detailing
numerous goals for almost all of its activities).
Often the objectives contain general statements
followed by State- or program-specific goals.
In every IAA, the goals are stated as being
mutually shared between the two (or more) agencies
involved, and the majority (24) list increased
coordination, strengthened relationships, and/or
establishing strong cooperative relationships
as part of their overall objectives.
Common objectives often include:
General and Coordination:
• To improve the health of women, pregnant
women, infants, children, and adolescents, CSHCN,
etc.
• To meet the requirements of the Social
Security Act and to comply with other applicable
State and Federal statutes, regulations, and
guidelines, including HIPAA.
• To increase coordination/collaboration
between the Title V and Title XIX (and other,
if applicable) agencies.
• To maintain clear communication between
agencies.
• To develop and implement initiatives
that address the underlying causes of preventable
diseases.
• To develop and implement standards of
care.
Programmatic and Local
Relationship Building:
• To prevent duplication, overlap, and/or
fragmentation of effort and/or services.
• To promote long-range planning.
• To strengthen relationships with local
health agencies.
• To develop and maintain local capacity
for MCH Services and to provide Medicaid information
and care coordination.
• To strengthen relationships with multi-cultural
and multi-ethnic organizations.
Identification, Outreach,
and Referral:
• To coordinate identification of infants,
children, adolescents, and women who are potentially
eligible for services.
• To provide outreach and increase public
awareness of the need for health care coverage
and services for women and children.
• To provide outreach related to the services
provided by Title V and Title XIX.
• To provide resource and referral information;
to refer the child and family to appropriate
services.
• To implement an established joint referral
process.
Reimbursement and
Financial:
• To specify the reimbursement and financial
arrangements applicable.
• To facilitate the claim for Federal
matching funds for the efficient and effective
administration of the State Plan.
• To ensure the maximum utilization of
Title XIX resources.
Data Sharing:
• To promote timely sharing of programmatic
data.
• To allow joint access to critical Medicaid
and public health data.
• To cooperate in creating linked, de-identified
data files that will be used for public health
and health care research, program evaluation,
and surveillance.
States that have issued separate IAAs addressing
specific topics (such as outreach, EPSDT services,
hotline establishment, non-emergency medical
transportation) most often include objectives
that are specific to the programs addressed.
These agreements (e.g., IA#1-4 and MO#1-6) spend
less time stating overarching goals than IAAs
that deal with Title V/Title XIX activities
as a whole.
(7) Responsibilities
States are divided when it comes to specifying
agency responsibilities. Thirty States provide
a summary of each agency’s programmatic
and/or administrative accountabilities, while
17 States do not include such a summary beyond
what agency is identified as Title V and Title
XIX.
In the documents that do include a listing
of responsibilities, a series of “whereas”
paragraphs at the beginning of the agreement
is often used to delineate specific agency responsibilities.
(e.g., “Whereas the [North Dakota] Department
of Human Services…is the state agency
responsible for administering Children’s
Special Health Services in conformity with Title
V of the SSA…” and “Whereas
the [North Dakota] Department of Health is the
state agency responsible for administering the
MCH Program…”).
Many of the responsibility statements also
include specific tasks beyond a listing of the
programs
for which an agency has oversight (e.g., “the
Georgia Department of Community Health is
responsible for all health planning issues in
the state,” and similarly, “the
Kentucky Department of
Community Based Services is responsible for
providing protective services, such as targeted
case
management and rehabilitative services”).
These “whereas” statements are
often used to “set the stage” by
introducing the objectives, services, and other
components of the IAA. These responsibilities
are often closely followed by a summary rationale
for the establishment of the agreement (e.g.,
“Now, therefore, be it resolved that the
Department of Human Services and the Department
of Health agree to perform the following in
connection with this agreement: …”).
Most of the IAAs that include responsibilities
break them out by agency, describing first what
the Title V agency’s responsibilities
are and then the corresponding Title XIX responsibilities.
However, a few States (e.g., MO and NY) list
joint or shared responsibilities. Often the
line between shared responsibilities and shared
objectives is blurred, so that it is difficult
at times to differentiate the two. Indeed, Federal
Medicaid regulation 42 CFR 431.605(d)(1) combines
objectives and goals into one requirement.
(8) Services Provided
by Agency
The primary focus of most State IAAs is the
specification of services to be provided by
each agency entering into the agreement. The
format and amount of information included by
each State varies substantially: some documents
include bulleted or numbered lists under each
agency while other States provide narratives
of various lengths to enumerate the division
of services. Often, the documents summarize
services to be supplied by both parties and
then treat the services to be provided by each
respective agency. Some IAAs (e.g., IN) break
these services down by topic, such as coordination,
confidentiality, data sharing, and reimbursement.
Other States divide this section by objective
(e.g., IA#2) or by State program (e.g., KS).
Section 8 of the State Summary Tables (listed
in Chapter Five) attempts to standardize the
reporting of these services across the States
(in numbered lists) and to present them in a
manner that is easy to summarize by State or
to compare across State, region, or IAA section.
At their best, the State IAAs present divisions
of tasks in such a way as to make such services
more than just “laundry lists” of
activities that each agency is assigned to complete.
It is obvious that across the country States
have put great thought and effort into coordinating
activities between various agencies to satisfy
(and in many cases, to go beyond) their stated
objectives.
In the most standard approach to services provided
by agency, the respective Title V agency agrees
to be the administrative unit responsible for
providing services (either through local programs
or by direct contracting with health providers)
while the Title XIX agency assumes responsibility
for providing reimbursement for such services.
Often, the two agencies further agree to a series
of mutual services or responsibilities in addition
to those tasks for which they are each responsible.
