Chapter Three
Analysis of State Title V / Title XIX Interagency Agreements

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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):

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:

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.

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.

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