"II.9
PCP and Specialist Access Standards
The State of
Delaware passed Senate Bill 78, during the 139th Session of the General
Assembly. Senate Bill 78 provides for direct access to OB/GYN services,
without referral, to providers within the MCOs panel. It also requires
that all MCOs allow OB/GYN physicians to choose to be primary care providers.
All of the following access standards apply.
The MCO must use specialists with pediatric expertise for children where the need for pediatric specialty care is significantly different from the need for adult specialists (e.g. a pediatric cardiologist for children with congenital health defects). The MCO must describe how they will assure that children with special health care needs have access, when needed, to pediatric sub-specialty care in a wide range of fields. Such assurance may include contracts, provider arrangements, and procedures for accessing out of network pediatric sub-specialty providers, to include Point of Service (POS) arrangements…" Delaware RFP, pages II.52, II.57, II.58.
FL
"B. Manner
Of Service Provision
1. Availability/Accessibility
of Services...
In accordance
with Section 1932 (b)(7) of the Social Security Act (as enacted by Section
4704(a) of the 1997 Balanced Budget Act), the plan shall provide the agency
with adequate assurances that the plan, with respect to a service area,
has the capacity to serve the expected enrollment in such service area,
including assurances that the plan: ...maintains a sufficient number, mix,
and geographic distribution of providers of services...
2. Minimum
Standards. Plans shall provide the following:
a. At least
one FTE primary care physician, per county, representing at least each
of these specialties: ...pediatrics…" Florida Contact, page 10.
FLMH
"2.5 Minimum
Staffing and Access Standards...
2. The
contractor's staff shall include at least one board certified child psychiatrist,
or one who meets all education and training criteria for board certification..."
Florida Mental Health RFP, page 28.
"To demonstrate the plan will have the staffing resources necessary for the provision of services complete and attach Attachment 26, PMHP Service Provider Staffing Table, denoting, for each count in the service area, the number of actual and proposed... child psychiatrists..." Florida Mental Health RFP, page 85.
HI
"APPENDIX
B
MINIMUM
PROVIDER REQUIREMENTS
PCP Requirement:
The health
plan must have contracts with at least 1 PCP per 600 QUEST members.
PCPs may
be any of the following:
*Pediatricians...
*Pediatric
Nurse Practitioners…" Hawaii RFP, Appendix B, page 1.
IA
"4.7 Coordination
and Continuation of Care
The HMO shall
ensure that the Enrollee's care is coordinated and continuous, including
at a minimum the following: ...
- Pediatric
subspecialty care when medically appropriate whether the Provider(s) is(are)
a participating or Non-Participating Provider." Iowa Contract, pages
26-27.
KY
"7.7.2 Provider
Program Capacity Demonstration...
The
Partnership shall provide the following: ...
•
Specialists shall be commensurate with the subpopulations designated by
the Department in 907 KAR 1:705 and include sufficient pediatric specialists
to meet the needs of Members under 21 years of age. A list of required
pediatric specialty care physicians and dentists is attached." Kentucky
RFA, page 48.
"Required Pediatric
Specialty Care Physicians and Dentists
Medicine
Pediatric Cardiologist
Pediatric Neurologist
Pediatric Pulmonary
Medicine Specialist
Pediatric Rheumatologist
Pediatric Hematologist
Geneticist
Pediatric Endocrinologist
Pediatric Infectious
Disease Specialist
Pediatric Nephrologist
Pediatric Gastroenterologist
Neonatologist
Rehabilitation
specialist with pediatric expertise
Immunologist
with pediatric expertise
Anesthesiologist
with pediatric expertise
Radiologist
with pediatric expertise
Pathologist
with pediatric expertise
Radiotherapist
with pediatric expertise
Oncologist
with pediatric expertise
Pediatric internist
Developmental
pediatrician
Surgery
Pediatric Ophthalmologist
Pediatric Orthopedic
Surgeon
Plastic Surgeons
with demonstrated expertise in cleft lip and palate, craniofacial anomaly,
burn management, and hand surgery
Otloaryngologist
with demonstrated expertise in management of ear disease in children
Orthopedic
Surgeon with expertise in scoliosis
Pediatric Neurosurgeon
Pediatric Urologist
Pediatric Surgeon
Pediatric Cardiovascular
Surgeon
Transplant
Surgeon with pediatric expertise
Dentistry
Maxillofacial
Surgeon
Orthodontist
Pedodontist
General Dentist"
Kentucky RFA, Attachment V, pages 48-49.
MD
"10.09.66.05...
B. Adequacy
of Provider Network.
(1) An
MCO shall develop and maintain a complete network of … pediatric primary
care … dental services for children …and any other providers…" Maryland
COMAR 10.09.66.05.
NM
"2.C.10
Local Department of Health Offices:
2.C.10.a
The CONTRACTOR shall contract with local and district public health offices
for the provision of the following services: ...
2.C.10a.ii
Vaccine administration fee for childhood and adult immunizations provided
to Medicaid members...
2.C.10.b
Children's Medical Services (CMS)
The MCO shall
contract with CMS which administer outreach clinics at sites throughout
the State. The clinics offer pediatric sub- specialty services in
local communities which include cleft palate, neurology, endocrine, and
asthma and pulmonary." New Mexico Contract, page 30.
