Medicaid Contract Purchasing SpecificationsUser’s Guide to Purchasing Specifications for Services Related to Epilepsy[Download a .pdf version of this document] The document “Optional Purchasing Specifications for Services Related to Epilepsy” sets forth a menu of draft provisions relating to the provision and delivery of medical services for people with epilepsy. They do not reflect a formal legal policy nor are they part of a formal practice guideline, but they are recommended for consideration because they reflect good practice in the opinion of a panel of experts. The illustrative contract language that is provided may be used in various types of formats for purchasing epilepsy treatment and services from managed care plans. The specifications are available at www.gwhealthpolicy.org. This User Guide, organized alphabetically by heading and topic, describes the major provisions in the epilepsy specifications and provides citations to the illustrative contract language. Access to Health Care Providers: Section 201 sets forth contract language regarding provision of enrollee access to health care providers for epilepsy-related services Case Management: Sections 103(a)(4) and 104(a) address case management services for enrollees with a diagnosis of epilepsy. The sections describe care management responsibilities for medical and non-medical services. Coverage Determinations: Section 108 sets forth contract language regarding the manner in which coverage determinations are to be made. Covered Benefits: The following sections set forth the scope of covered benefits for epilepsy-related services and provide descriptions of the service categories:
Data Collection and Reporting: Section 206 sets forth data collection and reporting requirements for information related to epilepsy and epilepsy-related services. Definitions: Section 109 provides definitions for terms used in the specifications. Enrollee Information: Section 207 sets forth language regarding information to be provided to enrollees. Enrollment and Disenrollment: Section 202 sets forth language relating to enrollment and disenrollment, including duties related to enrollees receiving treatment at the time of disenrollment. Guidelines and References: Section 107 identifies the guidelines and references applicable to epilepsy-related services. Provider Network Requirements: Section 203 contains language on the composition of provider networks, provider selection and retention, and reimbursement for network providers. The language also includes provision on out-of-network arrangements. Quality Measurement and Improvement: Section 205 sets forth language regarding quality measurement and improvement activities related to epilepsy, including dissemination of standards, guidelines, and other materials, and collection of quality improvement project data. Treatment Plans: Section 103(b) contains language regarding the development, implementation, and revision of a treatment plan for each enrollee with a diagnosis of epilepsy. |
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