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Chapter Two
Federal Legislation, Regulations, and
Policy
These services are “about people
-- children and adults who are sick, poor, and
vulnerable -- for whom life, in the memorable
words of poet Langston Hughes, ain’t been
no crystal stair.
It is written in the dry and bloodless language
of the law... but let there be no forgetting
the real people to whom this language gives
voice...
Behind every fact found herein is a human face
and the reality of being poor in the richest
nation on earth.”
-- Judge Gladys Kessler, U.S. District Court
A.
Federal Legislation and Regulations
B. Federal Policy
Ongoing and successful
coordination between Title V and Title XIX is
supported by a series of Federal legislation,
regulations, and policies. These legal requirements,
summarized in the tables below and discussed in
detail on pages 20-25, pave the way for the development
of successful IAAs and ongoing coordination.
Summary
of Requirements for Title V and Title XIX
Coordination |
Federal
Legislation: the Social Security Act
|
Title
XIX |
Requires
Medicaid agencies to: •
Enter into IAAs [§1902(a)(11)(B)].
• Use Title V programs to provide
services [§1902(a)(11)(B)(i)].
• Reimburse Title V agencies for services
[§1902(a)(11)(B)(ii)]. •
Coordinate information on immunizations
[§1902(a)(11)(B)(iii)]. |
Title
V |
Requires
Title V agencies to: •
Enter into IAAs [§505(a)(5)(F)(ii)].
• Coordinate EPSDT services [§505(a)(5)(F)(i)].
• Provide information to beneficiaries
about services & providers [§505(a)(5)(E)].
• Identify, help enroll, and provide
services to beneficiaries [§505(a)(5)(F)(iv)].
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Federal
Medicaid Regulations |
Title
42, Chapter IV, CFR |
Requires
Medicaid agencies to: •
Enter into IAAs that outline collaboration
with Title V programs. • Use Federal
funds to reimburse Title V programs for
services. |
Federal
Policy |
CMS’s
State Medicaid Manual |
Requires Medicaid
agencies to: • Enter into IAAs
with Title V, placing special emphasis on
payment arrangements. • Coordinate
with Title V grantees, especially in regards
to EPSDT services. • Reimburse
Title V providers. |
MCHB’s
Title V Guidance |
Requires Title
V agencies to: • Examine and report
on coordination activities with Medicaid
as well as numbers of Medicaid-eligible
people served and services provided. |
The summary of requirements for Title V and
Title XIX coordination can be viewed within
the broader overview of Federal legislation,
regulations, and policy in the table below.
Overarching
Federal Legislation, Regulations, and Policy
|
Federal
Legislation and Regulations |
Title
V |
Title
V of the Social Security Act [enacted
1935, amended by Omnibus Budget Reconciliation
Acts (OBRAs)] |
OBRA-1981 |
•
Converted Title V into a block grant program.
• Incorporated five other related
programs into Title V. • Granted
States increased spending flexibility. |
OBRA-1989 |
•
Provided stricter application, spending,
and reporting requirements. •
Stressed the importance of State Title V
agencies in meeting requirements set forth
in Title XIX of the SSA, with a particular
emphasis on coordination, accountability,
and reporting requirements. •
Required Title V agencies to:
o Participate in developing and carrying
out agreements on coordination of care and
services [§1902(a)(11); §505(a)(5)(E)(ii)].
o Coordinate activities with the EPSDT program
[§505(a)(5)(E)(i)].
o Assist in identifying and registering
pregnant women and infants who are eligible
for medical assistance [§505(a)(5)(F)(iv)].
o Provide a toll-free telephone number to
help parents obtain information about services
under Title V and Title XIX [§505 (a)(5)(E)].
|
Title
XIX |
Title
XIX of the Social Security Act [enacted
1965] |
Amended
(1967, 1981) |
•
Expanded requirements for cooperation with
health agencies to include Title V [§1902(b)(11)(B)].
• Required Medicaid agencies to act
as the payer of first resort and to:
o Use Title V-funded agencies to provide
services for Medicaid-eligible clients if
such services are included in the State
plan [§1902(a)(11)(B)(i)].
o Reimburse agencies for the cost of services
provided to any individual for which payment
would otherwise be made to the State [§1902(a)(11)(B)(ii)].
o Coordinate information and education on
pediatric vaccinations and delivery of immunization
services [§1902(a)(11)(B)(iii)]. |
Title
42, Chapter IV, Code of Federal Regulations
|
§431.615(b) |
Title
V grantees may receive Federal payments
for services including: • Maternal
and child health services. • Children
with Special Health Care Needs (CSHCN).