The range of activities provided by the respective
Title V, Title XIX, and other State agencies
greatly varies, in part due to the structure
of the State health system and the specific
needs of
the population served. However, there are many
activities that appear repeatedly in the IAAs.
General services that appear often in State
IAAs are outlined below (typically appearing
in more
than half of the IAAs summarized); these are
not meant to be exhaustive lists, but rather
an
overview of typical activities. Specific activities,
such as those related to identification and
outreach, referrals, coordination, reimbursement,
data, and liaison are discussed in detail in
their
corresponding sections.
Agencies
that administer Title V often have the
responsibility to:
- Provide EPSDT, family planning, immunizations,
prenatal care, early intervention, and/or
case management and related services
to those who meet eligibility requirements.
- Determine the level, intensity, frequency,
appropriateness, and service modality
of services to be provided.
- Identify and fund local health departments
and other contractors to provide the
infrastructure for health care programs.
- Use Medicaid funding to contract
for development, implementation, and
direction of services to eligible children
and mothers.
- Provide required financial and statistical
data/records to document reimbursement
for Medicaid services. Collect and maintain
appropriate records and health data
(e.g., records of covered services furnished
to eligible participants) and/or to
identify needs and to ensure that the
Medicaid agency will be able to collect
Federal matching funds.
- Refer potentially eligible children
and pregnant women to the Medicaid program
and/or assist them in applying for Medicaid.
- Inform potentially eligible families
of the availability and scope of the
EPSDT program.
- Support provider outreach; require
Title V providers to also be Medicaid
providers.
- Develop outreach materials for informing
recipients about Medicaid services.
- Maintain a toll-free number that
women and families can contact and receive
information from appropriately trained
personnel.
|
Agencies
that administer Title XIX often have the
responsibility to:
- Develop reimbursement methodologies
for the payment of MCH care services.
- Provide timely reimbursement for
the services provided by the Title V
agency, its local health departments,
or contracting providers with current
Medicaid rates and fees for all services
within the scope of Medicaid benefits
- Provide Medicaid data to the agency
that administers Title V.
- Provide case management services.
- Refer eligible children, adolescents,
and/or pregnant women to Title V providers
for EPSDT screenings and/or other Medicaid
services.
- Provide the agency that administers
Title V and/or local health departments
with a listing of EPSDT and/or other
Medicaid eligible beneficiaries and
related data.
- Provide training to Title V providers
on Medicaid services, and particularly,
Medicaid billing procedures.
- Monitor the quality of services being
provided by the Title V providers.
- Collect and analyze expenditure data
for Medicaid-covered services; develop,
implement, and monitor Medicaid provider
and contract agreements; investigate
inappropriate billing/utilization of
Medicaid reimbursement.
|
Agencies
administering Title V and Title XIX often
share responsibility to:
- Work collaboratively to improve the
health of State residents.
- Ensure that Title V, Title XIX (and
other) services are consistent with
the needs of the participants and the
programs’ objectives and requirements.
- Coordinate program initiatives to
avoid duplication of effort among agency
programs.
- Encourage referrals between various
programs.
- Develop and implement, in cooperation,
health care standards, program policies,
and pilot programs.
- Develop, in cooperation, provider
manuals, billing instructions, and provider
training.
- Develop statewide advisory groups
to oversee the implementation of care
coordination.
- Provide liaison between agencies
for interagency communication and coordination.
- Provide financial support/reimbursement
to local health agencies and other groups
and individuals engaged in the delivery
of health services to mothers and children.
- Comply with all applicable State
and Federal laws, regulations, and rules
regarding confidentiality of participant
information, ensuring that information
is disclosed only for the purpose of
activities necessary for administration
of the respective program(s) and for
audit and examination authorized by
law.
|
The majority of the State IAAs present services
in this manner, separated by the agency responsible
for their implementation. However, several documents
(CA, IA#2, IN, MD, and RI#2) further categorize
services by objective or by type of service.
For example, California lists the following
clearly defined objectives and then relates
agency activities directly to each objective:
- Objective 1: Assure and support the
provision of a comprehensive, coordinated,
and accountable health services delivery system
for all eligible pregnant women, infants,
children, and adolescents.
- Objective 2: Assure the provision of
high quality health care by organizations
and providers who meet professional practice
standards.
- Objective 3: Improve access to perinatal
and preventive health care services for low-income
women, particularly adolescents and children,
respectively, and services to CSHCN.
- Objective 4: Assure maximum utilization
of Title XIX funds by Title V contractors
and providers, including reimbursement by
Title XIX for all medically necessary services
within the Title XIX scope of benefits.
- Objective 5: Plan and support the delivery
of training and education programs for health
professionals and the community, including
beneficiaries of Title V and XIX services.
- Objective 6: 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.
- Objective 7: Improve ongoing intra
departmental communication between staff of
the two programs for information sharing,
problem solving, and policy setting (this
includes sharing of information and maintaining
regular, formal communications).
- Objective 8 : Maintain adequate Title
XIX and Title V program staff with the necessary
expertise necessary to carry out the specific
functions and responsibilities of providing
direct support in administering the Title
XIX program.
- Objective 9: Maximize utilization of
third party resources available to Title XIX
recipients.
In this IAA, each objective is followed by
a list of the Title V services to be provided
followed by a similar list of Title XIX services.
The Indiana MOU groups services provided by
agency according to type: coordination, confidentiality,
data sharing, and reimbursement. Similarly,
the Maryland cooperative agreement groups services
according to the following divisions: administration
and policy; reimbursement and contract monitoring;
confidentiality and data exchange; recipient
outreach and referral; training and technical
assistance; provider capacity; system integration;
and quality assurance activities.
