AZ
"SECTION D:
DEFINITIONS...
PRIMARY CARE
PROVIDER (PCP) An individual who meets the requirements of
ARS § 36-2901, and who is responsible for the management of a member’s
health care. A PCP may be a physician defined as a person licensed
as allopathic or osteopathic physician according to ARS Title 32, Chapter
13 or Chapter 17 or a practitioner defined as a physician assistant licensed
under ARS Title 32, Chapter 25, or a certified nurse practitioner licensed
under ARS Title 32, Chapter 15." Arizona Contract, pages 3, 6.
"SECTION D:
PROGRAM REQUIREMENTS
1. SCOPE OF
SERVICES…
Primary Care
Provider (PCP): PCP services are covered when provided by a physician,
physician assistant or nurse practitioner selected by, or assigned to,
the member. The PCP provides primary health care and serves as a
gatekeeper and coordinator in referring the member for specialty medical
services, behavioral health and dental services. The PCP is responsible
for maintaining the member’s primary medical record which contains documentation
of all health risk assessments and health care services of which they are
aware whether or not they were provided by the PCP." Arizona Contract,
pages 10, 15.
"SECTION D:
PROGRAM REQUIREMENTS
1. SCOPE OF
SERVICES…
22. PRIMARY
CARE PROVIDER STANDARDS
The Contractor
shall include in its provider network a sufficient number of PCPs to meet
the requirements of this contract. Health care providers designated
by the Contractor as PCPs shall be licensed in Arizona as allopathic or
osteopathic physicians who generally specialize in family practice, internal
medicine, obstetrics, gynecology, or pediatrics; certified nurse practitioners
or certified nurse midwifes; or physician’s assistants." Arizona
Contract, pages 10, 32.
AZBH
"PRIMARY CARE
PROVIDER (PCP)
An individual
who meets the requirements of ARS 36-2901, who is responsible for the management
of a member's health care. A PCP may be a physician defined as a
person licensed as an allopathic or osteopathic physician according to
ARS Title 32, Chapter 13 or Chapter 17,or a practitioner defined as physician
assistant licensed under ARS Title 32, Chapter 25, or a certified nurse
practitioner licensed under ARS Title 32, Chapter 15." Arizona Behavioral
Health Contract, page 6.
CA
"ARTICLE II
- DEFINITIONS...
J1. Non-Physician
Medical Practitioners (Mid-Level Practitioner) means a nurse practitioner,
certified nurse midwife, or physician assistant authorized to provide Primary
Care under Physician supervision...
U1. Primary Care means a basic level of health care usually rendered in ambulatory settings by general practitioners, family practitioners, internists, obstetricians, pediatricians, and mid-level practitioners. This type of care emphasizes caring for the Member's general health needs as opposed to specialists focusing on specific needs.
V1. Primary Care Physician means a Physician responsible for supervising, coordinating, and providing initial and Primary Care to patients; for initiating referrals for specialist care; and for maintaining the continuity of patient care. A Primary Care Physician has focused the delivery of medicine to general practice or is a board certified or board eligible internist, pediatrician, obstetrician/gynecologist, or family practitioner.
W1. Primary Care Provider means a person responsible for supervising, coordinating, and providing initial and Primary Care to Members; for initiating referrals and for maintaining the continuity of Member care. A Primary Care Provider may be a Primary Care Physician or Non-Physician Medical Practitioner." California Contract, pages 10-12.
"6.7.3.2 California
Children Services (CCS)...
E. A board-certified
physician who is a member of Contractor's provider network shall be determined
to meet the CCS standards for participation as a CCS provider and shall
be added to the CCS panel when all the following conditions are met:
1. The physician has successfully met Contractor's Credentialing standards;
2. The physician meets the CCS certification standards in accordance with Title 22, CCR, Sections 42320, 42321, 42336;
3. Contractor has submitted to the CCS program either a completed provider Credentialing application form used by Contractor or the information contained on lines one through five of the CCS Panel Application Form, extracted from Contractor's provider Credentialing application form for the physician;
4. Contractor has submitted to the CCS program a signed and dated CCS Panel Application Form with the Medi-Cal provider number for the physician." California Contract, pages 114-115.