• Maternal and infant care projects.
• Children and youth projects.
• Projects for the dental health of
children. |
§431.615(c) |
Each
State plan must: • Describe cooperative
arrangements with Title V and other programs
and grantees to maximize use of services.
• Provide arrangements for Title V
grantees to deliver services on behalf of
the State Medicaid agency. • Ensure
that all arrangements meet Federal requirements.
• Ensure that the Medicaid agency
reimburses the Title V grantee or provider
for the cost of service (if requested by
the grantee). |
§431.615(d) |
IAAs
must specify, as appropriate: •
The mutual objectives and responsibilities
of each party to the arrangement. •
The services each party offers and in what
circumstances. • The cooperative
and collaborative relationships at the State
level. • The kinds of services
to be provided by local agencies. •
Methods for beneficiary identification,
referrals, reimbursement, etc. |
§431.615(e) |
•
Federal financial participation (FFP) is
available for expenditures for Medicaid
services provided to beneficiaries under
such cooperative arrangements. |
Deficit
Reduction Act (DRA) of 2005 |
|
• Scheduled to reduce spending
by $4.7 billion over the 2006-2010 period
for provisions that cover Medicaid, SCHIP,
and funding for health care costs in areas
affected by Hurricane Katrina. |
Federal
Policy |
Title
V |
MCHB’s
Title V Guidance |
blank |
• As part of their 5 year needs
assessment, requires States to assess how
local delivery systems (including regional
areas) meet the population’s health
needs by examining existing systems and
collaborative mechanisms with Medicaid and
other programs [Part II(II)(B)(4)(d), p.
29]. • Requires States to report
in four areas:
o Coordination with other State human services
agencies, including Medicaid.
o Health Systems Capacity Indicators (HSCIs),
including Medicaid data.
o National and State Performance Measures
(NPMs), often documenting a State’s
partnership and coordination activities
with Title XIX agencies and populations.
o Program data, including individuals eligible
and served by Title XIX. |
Title
XIX |
CMS’s
State Medicaid Manual |
|
• Issues mandatory, advisory, and
optional Medicaid policies and procedures
to State agencies for use in administering
their Medicaid programs. • Serves
as guidance to overarching coordination
with Title V programs and with Title V grantees,
with special emphasis on EPSDT coordination.
• Requires that each State have in
effect an IAA that:
o Provides for care and services available
under MCH programs.
o Utilizes MCH grantees to develop more
effective uses of Medicaid resources.
• States that Medicaid agencies are
responsible for reimbursing Title V providers
for services provided to Medicaid beneficiaries
even if these services are provided free
of charge to low-income uninsured families.
• Stresses the importance of
including a detailed description of payment
arrangements in the IAA. • Advises:
o Limiting reimbursement of overhead costs
under IAAs to those identifiable as supporting
EPSDT services.
o Specifying within the IAA the conditions
under which private practitioners may bill
through Title V for services provided to
Medicaid beneficiaries.
o Detailing the conditions under which services
are covered (since services are often provided
by professionals who are not physicians).
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A.
Federal Legislation and Regulations
Title V Requirements Related to Coordination
with Title XIX
Related to coordination, Title V of
the Social Security Act requires the
Title V agency to:
- Participate “in the arrangement and
carrying out of coordination agreements described
in section 1902(a)(11) (relating to coordination
of care and services available under this
title and title XIX)” [§505(a)(5)(F)(ii)].
- Participate “in the coordination
of activities between such program and the
early and periodic screening, diagnostic,
and treatment program under section 1905(a)(4)(B)
(including the establishment of periodicity
and content standards for early and periodic
screening, diagnostic, and treatment services),
to ensure that such programs are carried out
without duplication of effort” [§505(a)(5)(F)(i)].
- Provide “for a toll-free telephone
number (and other appropriate methods) for
the use of parents to access information about
health care providers and practitioners who
provide health care services under this title
and title XIX and about other relevant health
and health-related providers and practitioners”
[§505(a)(5)(E)].
- Provide “directly and through their
providers and institutional contractors, for
services to identify pregnant women and infants
who are eligible for medical assistance under
subparagraph (A) or (B) of section 1902(l)(1)
and, once identified, to assist them in applying
for such assistance. [§505(a)(5)(F)(iv)].
For a complete list of Title V requirements,
see Social
Security Act Title V.