Several IAAs group services by the State program
they fall under. For example, the Colorado Title
V/Title XIX IAA (CO#1) organizes its services
by the following programs: Family Planning;
Prenatal Plus; Health Care Program for Children
with Special Needs; Developmental Evaluation
Clinic Services; Immunization Program; Lead
Poisoning Prevention Program; Breast and Cervical
Cancer Program; and the Nurse Home Visitor Program.
Many of the IAAs focus specific attention on
a specific set of activities. Often, in such
cases the State issues a separate IAAs for each
program rather than combine all Title V and
Title XIX activities into one document. Colorado
has issued a specific IAA (CO#2) on HIPAA requirements;
other States such as Connecticut, Indiana, and
South Carolina have written their IAAs to focus
on data files and sharing of confidential data.
Iowa has submitted a separate IAA on EPSDT services.
Missouri maintains multiple cooperative agreements
focusing on very specific topics: prenatal case
management and/or service coordination for pregnant
women; well child outreach; the Head Injury
Program; administration of the medical home
and community-based service waivers to targeted
individuals with physical disabilities; non-emergency
medical transportation; and case management
for the Healthy Children and Youth Program.
Finally, several States used their IAAs to
include services to be provided by other State
programs. Maryland’s cooperative agreement
is between its Title V and Title XIX agencies
and the State WIC program; Wisconsin’s
MOU includes Title V, Title XIX, Title XXI,
and WIC.
(9) Cooperative Relationships
One of the main purposes of the IAA is to define
how the agencies that administer Title V and
Title XIX (hereafter referred to as the “Title
V and Title XIX agencies”) will work together
efficiently to provide services to a shared
population. As such, most documents are filled
with language emphasizing the need for cooperative
relationships at the State level. Many States
stress the need for cooperative interagency
ties by integrating relationship-building into
each agency’s required activities (e.g.,
CA, IN, MO, and WA). Such states emphasize activities
that need to be done in collaboration; by planning
and implementing services together, the State
Title V and Title XIX agencies are building
the cooperative relationships necessary to fulfill
the IAA’s objectives.
Many IAAs follow the example of Colorado, which
specifically requires agencies to “collaborate
via mutually agreed upon activities.”
Wisconsin requires its Title V, Title XIX, and
WIC programs to “establish cooperative
and collaborative relationships, including work
groups and periodic meetings, with respect to
[its] programs and services.” Idaho likewise
requires its respective agencies to “jointly
participate in implementation of collaborative
services, such as an outreach campaign and a
toll-free information line and referral service.”
As can be seen in these examples, the line
between strictly defining cooperative relationships
(described here in Section 9) and actively coordinating
plans for health services (Section 13, summarized
below) is often quite thin, since the establishment
of cooperative relationships should lead to
coordinated plans between agencies.
(10) Services Provided
by Local Agencies
While Federal Medicaid regulations require
a description of the kinds of services provided
by local agencies [42 CFR 431.605(d)(4)], most
of the IAAs do not deal directly with this issue
(indeed, 34 of the documents discuss local agency
services only in the most general terms or do
not include such services at all). Instead,
in most instances services provided by local
agencies are integrated within those provided
by the Title V agency.
However, one aspect relating to local health
agencies that is addressed in a number of IAAs
involves ongoing communication and coordination
between local groups and Title V/Title XIX agencies.
For example, the Illinois intragovernmental
agreement (IL#2) requires its Title XIX agency
to “provide to the local health departments
data related to children enrolled in the Medical
programs within their jurisdiction to increase
EPSDT participation, including immunizations
and lead screening.” The Indiana MOU requires
both Title V and Title XIX agencies to inform
local health departments of the agreement and
“of the responsibilities of the local
program staff affected” by it. Michigan’s
IAA requires its respective agencies to provide
accurate lists of clients due for screenings
to local health departments or other organizations;
however, it does not spell out the screening
services that are to be provided by the local
agencies. Nebraska requires the Title XIX agency
to inform and educate all local health departments
to make them aware of the Medicaid services
offered.
There are a few examples of strong coordination
with local agencies that stand out. North Dakota
lists a section for “local coordination”
under each one of its service categories (in
Section 8). Local agencies are thus tasked with
making Title XIX eligibility determinations
for potentially eligible individuals referred
by other programs; referring Title XIX eligible
persons to the appropriate services; and providing
information to eligible recipients about Medicaid
services. Wisconsin also discusses services
to be provided by local agencies in detail:
these agencies are to participate in Medicaid
managed care advisory groups; provide information
to HMOs about the services they provide; and
join in collaboration with WIC projects, HMOs,
Title V, and Title XIX.
(11) Identification
and Outreach
42 CFR 431.605(d)(5)(i) calls for a description
of the methods used for early identification
of
individuals under 21 in need of medical or remedial
services. States, however, are split as to whether
their IAAs address this topic to any great extent.
Of the documents surveyed, 11 (AL, CA, HI, IL#2,
KS, MI, MN, MO#3, MO#5, MO#6, and UT) assign
the role of identification to one of the State
agencies or some combination of the 2. In such
instances when identification of potential eligible
beneficiaries is discussed, outreach to such
individuals is often paired with the discussion.
States are usually direct in their assignment
of an agency to identify potential beneficiaries.