CO
"I. DEFINITIONS
The following
terms as used in this Contract shall be construed and interpreted as follows
unless the context otherwise expressly requires a different construction
and interpretation: …
BG. 'Primary Care Physician' or 'Participating Primary Care Physician' shall mean the Physician who has entered into a professional service agreement to serve the Contractor's Members and has been designated by the Member, or the Member’s legal guardian as the Physician who will attend to the Member's routine medical care, supervise and/or coordinate all of the Member's health care, to and initiate all referrals.
BH. 'Primary Care Physician Program' or 'PCP Program' is the Department sponsored primary health care program described at 10 CCR 2050-10, § 8.200." Colorado Contract, page 10.
"XIII.
PROVIDER NETWORK…
N. Pursuant
to 42 U.S.C. 1902(a)(10)(A), the Contractor shall ensure that all Members
have appropriate access to certified nurse practitioners and certified
nurse midwives, through either provider agreements or referrals. This provision
shall in no way be interpreted as requiring the Contractor to provide any
services which are not Covered Services under this Contract." Colorado
Contract, pages 43, 46.
CT
"3.6 Geographic
Coverage
a… The
MCO shall ensure that its provider network includes access for each Member
to PCPs…" Connecticut Contract, page 19.
DE
"II.8
Provider Networks
The MCO must
establish and maintain provider networks in geographically accessible locations
for the populations to be served. These networks must be comprised of hospitals,
physicians, behavioral health providers, and other specialists in sufficient
numbers to make available all covered services in a timely manner...
8.2.2 PCP Teams
If the MCO's
primary care network includes institutions with teaching programs, primary
care provider teams, comprised of residents and a supervising faculty physician,
may serve as a PCP. In addition, all MCOs are encouraged to establish primary
care provider teams that include certified nurse midwives, or advanced
nurse practitioners who, at the member's discretion, may serve as the point
of first contact for the member. In both instances, the MCO must organize
its PCP teams so as to ensure continuity of care to members and must identify
a ‘lead physician’ within the team for each member. The ‘lead physician’
must be an attending physician and not a resident." Delaware RFP,
pages II.52-II.54.
DC
"I. SERVICE
AND ACCESS
1.
Network Composition and Capabilities
a.
Provider's network shall be sufficient to furnish all services covered
under this contract and at a minimum must include the following classes
of providers:
(1)
primary care providers in sufficient numbers so that no PCP has more
that 2,000 Medicaid Managed Care program enrollees in total across all
Providers participating in the Medicaid Managed Care Program.
With regards to the determination of the sufficient number of PCPs, the
following shall apply:
(a)
The District shall furnish information to all Providers showing the number
of Medicaid Managed Care Program patients assigned to each physician who
also participates in one or more health plans as a PCP" District
of Columbia Contract, pages 28-29.
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: family practice, pediatrics, and internal medicine.
The plan must ensure primary care physicians sufficient to ensure adequate
accessibility to all primary care services for all enrolled recipients
at all ages..." Florida Contact, page 10.
FLMH
"2.5 Minimum
Staffing and Access Standards...
3. The
contractor's outpatient staff shall include at least one FTE direct service
mental health care provider per 1,500 prepaid members. The Agency
expects the contractor's staffing pattern for direct service providers
to reflect the ethnic and racial composition of the community...
Mental health care case managers shall not be counted as direct service mental health care providers." Florida Mental Health RFP, pages 28-29.
HI
"30.410
Required Providers...
The following
is a listing of required components of the provider network...
* Primary
care physician services...
30.420
Primary Care Provider (PCP)...
Each PCP shall
be licensed in Hawaii as: 1) a physician, either and M.D. (Doctor of Medicine)
or a D.O. (Doctor of Osteopathy), and must generally be a family
practitioner, general practitioner, general internist, pediatrician or
obstetrician/gynecologist; or 2) a registered nurse recognized by the State
Board of Nursing as a family nurse practitioner, pediatric nurse practitioner,
or certified nurse midwife…" Hawaii RFP, page 9.
"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...
* Internists...
* Pediatric
Nurse Practitioners…" Hawaii RFP, Appendix B, page 1.
HIBH
"Primary care provider or PCP - licensed in Hawaii and is 1) a physician, either an M.D (Doctor of Medicine) or a D.O. (Doctor of Osteopathy), and must generally be a family practitioner, general internist, pediatrician or obstetrician/gynecologist (for women, especially pregnant women); or 2) a nurse practitioner, and must generally be a family nurse practitioner, pediatric nurse practitioner or nurse midwife (for pregnant women)." Hawaii Behavioral Health RFP, page A8.