Overall, Title V of the SSA stresses the importance
of State MCH agencies in meeting similar requirements
set forth in Title XIX, with a particular emphasis
on coordination, accountability, and reporting
requirements. For example, States must report
(1) the number of deliveries to pregnant women
who received prenatal, delivery, or postpartum
care under Title V or were entitled to such
services under Medicaid during the year; and
(2) the number of infants who received Title
V services or were entitled to Medicaid services
during the year.
Enhancing the reporting mechanisms for Title
V/Title XIX activities and services remains
a priority for MCHB. The Title
V Information System, the guidance and reporting
system for State Title V agencies, was developed
through the support of MCHB. This system has
become a valuable instrument in measuring the
performance and effectiveness of State Title
V activities, including coordination with Medicaid.
Title XIX Requirements Related to
Coordination with Title V
Related to coordination, Title XIX
of the Social Security Act requires
the Title XIX agency to:
- Enter “into agreements, with any
agency, institution, or organization receiving
payments under (or through an allotment under)
title V” [§1902(a)(11)(B)].
- Provide “for utilizing such agency,
institution, or organization in furnishing
care and services which are available under
such title or allotment and which are included
in the State plan approved under this section”
[§1902(a)(11)(B)(i)].
- Make “such provision as may be appropriate
for reimbursing such agency, institution,
or organization for the cost of any such care
and services furnished any individual for
which payment would otherwise be made to the
State with respect to the individual under
section 1903” [§1902(a)(11)(B)(ii)].
- Provide “for coordination of information
and education on pediatric vaccinations and
delivery of immunization services provide
for coordination of the operations under this
title” [§1902(a)(11)(B)(iii)].
For a complete list of Title XIX requirements,
see Social
Security Act Title XIX.
The Code of Federal Regulations (CFR), available
online at http://www.gpoaccess.gov/cfr addresses
cooperative arrangements in Title 42, Chapter
IV, focusing on Medicaid regulations. In these
regulations, a Title V grantee is described as
an “agency, institution, or organization
receiving Federal payments for part or all of
the cost of any service program or project authorized
by Title V” [§431.615(b)].
Coordination between [Title V and
Title XIX] will enhance their effectiveness
by, at a minimum, avoiding duplication
of effort and effecting better and
more organized outreach, screening,
and follow-up efforts. (Senate Report
No. 97-139) |
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Covered activities include:
• Maternal and child health services.
• Children with Special Health Care
Needs (CSHCN).
• Maternal and infant care projects.
• Children and youth projects.
• Projects for the dental health
of children. |
Under Medicaid regulations, each State plan
must:
(1) Describe cooperative arrangements with
Title V and other programs and grantees to
maximize use of services;
(2) Provide arrangements for Title V grantees
to deliver services on behalf of the State
Medicaid agency;
(3) Ensure that all arrangements meet Federal
requirements (described below); and
(4) Ensure that the Medicaid agency acts as
the payer of the first resort and reimburses
the Title
V grantee or provider for the cost of service
(if requested by the grantee) [§431.615(c)].
The Federal regulations further specify that
IAAs must specify, as appropriate:
- The mutual objectives and responsibilities
of each party to the arrangement.
- The services each party offers and in what
circumstances.
- The cooperative and collaborative relationships
at the State level.
- The kinds of services to be provided by
local agencies.
- Methods for:
- Early identification of individuals
under 21 in need of medical or remedial
services.
- Reciprocal referrals.
- Coordinating plans for health services
provided or arranged for recipients.
- Payment or reimbursement.
- Exchange of reports of services furnished
to recipients.
- Periodic review and joint planning
for changes in the agreements.
- Continuous liaison between the parties,
including designation of State and local
liaison staff.
- Joint evaluation of policies that affect
the cooperative work of the parties [§431.615(d)].
Federal financial participation (FFP) is available
for expenditures for Medicaid services provided
to beneficiaries under such cooperative arrangements
[§431.615(e)].
B.
Federal Policy
Title V Requirements
The 2006 Maternal and Child Health Services
Title V Block Grant Program: Guidance and Forms
for the Title V Application/Annual Report (the
“Title V Guidance”), valid through
May 31, 2009, mainly addresses Title V and Title
XIX coordination and IAAs through its reporting
requirements. As part of the “enabling
services” segment of the MCH Pyramid of
Health Services, coordination activities with
Medicaid must be reported in each State’s
5 year needs assessment.
The Title
V Guidance requires States to assess how
local delivery systems (including regional areas)
meet the population’s health needs by
examining existing systems and collaborative
mechanisms with Medicaid and other programs
as part of their 5 year needs assessment [Part
II(II)(B)(4)(d), p. 31].