Alabama’s provider contract states that
the Title V agency shall identify children who
have not received screenings and then follow
up with the appropriate sickle cell and metabolic
screenings, newborn hearing screens, and immunization
status. The contract also calls for the Title
V agency to utilize proper diagnosis codes to
identify high-risk children. California’s
IAA tasks its Title V agency to identify infants,
children, adolescents, and women who are potentially
eligible for Medicaid and, once identified,
assist them in applying. Title V must then collaborate
with the Medicaid agency in performing outreach
and informing all EPSDT eligible individuals
and/or their families about the program.
In Kansas, the Title V agency has the responsibility
of providing early identification and referral
of individuals of potential beneficiaries to
Medicaid and must also provide State and local
Title XIX offices with MCH program brochures
for distribution to these Medicaid consumers.
In the Minnesota interagency MOU, the Title
XIX agency is to receive screening and referral
information from managed care health plans that
is entered into a tracking system in order to
help identify children under 21 in need of medical
or remedial services. It then contracts with
counties to perform outreach and follow-up EPSDT
services to eligible children. Three of the
six Missouri cooperative agreements (MO#3, 5,
6) also require their Title V agency to identify
possible eligible beneficiaries for their respective
Head Injury, Non-Emergency Medical Transportation,
and Healthy Children and Youth Programs.
The topic of outreach is addressed in 25 of
the IAAs. Usually, this is done in a straightforward
manner as a subset of services to be provided
by agency. Most often outreach activities consist
of similar activities:
- 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.
Outreach activities often are seen as a joint
responsibility of the Title V and Title XIX
agencies (e.g., CA, CO#2), although they may
also be assigned specifically to one agency
(e.g., CN#2, FL) or split among agencies (e.g.,
HI). Some States (e.g., IA) have issued a separate
IAA dealing specifically with outreach activities
or have devoted large portions of Section 8:
Services Provided by Agency to outreach activities
(e.g., MD). These documents serve as good models
in defining the need for and activities related
to outreach.
(12) Reciprocal Referrals
Reciprocal referrals are dealt with briefly
yet effectively in the majority of the IAAs
collected. Most States include the responsibility
for reciprocal referrals to necessary services
within the listing of their services provided
by agency (see Section 8). Usually, the mandate
for the agency is quite simple, such as to “refer
the child and family to appropriate services”
(ID). The Kansas cooperative agreement is more
encompassing: “each party to this Agreement
will establish a system of referrals for those
services not directly rendered by the agency,
but which 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 [those provided by the Title
V and Title XIX agencies,] WIC, and Healthy
Start will fall into this category.”
Nebraska also includes a compelling requirement
for referrals in its IAA; it charges both its
Title V and Title XIX agencies to “encourage
comprehensive and continuous care to mutual
clients by encouraging or requiring providers
in each program enjoined by this Agreement,
to identify and refer potentially eligible individuals
through the use of reciprocal referrals.”
A few States go beyond a general mandate requiring
reciprocal referrals. As part of its program
planning activities, Idaho requires its Title
V and Title XIX agencies to work together in
developing a common referral form to be used
across the State. Iowa’s IAA on outreach
specifically requires its Title V agency to
maintain a toll-free number that women and families
can receive information and referrals for prenatal
care, family planning, and well-child services.
In many other States, referrals are grouped
together with identification of potential eligibles
and with outreach; as such, referral language
appears to be integrated in the overall services
provided by both Title V and Title XIX agencies.
(13) Coordinating Plans
With a basis in the cooperative relationships
established in Section 9, the logical next step
regarding collaboration is the coordination
between agencies for the development and implementation
of health service plans. Here again, States
vary widely in their approach, although there
are some familiar trends. Many of the IAAs (e.g.,
MO, NC) integrate the message of coordination
throughout their division of services. Such
IAAs often call for activities that involve
“collaboration,” taking part in
“joint initiatives,” and “coordinating
activities between agencies.” Other States
such as Indiana list coordination as a separate
category of service to be provided with mutual
responsibilities as well as agency-specific
tasks underneath it. Here again, language such
as “coordinating program activities,”
and “working collaboratively” appears
regularly in the agreements.
The Commonwealth of Virginia summarizes its
policy on coordinating plans with a powerful
rationale: “The scope of services covered
under the [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 to alter current levels of health related
services that could affect the plans or operations
of the other agency and to consider responses
concerning potential impacts before changes
are adopted.”
Most of the States that emphasize the coordination
of health plans (CA, CO, CT, GA, ID, IL, IN,
IA, KS, KY, MD, MI, MN, MS, MO, NY, NC, ND,
OK, RI, UT, VA, and WA) include a similar rationale.
Rhode Island devotes an entire section to interagency
coordination and explains that such coordination
will “improve the cost effectiveness of
the health care delivery system, improve the
availability of services, focus services on
specific population groups or geographic areas
in need of special attention and [help to] define
the scope of each agency’s programs”
and that working together to provide services
will “maximize effectiveness of service
delivery and accessibility to services and [will]
minimize duplication [of effort].”
(14) Reimbursement
As would be expected, a plan for the billing
of and payment for services provided to beneficiaries
is an integral component of almost every agreement
between State Title V and Title XIX agencies.
Generally, the relationship outlined in the
IAA is based upon the Title V agency, grantee,
or contractor providing services that the Medicaid
agency will reimburse either partially or in
full according to an agreed upon rate or limit.
Payment for services by Title XIX is also closely
tied to the provision of data from the Title
V agency in regard to the services it has provided
(see Section 15 below). Often the IAAs go into
great detail outlining the exact mechanism(s)
for filing reimbursement claims, the periodicity
for such claims or invoices, pursuit of third
party payment, ongoing documentation of services
provided and payments received, and options
for payment dispute resolution. These documents
often emphasize Medicaid as the payer of the
first resort.