NY
"10. BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES…
10.21
Children with Special Health Care Needs...
In addition,
the Contractor will implement the following for these children: ...
b) An adequate
network of pediatric providers and sub-specialists, contractual relationships
with tertiary institutions, to meet their medical needs." New York
Contract, pages 10-12-10-13.
NC
"6.10
Facilities and Resources
The Plan must
provide directly or by contract the following:
a. Specialists
for… pediatric care…" North Carolina Contract, page 10.
OH
"(b) Non-PCP
Minimum Provider Network
During the
verification phase, each MCP will also be required to submit documentation
or have documentation available to verify adequate capacity of the remainder
of its provider network within the following categories: … pediatricians...
Pediatricians - In order to meet the minimum provider network requirement for pediatricians, MCPs must verify during the documentation phase that they are contracting with the specified number of pediatricians for each service area. These must be pediatricians with a general pediatric practice (e.g., a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician ) who are listed as a pediatrician with the State Medical Board. In addition, a designated number of these physicians must also be certified by the American Board of Pediatrics. For the duration of the contract period, the MCP's provider network must include this minimum specified number of pediatricians, all of whom must have no practice limitations that would preclude them from accepting new pediatric patients of any age. If an MCP contracts with two or more pediatricians in the same specified county service area who have some practice limitations but who in combination are accepting new pediatric patients of all ages, this combination of pediatricians would count in total as one pediatrician in meeting the minimum provider network requirement...
The minimum provider network requirements for OB/GYNs and pediatricians are based on statewide ratios of providers to the general population, with age and gender modifications…" Ohio RFP, pages 24-26.
OK
"2.7 Provider
Network...
2.7.2
Primary Care Providers...
2.7.2.3
Eligible Specialties
Health Plan
agrees its PCPs will be physicians in the following specialties: ...
• Pediatrics
…" Oklahoma RFP, pages 32-33.
PA
"D. MEMBER ENROLLMENT
AND DISENROLLMENT...
9. Assignment
of PCPs...
• The HMO must
have adequate numbers of pediatricians in the network to permit all parents
wishing a pediatrician as a PCP to have one for their children within the
travel time limits set forth in Part II.J.2. …" Pennsylvania RFP,
pages 20-28.
"I. PROVIDER
NETWORK...
2. Network
Composition
The HMO must
establish and maintain adequate provider networks to serve all of the eligible
HealthChoices populations in geographically accessible locations within
the service area for the HealthChoices populations to be served... The
HMO shall ensure that its provider network is adequate to provide its MA
enrollees with access to quality patient care through participating professionals,
in a timely manner, and without the need to travel undue distances... The
HMO's network composition should include the following:
• Adequate
pediatricians to permit all patients wishing a pediatrician as a PCP to
have one for the child(ren) within the travel time limits set forth in
Part II.J.2. …" Pennsylvania RFP, pages 63-64.
PABH
"4. Provider
Network/Relations
a.
The MCO must provide access to all covered services for members through
a network of qualified professionals and facilities. The MCO
must not discriminate among classes of behavioral health providers on grounds
unrelated to effectiveness of efficiency. The network must have the
following features: ...
3)
Timely access to covered services and needed specialists; e.g., child and
adolescent clinical specialists..." Pennsylvania Behavioral Health
RFP, pages 61-62.
RI
"2.08.02.02
Eligible Specialties
Contractor
agrees to limit its PCPs to licensed, board-certified, eligible, or trained
Medical Doctors and Doctors of Osteopathy in the following specialties:
...
-
Pediatrics..." Rhode Island RFP, pages 33-34.
SC
"The Contractor shall ensure the availability of Specialty Providers as appropriate for both adult and pediatric members. The Contractor must ensure access to appropriate service settings for members needing medically high risk perinatal care, including both prenatal and neonatal care." South Carolina Contract, page 26.
TX
"6.13
PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS...
6.13.5
For services to children with disabilities or chronic or complex conditions,
HMO must have in its network PCPs and specialty care providers that have
demonstrated experience with children with disabilities or chronic or complex
conditions in pediatric specialty centers such as children’s hospitals,
medical schools, teaching hospitals and tertiary center levels…
6.13.8
HMO must include TDH approved pediatric transplant centers..." Texas
Contract, page 49.
"6.10
EARLY CHILDHOOD INTERVENTION (ECI)...
6.10.2
ECI Providers. HMO must contract with qualified providers to provide
ECI services to Members under age 3 with developmental delays…" Texas
Contract, page 45.
"7.8 PRIMARY
CARE PROVIDERS...
7.8.3
HMO must maintain a provider network that includes pediatricians and physicians
with pediatric experience in sufficient numbers and geographic distribution
to serve eligible children and adolescents in the service area and provide
timely access to the full scope of benefits, especially THSteps checkups
and immunizations...
7.8.5 HMO must have physicians with board eligibility/certification in pediatrics available for referral for Members under the age of 21." Texas Contract, page 63.
VA
"5. Specialist
Services
The Contractor
shall maintain in its network and in its referral listing a number of specialists
in the following specialties which is adequate to provide covered services
to its Medallion II enrollees: ...
Pediatric Physical
Medicine and Rehabilitation
Pediatrics
Pediatric Sub
specialists…" Virginia Contract, pages 64-65."