Related to Medicaid, Title V guidance requires
States to report on: (1) coordination with other
State human services agencies, including Medicaid,
(2) Health Systems Capacity Indicators (HSCIs);
(3) State Performance Measures (SPMs); and (4)
a range of program data.
(1) Coordination among State human service
agencies and providers. States must provide
their plans for coordination (1) with the EPSDT
program; (2) with other Federal grant programs
(e.g., WIC, related education programs, and
other health, developmental disability, and
family planning programs); and (3) with service
providers in order to identify pregnant women
and infants who are eligible for Title XIX services
and to assist them in applying for these services
[Part II(III)(E), p. 38, reflecting §505(a)(5)(F)
of the Social Security Act].
(2) Health Systems Capacity Indicators
(HSCIs). Information on the State Title
V agency’s systems and program capacity
to promote women’s and children’s
health (including coordination with Medicaid)
must be reported annually and is summarized
through a series of Health Systems Capacity
Indicators. The indicators that focus upon Medicaid
include:
• The percent of Medicaid enrollees whose
age is less than 1 year who received at least
one initial or periodic screen (HSCI 2, p. 141).
• Comparison of HSCIs for Medicaid, non-Medicaid,
and all MCH populations in the State (HSCI 5,
p. 145).
• The percent of poverty level for eligibility
in the State’s Medicaid and SCHIP programs
for infants (0 to 1), children, Medicaid and
pregnant women (HSCI 6, p. 145).
• The percent of potentially Medicaid-eligible
children, aged 1 to 21 years, who have received
a service paid by the Medicaid Program (HSCI
7A, p. 142).
• The percent of EPSDT eligible children
Medicaid aged 6 through 9 years who have received
any dental services during the year (HSCI 7B,
p. 142).
(3) State Performance Measures (SPMs).
The Title V Guidance requires States to
report on 7–10 State Performance Measures
designed to meet specific priorities determined
through the State needs assessment. These SPMs
often document a State’s partnership and
coordination activities with Title XIX agencies
and populations.
(4) Program Data. States are required
to report a wide range of program data, including
their overall priority needs, individuals served,
and health screenings provided. Program data
to be reported that address individuals covered
by Medicaid include:
• Number and percentage of individuals
served by Title V (by “class of individuals”
and by “source of coverage,” including
Title XIX).
• Number of deliveries and number of infants
served under Title V who are eligible for services
under Title XIX (by State, by race, and by Hispanic
ethnicity).
Title XIX Requirements
The State
Medicaid Manual is the official document used
by CMS to issue mandatory, advisory, and optional
Medicaid policies
and procedures to State agencies for use
in administering their Medicaid programs.
The State Medicaid Manual provides guidance
on Parts 42 and 45 of the Code of Federal
Regulations (specifically 42 CFR 431.615),
with emphasis on Title V and Title XIX coordination
of EPSDT. This document replaces the Medical
Assistance Manual (§5-40-20).
While these provisions place an emphasis
on EPSDT coordination, they serve as guidance
to overarching coordination with Title V
programs and with Title V grantees.
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Title V (MCH block grant) grantees
and Medicaid share many of the same
populations, providers, and concerns
for child health. Assure that each
MCH grantee and the State Medicaid
agency have in effect a functional
relationship. (§5230.1) |
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The introduction of §5230 summarizes Medicaid’s
emphasis on coordination:
Written agreements are essential to effective
working relationships between the Medicaid agency
and agencies charged with planning, administering
or providing health care to low-income families.
Although agreements by themselves do not guarantee
open communication and cooperation, they can
lay the groundwork for collaboration and best
use of each agency’s resources.
CMS’s guidance cites several key factors
for effective coordination and partnership in
the IAAs:
• Detailed planning.
• Clearly identified roles and responsibilities.
• Program monitoring.
• Periodic evaluation and revision.
• Constant communication.
CMS states that the IAA, defined as a formal
document signed by each agency’s representative
or a written statement of understanding between
units of a single department, should be developed
by both parties and should provide a clear statement
of each agency’s responsibilities.
The State Medicaid Manual further requires that
each IAA be signed by persons with authority
to make it binding and should specify the participating
parties, their intent, and the effective agreement
date. The IAA should also be reevaluated annually
and when a major reorganization occurs to determine
if it remains applicable to the organization,
functions, and programs of the participating
parties. The recommended content of the IAA,
as outlined by the CMS policy, repeats 42 CFR
431.615(d) word-for-word.
Section 5230.1 specifically deals with “relations
with State MCH programs” and requires
that each State have in effect an IAA that:
• Provides for the maximum utilization
of the care and services available under MCH
programs.