While a few States outline payment responsibilities
generally, the trend in most of the documents
collected is to provide as detailed information
as possible about payment policies, responsibilities,
and mechanisms. The rate and/or total amount
of reimbursement is one of the primary concerns
addressed in these documents. Many of the IAAs
specify that billing and reimbursement shall
be made at the current Medicaid reimbursement
rate or at the State match/share of costs based
on a mutually agreed upon fee schedule (and
always a level that shall not exceed the cost
of providing the service). States often cite
45 CFR Part 74 or similar (State and/or Federal)
regulation(s) as the determination of reimbursable
costs. In many of the agreements, reimbursement
is guaranteed only up to a certain specified
dollar amount (e.g., CO#2, HI, IA#1,4); additional
expenditures will be reimbursed only if the
necessary State match is provided to the Title
XIX agency. Most documents also spell out what
the reimbursement will cover in terms of administration
costs and/or the cost of services. In most of
the agreements, the need is stressed for the
Title V agency to provide the Title XIX agency
with the proper documentation to ensure appropriate
reimbursement for services.
States differ on the ways they approach their
discussions of reimbursement. About half of
the documents contain separate sections outlining
payment mechanisms, while the remainder include
these mechanisms integrated with other required
services by each party. There is further difference
to the timing each State assigns to reimbursement
activities. Some States require monthly invoices
for services, while others accept quarterly
billing and payment; almost half of the documents
do not assign a timetable to such activities.
Throughout the majority of the IAAs, there is
a common theme that the reimbursement requirements
are established to ensure that Medicaid funds
are being used appropriately, that the State
receives the appropriate Federal Financial Participation
amount, and that providers are compensated fairly
and in a timely manner.
A large number of the IAAs (e.g., KS, NE) remind
the respective State agencies that according
to Federal legislation and regulations, Title
XIX funds are to be considered the first and
primary source of payment for billed services.
Most agreements reiterate legislation stating
that the Title V agency must consider payment
from Medicaid to be in full. Title V funds cannot
be used to supplement Medicaid reimbursement
rates.
The following table summarizes how several
IAAs treat reimbursement. These examples are
not meant to be exhaustive as to how States
coordinate billing and payment, but provide
a sample of the creativity found amid State
plans. For a more detailed presentation of how
each IAA deals with this issue, see Chapter
Four.
Reimbursement Discussed
in Sample State IAAs (listed alphabetically) |
Alabama (Region
IV) |
Medicaid will reimburse
Title V for care coordination services
based on Medicaid’s current reimbursement
rates. Title V agrees to reimburse Medicaid
the State’s share of costs associated
with providing care coordination services. |
Colorado (Region
VIII) (CO#1) |
A. Title XIX shall intervene
with the Department’s Designated Entity
to ensure payment of the correct rate
for Medicaid covered services.B. Title
XIX shall bill the State match for Medicaid
expenditures to CMS.C. Title V shall
bill the Department no less than quarterly.D.
Title V shall submit a request for reimbursement
within 45 working days after the final
State fiscal year.E. Family planning
client claims are paid directly out of
MMIS.F. Payments shall be made from State
funds not to exceed $102,346 for the administrative
costs of the Medicaid Prenatal Plus Program.G.
HCP specialty clinic providers are paid
out of MMIS.H. HCP Developmental and
Evaluation Clinic services are billed
directly by Medicaid providers and paid
through the Department Designated Entity.I.
Immunizations and vaccines are paid out
of the MMIS.J. Medicaid covered Lead
Poisoning Prevention Program benefits
are paid out of MMIS.K. Benefits to BCCP
clients are paid directly out of MMIS.L.
Payment shall be made to the NHVP providers
as earned. |
Georgia (Region
IV) |
Title XIX agrees to provide
to Title V the FFP payments received by
Title XIX that are attributable to the
administrative cost of these services
on a quarterly basis. For specified services,
Title XIX agrees to pay Title V the appropriate
non-Federal share of the benefit cost
on a regular basis.Both Title V and Title
XIX agencies agree that this is a cost
reimbursement agreement. Title V agrees
to provide the State portion of matching
funds necessary to receive FFP for all
applicable supplements. Title V agrees
that reimbursable costs will be determined
in accordance with 45 CFR Part 74. This
includes reimbursement for administration
cost and reimbursement for benefit cost. |
Hawaii (Region
IX) |
The Title V agency shall
submit a monthly invoice to Title XIX
for Early Intervention Services provided
to Medicaid infants and toddlers receiving
services.
A. The Title XIX agency shall pay the
Title V agency for the Federal share at
the Hawaii Federal Medical Assistance
Percentage (FMAP) in place for the month
for which reimbursement is made. The
Title V agency is responsible for the
State share of the expenditures.
B. All Federal reimbursement funds received
under this agreement will be deposited
into the Early Intervention Special Fund.
C. The total amount of the MOA shall
not exceed $2,500,000 in Federal funds
per State fiscal year.
D. Title V shall reimburse Title XIX
any amount disallowed by CMS for services
provided under this MOA.
E. If State and/or Federal regulations
and/or QAP standards are not met, the
Medicaid division will provide Title V
with notice and such other due process
protections as the State may provide.
Title V and Title XIX will collaborate
to develop a Correction Action Plan that
will include clearly stated objectives
and time frames for completion. |
Iowa (Region VII)
(IA#2) |
Each of the parties to
this agreement shall continue to cooperate
in their usual and customary fiscal relationship
to ensure Federal dollars will be used
more productively.
It is intended that WIC funds will be
the first and primary source of payment
for nutritional products and services
for persons eligible for WIC services.
