PUP 4931r Lecture Notes - Lecture 78: Public Health, Selection Bias
16 May 2018
School
Department
Course
Professor
Study of MCO Contracts
Studied content of 45 States & Wash DC RFPs and contracts
Included standard MCO & Mental and Behavioral Health Carve Outs
Typically separate carve outs for MH and BH
Most contracts are dual coverage
MCO responsible for many services,
But some provided directly by the state
Frequently permit MCO to exclude some coverages,
and some limitations on amount, scope and duration
that are impermissible under Medicaid law.
So when excluded or limited by MCO, must be covered by the state.
What’s Left Out Ma Leave Patients, States on the Hook
“tates do’t tpicall iclude the actual statute in the RFP or contract
Instead they refer to state law and regulations.
But if a cliet sues, the court ill reie the state’s perforace against
the Federal statute.
So when RFP and Contract let states limit coverage or amount, duration,
and scope, they must be prepared to directly provide required services.
An Example: Pregnancy coverage
Federal law says:
"prenatal, delivery,
postpartum services and [services for]
any other condition which may complicate pregnancy."
Pregnancy coverage continued...
Authors found that:
none of the contracts reviewed tracks the federal definition.
As a result, certain federal pregnancy-related services may be left outside the
scope of the cotract.
Eaple of hat’s left out:
Washington DC: omits coverage of conditions that could complicate pregnancy
TN: allows state to limit coverage to conditions that:
"seriously affect the usual expected medical management of the
pregac.
Which is not everything the Federal law requires.
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