IN
"3.2.2
Primary Medical Providers
Hoosier Healthwise
allows eligible Medicaid recipients to select a PMP who provides, through
an ongoing recipient/PMP relationship, preventive and primary medical care,
as well as authorization and referral for all medically necessary specialty
services. The PMP is available 24-hours a day, seven days a week,
and assumes total management of the Medicaid recipient's non-emergency
medical needs.
A PMP must be a physician in the field of general practice, family practice, general pediatrics, general internal medicine, or obstetrics/gynecology (OB/GYN). An OB/GYN may choose to be a PMP for pregnant women only, or for all women. Primary care physicians in any setting are eligible to be PMPs." Indiana RFP, pages 3-7 -3-8.
"Section 3. General Contents of State Child Health Plan (Section 2102)(a)(4)) Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 4.
3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children: (Section 2102)(a)(4)...
Providers who serve as PMPs may choose to participate in both the PCCM and the RBMC systems; however, they may accept new recipients in only one of the two systems at any given time. In the case of the RBMC system, PMPs may only participate in one managed care organization (MCO) in each region. With limited exceptions for former patients, new family members, and medically underserved areas, the PMP panel size is limited to a maximum of 2,000 combined Medicaid and CHIP recipients for both the RBMC system and the PCCM system together. PMPs are expected to accept a minimum of 150 enrollees, and must be available to see patients at least 20 hours per week, with certain exceptions. In addition, PMPs, or their clinically qualified designees, must be available 24 hours a day, 7 days a week. The 24 hour number is monitored randomly to assure compliance with this requirement.
There are currently 1941 PMPs enrolled throughout the state, 1433 in the PCCM system and 508 in the RBMC system. To serve as a PMP, a physician must be in one of the following specialty areas: family practice, pediatrics, general practice, obstetrics/gynecology or internal medicine. PMPs can practice in any setting, including in FQHCs.
The PMP to recipient ration is currently approximately 231 enrollees for every PMP. Public Law 273-1999 mandates that providers who participate under the Medicaid program are also considered to participate under the CHIP program. Even if all of the estimated eligible children were to enroll in CHIP and Medicaid, the average enrollment per PMP would still be significantly below the maximum PMP panel size." Indiana SCHIP Amendment, Attachment C-3, pages 12-13.
IA
"1.3 Definitions...
- Primary Care
Physician (PCP) - a physician under contract with the HMO who is duly licensed
and certified under the laws of the state of Iowa. A Primary Care
Physician shall be responsible for the initial and primary care given to
an Enrollee and shall be a general practitioner, internist, family practitioner,
pediatrician or any other physician approved by the HMO. If an Enrollee
suffers from a chronic condition lasting, or anticipated to last, more
than 12 months, and both the Provider and the Enrollee agree to provide
and receive, respectively, a full spectrum of primary care services, other
specialty Providers may be enrolled/assigned as a PCP." Iowa Contract,
pages 6, 9.
KS
"Travel Distance…
The HMO Must
have at least one primary care provider… in each county in which
the plan has participating Medicaid members or providers…" Kansas
Contract, pages 18-19.
"Provider Network
Coverage
• The
HMO Must have at least one primary care provider… in each county
in which the plan has participating Medicaid members or providers…"
Kansas Contract, page 20.
KY
"To be the eligible
applicant, Kentucky's Health Care Partnership (a.k.a. The Partnership)
must meet the following requirements: ...
•
have a Program of providers in each county who are serving a significant
portion of the current Medicaid members. This requirement applies
to each of the following provider types: ...
•
primary care;
•
have a provider Program representing the complete array of provider types
including primary care providers; primary care center, including Federally
Qualified Health Center and rural health clinics." Kentucky
RFA, pages 10-11.
"The Partnership
shall include at least the specified providers in its Program as follows:
...
(c)
Primary care centers, including FQHCs and rural health clinics, that serve
The Partnership region...
(e)
Public health departments that serve The Partnership region." Kentucky
RFA, pages 49-50.
"2.4.5
Provider Enrollment...
Other providers
of behavioral health services who may participate in the network can include…
primary care centers, or rural health clinics." Kentucky RFA, pages
51-52.
"A.
Providers to Be Enrolled
The
Partnership shall enroll into its Network…primary care centers including
Federally Qualified Health Centers (FQHCs), rural health clinics…"
Kentucky RFA, Attachment V, page 43.