Title XIX will be the primary source of
payment for Title XIX medical services
provided to mutual beneficiaries through
Title V providers. |
Kansas (Region
VII) |
Unless there are other
third party resources, Title XIX shall
reimburse eligible providers for any service
covered under the State Medicaid Plan
for eligible Medicaid consumers. Services
provided to consumers covered under managed
care programs will be paid in accordance
with managed care guidelines.
Title XIX funds shall be the first and
primary source of payment for medical
services provided to mutual beneficiaries
of the Title V and Medicaid Programs. |
Kentucky (Region
IV) |
A. The Title XIX Agency
shall be billed for services as per this
agreement.B. The Title XIX Agency shall
pay for services under this agreement
up to a specified amount in State and
Federal matching funds. Any additional
expenditures in excess of that amount
will be reimbursed only if the necessary
state match is provide to the Title XIX
Agency.C. The Title XIX Agency shall
reimburse the certified and enrolled provider
at payment levels that shall not exceed
the cost of providing the service. |
Maryland (Region
III) |
1. Title V and Local
Health Departments shall:
A. Ensure that clinical services are
furnished.
B. Maintain adequate medical and financial
records.
C. Refrain from knowingly employing
or contracting with entities that have
been disqualified from the Medicaid program.
D. Not require additional payment from
an individual after Medicaid makes payment
to the Title V designee for a covered
service. If Medicaid denies payment or
request repayment on the basis that an
otherwise covered service was not medically
necessary or preauthorized, the Title
V Agency will not seek payment for that
service from the recipient.
E. Title XIX funds will be used to reimburse
providers for services covered by that
program if the individual is eligible
for services covered by both Title XIX
and Title V programs.
F. Collaborate with Medicaid regarding
oral health initiatives.
G. Provide specialty services that are
not covered by Medicaid.
2. Mutual Services (Title V and Title
XIX).
A. All parties will ensure that services
provided by its grantees are not duplicative.
B. All parties will maintain a system
to ensure coverage for special infant
formulas. |
Mississippi (Region
IV) |
The case management agencies
shall be reimbursed as a provider of
medical services through the Title XIX’s
Fiscal Agent on the basis of the service
cost as set out in appropriate regulations.
The case management agencies shall bill
Title XIX through its fiscal agent for
their services within 60 days from the
date of service or within 30 days of the
recipient’s receipt of the Medicaid card.
Title V will be responsible for providing
state matching funds only for case management
and extended services actually provided
by Title V to those individuals determined
to be eligible. Reimbursement shall be
made from monthly billings. The reimbursement
fees will be at a flat rate per month. |
Nebraska (Region
VII) |
A. Title XIX Agency.
1. Reimburse Title V program providers
who are also Medicaid providers.
2. Establish a formal method of communication,
collaboration, and cooperation with Title
V regarding procedures, periodicity, and
content standards for EPSDT, rates and
reimbursement methods by regularly scheduled
meetings.
3. Encourage and support the Title V
policy to recover third party reimbursement
and other revenues. It is the intent
to make Medicaid funds the first and primary
source of payment for medical services
provided to Medicaid clients through the
Title V programs.
4. Plan, in conjunction with the Title
V agency, to address billing concerns.
5. Identify overall services and provide
the maximum allowable rate information
for procedures.
B. Title V Agency.
1. Ensure that Medicaid providers shall
bill the Title XIX agency.
2. Respond to and attend annual meetings
regarding rates and reimbursement methods.
3. Assure all third-party revenues shall
be retained by the Medicaid provider.
4. Cooperate and participate in the
planning process. |
Oregon (Region
X) |
Billings will be done
on the UB-92 in accordance with billing
instructions and requirements in the Title
XIX agency’s Hospital Services Guide.
Title V agrees that it is not a direct
provider of augmentative communicative
devices or other large items of durable
medical equipment. Title V is not required
to obtain prior authorization before billing
for covered services, except that it agrees
to conform to all limitation on services
in the provision of hearing aids. |
Virginia (Region
III) |
Title XIX will reimburse
Title V by one of three methods (Pass
Through Transaction; Vendor Transaction;
Licensure and Certification; or Claims
Processing). Title V shall bill Title
XIX via Interagency Transfer (IAT) for
its monthly costs within 24 days of the
close of each month. The IAT shall reflect
the total expenditures (both direct and
indirect). Specific amounts for reimbursement
are detailed for each section: 1. Long-term
Care Agreements; 2. Business Associate
Agreement and Data Projects; 3. Maternal
and Child Health Collaborative. |
Washington (Region
X) |
A. Consideration for
the work provided in accordance with this
Agreement has been established under the
terms of RCW 39.34.130. Compensation
for services shall be based on established
rates or in accordance with establish
terms.
B. For all Title XIX delegated program
and administrative activities included
in this agreement, Title V is responsible
for maintaining compliance with Medicaid
Federal regulations and any overpayments
requested as a result of audit findings. |
Wisconsin (Region
V) |
Title V-funded agencies
will adhere to the precedence of Medicaid
billing principles: Medicare and private
third party payers as first recoverable
dollar, Medicaid as second dollar, and
Title V as third dollar, in payment for
services rendered. Medicaid-certified
Title V agencies must have an established
fee schedule on file and bill Medicaid
according to the schedule. |
(15) Reporting Data
The need to delineate a process for sharing
information is quite evident throughout the
IAAs collected; of these documents all but three
address the issue of data exchange. Often, the
topic of data is addressed with a preface that
related activities are to be undertaken to fulfill
State and related Federal requirements. As such,
there is an overall obligatory sense that a
system of information exchange has to be addressed;
however, most States also see beyond the requirements
to added benefits of reporting data.