• Utilizes MCH grantees to develop more
effective uses of Medicaid resources in financing
services to Medicaid-eligible children.
Goal of MCH-Medicaid Interagency Agreements.
Coordination is essential to the overall goal
of State MCH-Medicaid IAAs of improving “the
health status of children by ensuring the provision
of preventive services, health examinations,
and the necessary treatment and follow-through
care.” This is most effective in the context
of an ongoing provider-patient relationship
and from comprehensive, continuing care providers.
CMS’s manual states that Medicaid agencies
should inform Title V-eligible recipients of
available services and refer them to the appropriate
Title V grantees that provide such services.
CMS advises State Medicaid programs to enlist
the assistance of Title V programs in a number
of areas, which include:
• Recruiting providers from both the
private and public sectors to provide comprehensive,
continuing care for children.
• Providing outreach and referral services
at the local levels.
• Using Maternal and Infant Care (MIC)
projects, Children and Youth Projects (CYP),
and other specialty and primary care programs
as providers of comprehensive, continuing care.
• Delegating tasks by the Medicaid agency
to State MCH programs to ensure that Medicaid-eligible
children have access to and receive the full
range of assessment, diagnostic, and treatment
services.
• Developing health services policies
and standards, and assessing quality of care
issues.
• Ensuring continuity of care. Public
Health Service (PHS)-supported primary care
projects provide continuing care to all eligible
children, regardless of their payment status.
State MCH programs develop linkages with these
projects to ensure the full range of care for
mothers, infants, and children, including CSHCN
[§5230.1(A)].
CMS reminds Medicaid agencies that they are
to act as the payer of first resort and that
MCH
programs have extensive experience establishing
standards, policies, and procedures for health
care services that may be relevant to Medicaid
populations [§5230.1(C)]. The
State Medicaid Manual calls for mutual
program referral arrangements and outreach activities
by State MCH
and EPSDT programs, specifically requiring both
programs to refer those eligible for EPSDT
services to MCH programs, where appropriate,
and to cover this implementation in the IAA
[§5230.1(D)].
While coordination with Title V programs is
primarily addressed in §5230 of the
State Medicaid Manual, CMS emphasizes partnership
in a number of provisions. For example, CMS
urges development of examination and diagnostic
resources and centers with the assistance of
Title V programs, medical and dental societies
and schools, other practitioner organizations,
and State, regional, and local health departments
[§5310(A)].
Reimbursement and Documentation. The
State Medicaid Manual clearly states that
Medicaid agencies are responsible for reimbursing
Title V providers for services provided to Medicaid
beneficiaries even if these services are provided
free of charge to low-income uninsured families.
The manual stresses the importance of including
a detailed description of payment arrangements
in the IAA.
The manual reiterates that Medicaid is to be
considered the payer of first resort and contains
the following payment, reimbursement, and documentation
provisions related to IAAs between Medicaid
agencies and Title V (and other) programs:
- Title V programs that enter into IAAs with
Medicaid agencies must specify in the IAA
the terms of reimbursement for services to
be provided.
- A fee schedule for each service billed
to Medicaid by Title V must be established;
information and billing of all third party
liable resources must be obtained and documented
[§5340(A)].
- Medicaid agencies must document
the payment mechanism of services provided.
This may consist of two alternatives:
- If the same payment mechanism
is used, agencies must specify that payment
is based on the Medicaid fee schedule
or reasonable charge.
- If an alternative payment
mechanism is used, agencies must specify
the type of arrangement, which may include:
- Prospective interprogram transfer
of funds, with retrospective adjustments
based on the volume of services actually
delivered;
- Capitation payments for a pre-determined
package of services; or
- Reimbursement for actual costs
[§5230.1(B)]
- IAAs with Title V (and other) programs
may provide payment for certain administrative
functions (outreach, quality assessment, and
transportation; the DRA of 2005 has limited
the scope of services related to targeted
case management, which previously had qualified
as allowable administrative functions); 75
percent Federal matching funds are available
for the cost of medical personnel and direct
support staff employed by the Medicaid agency
if they meet requirements of 42 CFR 432.50
[§5340(B)].
CMS further advises (1) limiting reimbursement
of overhead costs under IAAs to those identifiable
as supporting EPSDT services when this is the
focus of the IAA; (2) specifying within the
IAA the conditions under which private practitioners
may bill through Title V for services provided
to Medicaid beneficiaries; and (3) detailing
the conditions under which services are covered
(since services are often provided by professionals
who are not physicians).
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