ME
"II. DEFINITIONS.
A. The
following terms used in this Contract shall be interpreted as defined herein,
except to the extent that the context may clearly require otherwise: ...
45. Primary
Care Provider (‘PCP’) is the individual practitioner or team selected to
provide and coordinate all of the Enrollee's health care needs and to initiate
and monitor referrals for specialized services when required. PCPs are
medical doctors or doctors of osteopathy in the specialties of family or
general practice, pediatrics, obstetrics and gynecology, or internal medicine,
or nurse practitioners or certified nurse midwives, or physician assistants,
who meet the credentialing criteria established by a health plan and approved
by the State." Maine Contract, pages 2, 7.
"3.4 SERVICE
DELIVERY
A. PROVIDER
NETWORKS...
The Contractor
shall ensure that, at a minimum, its provider networks are comprised of...
primary care physicians, specialists, and other providers in sufficient
numbers to make available all covered services in a timely, effective and
efficient manner.
B. PRIMARY
CARE PROVIDERS
The Contractor
must limit its primary care network to licensed family physicians, general
practitioners, pediatricians, obstetricians and gynecologists (OB/GYN),
internists, advanced nurse practitioners certified nurse midwives, pediatric
and family nurse practitioners, and physician assistants practicing under
physician oversight in accordance with State regulations. The Contractor
is not required to include all of these specialties in its primary care
provider network. The Contractor shall remain at all times responsible
to the Department for sufficiently monitoring its network member's compliance
with all federal and state laws and regulations related to or effecting
the performance of this Contract and shall take all actions within its
power to ensure that members of its network are in compliance with all
federal and state laws and regulations. Such actions shall include, but
are not limited to enforcement and termination as provided in any contracts
between the Contractor and its network providers." Maine Contract,
pages 25-26.
MD
"Chapter 62
Maryland Medicaid Managed Care Program: Definitions
.01 Definitions…
(133)
'Primary care provider (PCP)' means a practitioner who is the primary coordinator
of care for the enrollee, and whose responsibility it is to provide accessible,
continuous, comprehensive, and coordinated health care services covering
the full range of benefits required by the Maryland Medicaid Managed Care
Program, as specified in COMAR 10.09.67." Maryland COMAR 10.09.62.01.
MA
"SECTION 1.
DEFINITION OF TERMS...
Primary Care
Practitioner (PCP)...
Primary Care
Practitioners who are physicians must practice one of the following specialties:
Family Practice, Internal Medicine, General Practice, Adolescent and Pediatric
Medicine, or Obstetrics/Gynecology (for women only)… PCPs for persons with
disabilities, including persons with HIV/AIDS, may include practitioners
in other relevant specialties, e.g., infectious disease…" Massachusetts
Contract, pages 6-14.
"Section 2.5
Provider Network
A. General...
6. The
Contractor shall maintain a Provider Directory (or Directories) that identifies
the Contractor's Providers, including at a minimum the following:
PCP…
C. Primary
Care Practitioner (PCP) Network...
2. The
PCP network shall include a sufficient number of PCPs to offer each Enrollee
a choice of at least 2 appropriate PCPs with open panels…" Massachusetts
Contract, pages 39-43.
MABH
"SECTION 2:
DEFINITIONS
The following
terms shall have the meaning stated, as they appear hereunder, unless the
context clearly indicates otherwise…
Primary Care Clinician (PCC) - shall mean a Division-contracted primary care provider participating in the managed care program pursuant to 130 CMR 450.118.
Primary Care Clinician Plan (PCCP/PCC Plan) - shall mean the Division program that includes PCCs who provide comprehensive, primary care services and function as the referral source for a Recipient's specialty care." Massachusetts MH/SAP Contract, Appendix A, pages 6, 12.
MI
"DEFINITIONS/
EXPLANATION OF TERMS...
PCP
Primary
Care Provider. Those providers within the Health Plans who are designated
as responsible for providing or arranging health care for specified Enrollees
of the Contractor. A PCP may be any of the following: family practice physician,
general practice physician, internal medicine physician, OB/GYN specialist,
pediatric physician when appropriate for an Enrollee, other physician specialists
when appropriate for an Enrollee's health condition, nurse practitioner,
and physician assistants…" Michigan Contract, pages vi, viii.