Many of the States require an exchange of reports
relating to services provided to recipients
in order to document charges that the Title
V agency or grantee has billed to the Title
XIX agency. The Title XIX agency then uses this
documentation to provide the appropriate level
of financial reimbursement to the grantee. Often,
as with Missouri and Nebraska, the specified
goal is to provide the information necessary
to request Federal funds available under the
State Medicaid match rate. Another goal often
expressed is to provide the data necessary for
the MCH Block Grant Application and Annual MCH
Report. (e.g., MD, UT).
The ultimate goal listed for sharing of data
in many of these agreements is first to identify
service delivery gaps and barriers and then
to improve the delivery of services. The California
IAA lists this as one of its main objectives:
“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.”
The Indiana MOU also lists data sharing as
one of its primary responsibilities and provides
a model summary of services to be provided jointly
and by each agency (see details in the summary
of Indiana’s MOU in Chapter Four). In
this agreement, the Title V and Title XIX agencies
agree to work together to utilize program data
to improve program administration and outcomes;
to develop 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; and to use
shared data for program monitoring and evaluation.
The frequency and specific details of the method
of sharing data between agencies varies widely
from State to State, depending on their individual
structures. However, throughout all the agreements
the need for an ongoing, regular exchange of
information (no less frequently than monthly)
is expressed quite clearly. The agreements are
also very sensitive to issues of confidentiality
of information and security of data transmission
and storage. These issues are discussed further
in each document’s general contract provisions
(Section 19).
(16) Review
A built-in process for periodic review and
planning for coordinated changes in the IAA
between agencies would seem to be an automatic
item for inclusion in any agreement of the type
collected. However, 28 of the agreements have
no comparable clause other than a brief statement
that the document can be modified and/or terminated
upon mutual agreement. Nevertheless, in documents
where a coordinated review is agreed upon, a
powerful mechanism for maintaining the relevance
of the agreement for all parties (and thus the
mutual constituents they serve) is established.
Often, in documents that do include a mechanism
for review, the language is straight-forward
and follows Illinois’ example: “this
Agreement may be reviewed periodically and,
if necessary, amended upon mutual agreement
of the parties. Any amendments shall be in writing
and signed by the authorized representative
of each party.”
Some States, however, do go into greater detail
about the process for document review. Louisiana’s
intra-department agreement states that their
Title V agency will establish, jointly with
Medicaid, an advisory committee to monitor implementation
of their Agreement, to coordinate services offered,
and to review and update its provisions as necessary.
This advisory committee will be comprised, at
a minimum of the MCH Director, the MCH Medicaid
Director, the WIC Director, and a Medicaid representative;
it will meet at least every 6 months when either
party requests that a formal meeting be conducted.
California’s IAA calls for meetings to
be held “at least once a year, and more
frequently if
necessary, among the Branch Chiefs, or their
representatives…for the purpose of reviewing
the
need for any changes or clarifications to the
Agreement, carrying out the services, evaluating
activities and policies set out, and providing
coordinated input to the required plans of the
respective programs.” Finally, Illinois’
IAA (IA#1) calls for a multi-tiered approach,
consisting
of both an annual review of the entire document
and a periodic review. The annual review is
necessary for the purpose of continuing the
Agreement, maintenance of the services agreed
upon, and/or including clarifications as may
be necessary. The periodic review, which can
be
scheduled at the request of either agency, may
be conducted to modify, amend, or terminate
the
Agreement.
The cooperative agreement established in Kansas
also handles periodic review by committee. It
requires that a committee be appointed to ensure
coordination between the State Title V Assurance
Statement and the Title XIX State Plan. The
committee meets at the request of either agency’s
Secretary or designee, or at least annually,
to permit the parties to the Agreement to provide
input, to resolve any problems/issues which
may arise, to review, evaluate, and make recommendations
to the Secretaries regarding the conditions
of the Agreement or the services to be provided.
(17) Liaison
The maintenance of a formal agreement between
parties ensures that accountabilities are established
and provides a record of the services to be
provided between the various groups. However,
this agreement cannot exist in a vacuum; it
needs the ongoing attention of both parties.
The establishment of a system of continuous
liaison between agencies is thus vital in ensuring
that the State IAAs remain current and meaningful.
The majority of State IAAs collected recognize
the need for such liaison and make ample provisions
for it in various ways. Some States (e.g., ID,
KS) address the need for continuous liaison
in general ways, requiring that meetings to
take place on a regular basis and also that
Title V and Title XIX Agency Chiefs (or similar
positions) promote liaison between the regional
directors, the district health department directors,
and others.
Other States take a more focused approach by
calling for specific staff members to serve
as that liaison. New York’s action plan
states that there is a shared responsibility
to designate specific personnel from Title V
and Title XIX to be responsible for continuous
liaison activities. It requires that designated
personnel from relevant divisions meet on a
regular basis, at least quarterly, for the following
purposes: (1) to discuss all areas of mutual
and singular responsibility for respective programs;
(2) to update each other on new developments;
and (3) to maintain and enhance communication
and cooperation between the entities. North
Dakota acts similarly in requiring that its
Title V and Title XIX agencies identify staff
that will serve as liaisons between programs.
These persons are to have the authority to represent
their respective agencies in the development
and implementation of work plans and in the
resolution of any programmatic problems.
Some States (e.g., GA, NC) assign the role
of liaison to a specific title; for example,
in North
Carolina the Assistant Director of Medical Policy
in the Division of Medical Assistance [Title
XIX] and the Deputy Division Director in the
Division of Public Health [Title V] are assigned
as the positions responsible for liaison. A
few IAAs (e.g., MN, VA) actually list the name
of the
individual responsible for liaison. While this
allows for the document to become quickly dated
as personnel in State agencies change, it does
provide a high degree of accountability.
