TennCare Standard Operating Procedures
STATE OF TENNESSEE
BUREAU OF TENNCARE
DEPARTMENT OF FINANCE AND ADMINISTRATION
729 CHURCH STREET
NASHVILLE, TENNESSEE 37247-6501
MEMORANDUM
DATE: November 8, 1999
TO: TennCare MCOs & BHOs
TSOP: TSOP: 036 Addendum 2
FROM: John F. Tighe
Deputy Commissioner
Department of Finance and Administration
SUBJECT: Coordination of EPSDT Services
Coordination between MCOs/BHOs and other children's health and education services and programs is essential to ensure and maximize children's health care services and to prevent duplication. Ideally, EPSDT services are part of a continuum of care. This TSOP has two purposes:
- to provide MCOs and BHOs with guidance and information about EPSDT resources available through other government agencies (see accompanying list); and
- to suggest strategies for ensuring coordination of EPSDT services among MCOs/BHOs and with other programs and services included in the accompanying list.
It is the Bureau's position that the use and coordination of services provided by other government agencies will result in several benefits to both the enrollees and MCOs/BHOs. The ultimate responsibility for providing EPSDT services to qualified enrollees is that of the MCOs and BHOs. This means that MCOs/BHOs cannot refuse to provide a necessary service because someone else should be providing it. The only reason for denying a requested service is because it lacks medical necessity. Among these benefits are:
- the containment of costs and improvement of services by reducing service overlaps or duplications and closing gaps in the availability of services;
- the ability to focus services on specific population groups or geographic areas in need of special attention; and
- a greater availability of needed services in a more localized area, reducing the amount of travel time and expense for the MCOs.
Coordination of effort includes the use of child health initiatives with other related programs, such as Head Start, the Special Supplemental Food Program for Women, Infants, and Children (WIC), school health programs of State and local education (including the Individuals with Disabilities Education Act of 1975). There is no single "list of approved roles", but other government agencies may provide a variety of outreach, screening, diagnostic or treatment services, health education and counseling, case management, facilities, and other assistance in achieving an effective child health program. MCOs may find it beneficial to establish active child health coordinating committees, with representation from providers, private voluntary and public agencies, which may be helpful in promoting cooperation in providing health services. The attachment to this TSOP is a statewide list of services for which EPSDT coordination is appropriate. The Bureau previously sent this list to MCOs and BHOs September 22, 1998.
In order to insure effective coordination with other agencies, TennCare suggests that formal or informal coordination agreements be developed as appropriate. Such agreements should contain the following elements:
- delineation of the mutual objectives and responsibilities of each party (i.e., MCO/BHO, local agency, and/or subcontractor);
- identification of the services each party offers and in what circumstances, including any restrictions;
- appraisal of the types of services provided by local agencies; and
- methods for:
- early identification of individuals under 21 needing health services;
- reciprocal referrals;
- coordinating plans for health services provided or arranged for enrollees;
- exchange of reports of services furnished;
- continuous liaison between the parties; and
- joint evaluation of policies that affect the cooperative work of the parties.
The overall goal is to improve the health status of children by assuring the provision of preventive services, health examinations, and the necessary treatment and follow-through care, preferably in the context of an ongoing provider-patient relationship and from comprehensive, continuing care providers.
Organization and Administration of EPSDT Programs
TennCare MCOs' and BHOs' provider networks should include providers who can deliver a broad array of services to children on a continuing basis. Other government programs can help in a number of ways such as:
- provision of outreach and referral services at the local level;
- utilization of Maternity and Infant Care and Children and Youth Projects, and other specialty and primary care programs as providers of comprehensive, continuing care;
- development of health services policies and standards and the assessment of quality of care issues including: implementation of professionally recognized protocols and standards of care; integration of services at local and regional levels with a view toward elimination of unnecessary services and duplication of services; providing acceptable quality of care; and
- integrating and providing all necessary services to this population.
TennCare, MCOs/BHOs, and government agencies working together have a major role in establishing standards, policies and procedures for health care services.
Coordination with:
- Local Education Agencies (LEAs)
The development of linkages through the family to public, private, and community health and social agencies help link existing prevention and treatment programs with those services provided in the schools. Schools can be a focal point from which to identify children with problems, to increase student's access to both preventive and curative health services, and to assure appropriate use of health care resources. Coordinating services can avoid duplicating efforts that increase costs of services and adding further stress to the child and family. There is no single "best" way for schools to relate to EPSDT, since the populations, traditions, resources, and other factors vary greatly.
The Bureau has already notified LEAs of the need to coordinate with MCOs and BHOs the needs of children that have been identified through the child's Individual Education Plan (IEPs). These plans are to be shared with the child's primary care physician. As an attachment to this TSOP is the release of information that the child's parent(s) is to sign giving permission to share this information.
- The Head Start Program
Head Start shares the same child health and development goals as EPSDT. Approximately 50% of Head Start families are also TennCare families. Eligibility for the Head Start Program is based on income and family, similar to Medicaid criteria eligibility. There are additional criteria which gives an applicant "points" to qualify for Head Start.
- The Special Supplemental Food Program for Women, Infant, and Children, Food and Nutrition Service, U.S. Department of Agriculture (WIC)
WIC provides specific nutritious supplemental food and nutrition education at no cost to low-income pregnant, postpartum, and breastfeeding women, infants, and children up to their 5th birthday. They must meet income guidelines, a State residency requirement, and be individually determined to be at "nutritional risk" by a health professional such as a physician, nutritionist, or nurse. WIC serves as an adjunct to good health care. Many TennCare families are WIC recipients.
Summary
EPSDT components are often part of a larger network of social service agencies and health programs for children. Coordination among these entities is crucial to ensure and improve access to services and to prevent duplication. Varying kinds of coordination and strategies are possible which can be used between MCOs/BHOs and other agencies. These collaborative efforts may include interagency agreements, cross-referrals, child-health coordinating committees, or other activities; the desired outcome shall be the stimulation of partnerships that ensure the improvement of the health and well being of children.
The Bureau of TennCare strongly recommends that MCOs and BHOs become familiar with the services provided by other government agencies and how they may benefit the enrollees through coordination of an enrollee's medical and mental health care, especially through EPSDT services. Identifying an individual(s) within your organization that could serve as the contact, or lead person, for EPSDT services can help to bring the various treatment plans together to provide the best service possible and work to eliminate duplicate services. This person should also be available to assist your customer relations representatives in resolving problems involving your enrollees. The Bureau will take the lead in urging other public and private agencies to designate a lead person to interface with the MCOs and BHOs in meeting the needs of the EPSDT population. Close working relationships will enhance the rapid identification of a child's problems and how to best meet those needs.
TennCare Authority:
U.S. Code Annotated Section 1396
Social Security Act Sections 1902(a)(43) & 1905(a)(4)(B);
Social Security Act Section 1905(r) as created by OBRA 89;
HCFA's State Medicaid Manual;
TennCare Rules and Regulation 1200-13-12-.04(1)(w) & 1200-13-12-.04(7);
TennCare/MCO Contract Section 2-3.a.1.;
TennCare/BHO Contract Section 2.6.1.