MN
"Section 2.53. Primary Care Provider means a provider or licensed practitioner, pursuant to Minnesota Rules, Part 4685.0100, Subpart 12 a, or a nurse practitioner or physician assistant, pursuant to Minnesota Rules, Part 4685.0100, Subpart 12b, under contract with or employed by the HEALTH PLAN." Minnesota Contract, page 15.
MO
"2.2.2 Provider Networks: The health plan must establish and maintain provider networks in…physicians, advanced practice nurses…
a. Primary Care Provider Responsibilities: The health plan must have written policies and procedures for linking every member to a primary care provider..." Missouri RFP, page 24.
"2) The health plan may also elect to make available clinics to serve as primary care providers. The clinic must provide the range of services required of all primary care providers." Missouri RFP, page 25.
MT
"PRIMARY CARE PROVIDER (PCP)- the physician, certified nurse practitioner, certifies nurse midwife, or physician's assistant who has, or an FQHC or RHC which has, entered into professional service agreement to serve the CONTRACTOR's ENROLLEES and has been designated by the ENROLLEE as the PROVIDER through whom the ENROLLEE will obtain the health care benefits provided by the contract…" Montana Contract, page 29.
"2.4.1
Choice of Primary Care Provider (PCP)
The CONTRACTOR
must inform each ENROLLEE about the full panel of PARTICIPATING PROVIDERS.
To the extent possible and appropriate, the CONTRACTOR must offer each
ENROLLEE covered under this Contract to choose a PRIMARY CARE PROVIDER
from among PARTICIPATING PROVIDERS at the time of enrollment…Primary Care
Providers (PCPs) may include:
-Family
Practice Physicians
-General
Practice Physicians
-Internal
Medicine Physicians
-Pediatric
Physicians
-OB/GYN
physicians
-Clinics:
-Federally Qualified Health Clinics(FQHCs)
-Rural Health Clinics(RHCs)
-Mid
Level Practitioners:
-Physicians Assistants
-Certified Nurse Practitioners
-Certified Nurse Midwives
-Clinical Nurse Specialists" Montana Contract, page 35.
NE
"4.1.28 The term 'Interim PCP' means a Primary Care Physician (PCP) designated by the plan when the client’s chosen or assigned PCP is not available, and shall only be applicable until the client requests a different PCP. The duration of an 'interim PCP' is only until a subsequent change is activated, effective with the first month possible given system cutoff...
4.1.41 The term 'Primary Care Case Management (PCCM) Network' means a network of contracted Primary Care Physicians (PCPs) who provide the Basic Benefits Package to NHC clients. Services provided through the PCCM Network are reimbursed on a fee-for-service basis by the Department. The PCCM Network is a non-risked-based managed care model. The Department contracts with a PCCM Network Administrator who is responsible for the development, oversight and operation of the PCCM Network and all related PCCM Network administrative services under a separate contractual arrangement. The PCCM Network and Network Administrator is not part of this contract, but is addressed under a separate contract.
4.1.42 The term 'Primary Care Physician (PCP)' means a plan credentialled physician chosen by the client or assigned by the Department who provides a 'medical home' for the client and whose primary expertise is in family practice, pediatrics, general practice, internal medicine, or obstetrics/gynecology. A PCP may participate in the NHC with any of the contracting plans. The PCP shall be a Medicaid-enrolled provider." Nebraska Contract, pages 10-11.
"13.3 Plan Relationship
to PCP: ...
13.3.2 Types
of Providers: To participate in the NHC, a PCP shall be a primary care
physician whose primary expertise is in family practice; general practice;
pediatrics; internal medicine; or obstetrics/gynecology, as identified
as the primary specialty in the Department’s Provider File System. These
five specialties shall be available for the client to choose as his/her
PCP in either the HMO or PCCM Network.
13.4 Teaching Clinics: For teaching clinics, the client shall choose the facility’s attending physician in the teaching clinic as the PCP, even though the clinic’s resident actually provides care to the client. This attending physician shall supervise and sign off on all medical care provided to the client.
13.5 Designated Specialty Care Physicians: An appropriate specialist shall be allowed to function in an extended capacity with the PCP for clients with chronic conditions requiring specialty care." Nebraska Contract, page 78.