(18) Evaluation
A joint evaluation of policies that affect
the cooperative work of the agencies involved
is closely related to the agreement review and
continuous liaison between parties (Sections
16 and 17, respectively). It is through ongoing
liaison between agencies that a review of the
IAA can occur to lay the foundation for an overall
evaluation of their work together. Almost exactly
one-half of the documents collected (23 out
of 47) contained instructions to carry out such
evaluation. In many cases, as with the review
of the IAA, such evaluation is to take place
in a committee comprised of representatives
from each agency. Idaho’s cooperative
agreement further tasks the Title V agency to
plan, collect, analyze, interpret, and report
data demonstrating the effectiveness of MCH
services and the impact on the health status
of mothers and children.
Louisiana devotes a section of its intra-departmental
agreement to the “joint evaluation of
policies.” It calls for a joint Medicaid/Title
V Advisory Committee to review periodically
the tenants of their agreement with the aim
of ensuring: (1) that all Medicaid-eligible
persons in need of Title V services receive
them; (2) that appropriate fiscal documentation
is ongoing; and (3) that information flows freely
between both parties.
Missouri’s multiple agreements similarly
call for evaluation by committee, in this case
a task force that meet at least quarterly, for
the purpose of program development, review,
and evaluation to discuss problems, and to develop
recommendations to improve programs for better
and expanded services to individuals. The task
force is to concentrate on multiple topics,
including: (1) the evaluation of policies, duties,
and responsibilities of each agency; (2) arrangement
for periodic review of the agreements and for
joint planning for changes in the agreements;
and (3) arrangements for continuous liaison
between the divisions and departments and designated
staff responsibility for liaison activities
at both the State and local levels. As such,
this neatly wraps up requirements in Sections
16-18.
General
(19) General Contract Provisions
The list of general contract provisions below
summarizes those items most often dealt with
in the 47 IAAs reviewed. These items, often
found near the end of the documents, are most
often highly contractual in nature. A number
of the provisions, such as confidentiality of
records and non-discrimination clauses, often
are required by State and/or Federal law. While
formulaic in structure, they can provide additional
information about the nature of the relationship
between State agencies and the environment in
which they operate.
General Contract Provisions in the IAAs:
• Amendment/modification
of agreement. |
• Provisions for lack of
funds. |
• Audit. |
• Lobbying statements. |
• Confidentiality/HIPAA
compliance. |
• Systems for maintenance
of records. |
• Default. |
• Nondiscrimination clauses. |
• Dispute resolution mechanisms. |
• Methods for payment. |
• Drug-free workplace provisions. |
• Regulations regarding
subcontracts. |
• Failure to satisfy scope
of work (SOW). |
• Tobacco policies. |
• Indemnification/liability
clauses. |
• Grounds for termination
of agreement. |
States vary in the number and detail of general
contract provisions included in their IAAs.
Some documents include only a listing of the
appropriate provisions, while others include
addenda for provisions to cover specific services
and/or responsibilities. Some of these provisions
and addenda appear to be boilerplate and most
likely appear in other State-authorized documents,
while others seem to be written for the specific
purpose of the IAA.
Of particular note in this section is how States
deal with medical record and data confidentiality.
Twenty-six of the 40 documents that include
general contract provisions deal with confidentiality
to various degrees. Often, as in the case of
Kentucky, the State will provide contractual
language requiring that any employee or representative
of the agencies involved will abide by the State
and Federal rules and regulations governing
access to and use of information provided in
the administration of the contract. Standard
State agreements must often be signed and maintained
that govern the access to confidential data.
The mandates of the Health Insurance Portability
and Accountability Act (HIPAA, mandated in 42
USC 1320d and set forth in Federal regulations
at 45 CFR Parts 160 and 164) are also addressed
in detail by the majority of the IAAs in the
use and disclosure of protected health information.
The agreement to comply with HIPAA ensures that
individually identifiable information in any
medium pertaining to the past, present, or future
physical or mental health or condition of an
individual; the provision of health care to
an individual; or the past, present or future
payment for the provision of health care to
an individual is protected by law.
Several States such as Illinois (IL#1) include,
as an attachment to their IAA, a list of HIPAA
compliance obligations that includes definitions
and citations of HIPAA; permitted uses and disclosures;
limitations on uses and disclosures; and interpretations
dealing with cases of ambiguity. Colorado treats
HIPAA in even greater detail by creating a separate
interagency memorandum of understanding (CO#2;
see summary in Chapter Four). This extensive
document contains stipulations dealing with:
permitted uses; permitted disclosures; appropriate
safeguards; reporting of improper use or disclosure;
accounting rights; governmental access to records;
data ownership; retention of protected information;
notification of breach; audits, inspection,
and enforcement; and safeguards during data
transmission.
One final recurrent general contract provision
that deserves attention is the nondiscrimination
clause found in many of the IAAs. Most of the
documents that include such a clause agree to
comply with the provisions of the Americans
with Disabilities Act (ADA), Public Law 101-336,
and other applicable Federal regulations relating
to prohibiting discrimination against otherwise
qualified disabled individuals. The parties
of these agreements agree to take affirmative
action to ensure that applicants are employed
and that employees are treated during employment
without regard to their race, religion, color,
national origin, sex, age, or disability. Some
States, most notably California, take this commitment
a step further by including in their agreed-upon
services, additional provisions such as to “support
the retention of culturally and linguistically
competent, and geographically strategic, safety
net and traditional providers of MCH services.”
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