NV
"F. Provider Network Access. The Contractor must establish and maintain provider networks in geographically accessible locations as specified in NRS 695C.070.11 and .080.2(a) for the populations to be served and in sufficient numbers to make available to participants all Contractor services in a timely manner in the service area. The Contractor's network must contain all of the provider types necessary to furnish the Contractor benefit package. The Contractor may be required to submit a signed contract for each contracted provider." Nevada Contract, pages 34-35.
NH
"Article I
Definitions...
1.29 The term
'Physician' means a Doctor of Medicine who is licensed to practice medicine
in the State of New Hampshire or under statute of the state in which he
or she practices.
A)
Contractor Physician
A Physician
directly employed by or associated with Contractor who will provide, authorize
or arrange for Covered Services under this Agreement.
B)
Consulting Physician
A Physician
to whom a patient is referred for consultation by a Contractor Physician
or the Plan...
1.32 'Primary Care Physician' (PCP) means a 'Physician' who will provide, authorize or arrange for Covered Services under this Agreement." New Hampshire General Service Agreement, page 6.
"Article II
Functions and
Duties of Contractor
In consideration
of the Agreement of the State contained in Article III, Contractor agrees:
...
2.22 AVAILABILITY-----Contractor
shall ensure to Enrollee adequate PCP coverage.
(1) Primary
Care Physician Annual Turnover: PCP annual turnover shall not have exceeded
seven percent (7%) for each of the past three (3) years. Mental health
and substance abuse provider annual turnover shall also not have exceeded
seven percent (7%) for each of the past three (3) years.
(2) Closed/Frozen Physician Practices: The Contractor shall report all groups. health centers, and individual physician practices and sites which are not accepting new patients and have been granted the ability to do so by the Contractor. The Contractor shall not close or freeze enrollment for Enrollees unless the same limitations apply to all commercially insured members." New Hampshire General Service Agreement, pages 13-15.
NJ
"ARTICLE 10
COVERED HEALTH
CARE SERVICES...
10.6
The contractor shall offer each enrollee a choice of two (2) or more primary
care physicians furnished by the contractor…" New Jersey Contract,
pages 51-52.
"ARTICLE 20
PROVIDER CONTRACTS...
20.1
The contractor shall at all times have satisfactory written contracts with
a sufficient number of providers in and adjacent to the enrollment area
to ensure enrollee access to all medically necessary services…The provider
network shall be reviewed and approved by DMAHS and the sufficiency of
the number of participating providers shall be determined by DMAHS...
20.2 The
contractor must ensure that its provider network includes, at a minimum:
A. Access to primary care physicians (PCPs)...
H. Primary care network shall include internists, pediatricians,
family and general practice physicians...
I. Sufficient number, available and accessible, of physician and
non-physician providers of health care to cover all services in amount,
duration, and scope included in the benefits package under this contract…"
New Jersey Contract, pages 110-111.
NM
"2.C.2
The Primary Care Provider (‘PCP'):
The PCP must
be a medical provider participating with the MCO who has the responsibility
for supervising, coordinating, and providing primary health care to members,
initiating referrals for specialist care, and maintaining the continuity
of the member's care. The CONTRACTOR shall distribute information
to the network providers which explains the Medicaid-specific policies
and procedures that relate to PCP responsibilities. The CONTRACTOR
is prohibited from excluding providers as primary care providers based
on the proportion of high-risk patients in their caseloads...
2.C.4
MCO Responsibility for PCP Services:
The CONTRACTOR
shall retain responsibility for monitoring PCP activities to ensure compliance
with MCO and HSD policies. The MCO shall educate PCPs about special
populations and their service needs. The CONTRACTOR shall ensure
that PCPs successfully identify and refer patients to specialty providers
as medically necessary." New Mexico Contract, pages 27-28.
NY
"21. PARTICIPATING
PROVIDERS
21.1 Network
Requirements
a) Sufficient
Number
i) The
Contractor will establish and maintain a network of Participating Providers.
ii) The Contractor's
network must contain all of the provider types necessary to furnish the
prepaid Benefit Package, including but not limited to: ...physicians (primary
care …)...
iii) To be
considered accessible, the network must contain a sufficient number and
array of providers to meet the diverse needs of the Enrollee population.
This includes being geographically accessible (meeting time/distance standards)
and being accessible for the disabled.
iv) The Contractor
shall not include in its network any provider who has been sanctioned or
prohibited from serving Medicaid recipients or receiving Medical Assistance
payments…" New York Contract, page 21-1.
"21. PARTCPATING
PROVIDERS...
21.12 Primary
Care Practitioners
a) General
Limitations
The Contractor
agrees to limit its PCPs to the following primary care specialties: Family
Practice, General Practice, General Pediatrics, General Internal Medicine,
except as specified in (b), (c), (d) and (e) of this Section…"
New York Contract, pages 21-1-21-7.
ND
"Primary Care Provider (PCP) - The physician, certified nurse practitioner, certified nurse midwife, or physician's assistant who has, or an FQHC or RHC which has, entered into a professional service agreement to serve the Contractor's enrollees and has been designated by the enrollee as the provider through whom the enrollee will obtain the health care benefits provided by the contract…" North Dakota Contract, Attachment C, page 6.
OH
"E. Service
Delivery Specifications
1. Primary
Care Physician Responsibility...
The MCP must
assure that each enrollee has a primary care provider within two months
of enrollment. Primary care physicians may be general/family practitioners,
internists, pediatricians or OB/GYNs...
*
MCPs may permit PCPs to use the services of physician assistants, advanced
practice nurses, nurse practitioners or registered nurse case managers
as clinical managers in accordance with state licensure regulations."
Ohio RFP, pages 14-15.
"7. Provider
Network...
(a) Primary
Care Physicians (PCPs)
Primary Care
Physicians (PCPs) may be individuals or group practices/clinics...
Generally acceptable
specialty types for PCPs are general/family practice, internal medicine,
pediatrics and obstetrics/gynecology…" Ohio RFP, pages 22.
OK
"2.7 Provider
Network
2.7.1
General
Health Plan
must establish and maintain a provider network with sufficient numbers
of providers and in geographically accessible locations for the populations
it serves, as defined in Section 2.7.2.7...
The Health Plan's up-to-date listing must include open capacity for PCPs...
2.7.2
Primary Care Providers
2.7.2.1
Responsibilities
Health Plan
will provide each member with a Primary Care Provider...
2.7.2.3
Eligible Specialties
Health Plan
agrees its PCPs will be physicians in the following specialties:
• Family Medicine
• General Medicine
• Pediatrics
• Internal
Medicine
• Obstetrics
and Gynecology...
2.7.2.3.1
Medical Residents Serving as PCPs
Health Plans
may use medical residents as PCPs if the following conditions are met:
• The resident
is licensed to practice in the State of Oklahoma;
• The resident
is at least at the Post-Graduate 2 (‘PG-2’) level;
• The resident
serves as a PCP only within his or her continuity clinic setting...
• The resident
works under the supervision of a licensed attending physician…" Oklahoma
RFP, pages 32-34.
ORMH
"DEFINITIONS
With the following
exceptions and additions, the terms in this agreement have the same definitions
as those terms appearing in Oregon Administrative Rules(OARs)...
Primary Care
Practitioner(PCP): A general practice physician, Family physician,
general internist, pediatrician, or gynecologist who is responsible for
providing and coordinating the OMAP Member's health care services. This
person authorizes referrals to specialists and payment is contingent upon
these authorizations." Oregon Mental Health Contract, Appendix K,
pages K1, K17.
PA
"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, to include,
but not be limited to...physicians... In sufficient numbers to make available
all services in a timely manner...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:
• An
adequate number of PCPs specializing in the treatment of persons with HIV
and AIDS...
3. Primary Care Practitioners (PCPs)
b. Eligible
Specialties
The HMO must
limit its PCPs to Board-certified, Board-eligible Medical Doctors in the
following specialties...
• Family
and general practitioners
• Internists...
The Department of Health's HMO regulations currently do not address any PCP other than a 'primary care physician'. Accordingly, in order to contract with CRNP practices to serve as PCPs, the HMO must formally request and receive Department of Health approval of an 'exception' under 28 Pa. Code §9.97...
c. PCP Teams
If the HMO
primary care network includes institutions with teaching programs, it may
use PCP teams, comprised of residents and a supervising faculty physician,
to serve as a PCP. In addition, all HMOs are encouraged to establish PCP
teams that include Certified Nurse Midwives, Certified Registered Nurse
Practitioners, and/or Physician Assistants who, at the member's discretion,
may serve as the point of first contact for the member…" Pennsylvania
RFP, pages 63-65.
PABH
"Request for
Proposals (RFP) Definitions
For the purpose
of this HealthChoices behavioral health services RFP, the definitions set
forth shall apply…
Primary Care Practitioner (PCP) - A specific physician, physician group, or health center operating under the scope of individual licensure responsible for providing primary care services and locating, coordinating, and monitoring other medial care and rehabilitation services on behalf of a recipient." Pennsylvania Behavioral Health RFP, pages 6-7.
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:
- Family
and General Practice
- Internal
Medicine...
2.08.02.03
PCP Teams
If Contractor
primary care network includes institutions with accredited primary care
residency training programs, it may use PCP teams, comprised of residents
and a supervising faculty physician, to serve as a PCP… The "lead
physician" must be an attending physician and the physician who is accountable
as the PCP..." Rhode Island RFP, pages 32-34.
SC
"4.8.2
Adequacy of Providers
The Contractor
shall maintain appropriate levels, as determined by SCDHHS, of organizational
components, including, but not limited to primary care providers…
4.8.3
Contractor's Network Composition
4.8.3.1
Primary Care Providers (PCP)
A PCP in the
Medicaid HMO Program must be a physician or network provider/subcontractor
who provides or arranges for the delivery of medical services, including
case management, to assure that all services which are found to be medically
necessary are made available in a timely manner as outlined in § 4
of this Contract. The PCP may practice in a solo or group setting or may
practice in a clinic (i.e., federally qualified health center or rural
health center) or outpatient clinic. " South Carolina Contract, pages
23-24.
"Provider Certification
and Licensing...
Medical Doctor
- an individual physician must be licensed by the Board of Medical Examiners,
under the South Department of Labor, Licensing and Regulations, and/or
appropriate medical boards in other states...
Physician's Assistant - A physician assistant is defined as a health professional who performs such tasks as approved by the State Board of Medical Examiners in a dependent relationship with a supervising physician or under direct personal supervision of the attending physician.
Certified nurse Midwife/Licensed Midwife - A certified nurse Midwife must be licensed to practice as a registered nurse by the Board of Nursing under the South Carolina Department of Labor, Licensing and Regulations…A midwife must be licensed by the Department of Health and Environmental Control (DHEC).
Certified Registered Nurse Anesthetist (CRNA) - A CHNA must be licensed to practice as a Registered Nurse and CRNA/AA in the state of South Carolina by the Board of nursing, under the Department of Labor, Licensing and Regulations, and certified by the American Association of Nurse Anesthetists...
Nurse Practitioner and Clinical Nurse Specialist - A registered nurse must complete an advanced formal education program and be licensed and certified by the Board of Nursing under the Department of Labor. Licensing and Regulations, or the appropriate medical board in other states…" South Carolina Contract, Appendix C, Tab 3, pages 1-2.
"Network Providers
and Subcontractors...
For each county
utilize the following to describe the provider's type of service and specialty.
1. Type
of Service***Provider Type/Practice Specialty...
Primary Care
Providers***Family/General Practice, Internal Medicine, OB/GYN, Pediatrics,
Other (specify type)." South Carolina Contract, Appendix D, Tab 1,
page 1.
TN
"SECTION 2 -
CONTRACTOR RESPONSIBILITIES...
2-2.
CONTRACTOR Qualifications
The
CONTRACTOR shall comply with the following requirements at the inception
of this Agreement and at all times during the life of this Agreement: ...
Clearly demonstrate the capability and intent to provide primary care case management services to TennCare eligible enrollees either by the organizational structure of the MCO using...primary care providers (PCPs), at the MCO's discretion, for all health care services provided to enrollees.
Primary care providers may include licensed physicians as well as registered professional nurses and physician assistants practicing in accordance with state law. Each enrollee must have an identified primary care provider with the exception of the dually eligible Medicare/Medicaid enrollees and children who are appropriately enrolled in TennCare…" Tennessee Contract, pages 3-4.
"2-3.
Benefits/Services Requirements and Limitations...
b. Availability
and Accessibility of Services...
2.
Minimum standards for this Agreement shall be:
(b)
One (1) or more primary care providers, willing and able to provide the
level of care and range of services necessary to meet the medical needs
of the enrollees including those with chronic and acute diseases.
There shall be a sufficient number of primary care providers who accept
new TennCare enrollees within each geographical location in which the plan
is marketed so that each primary care provider has a reasonable case load…"
Tennessee Contract, pages 7-13.
TX
"7.7 PROVIDER
QUALIFICATIONS - GENERAL...
The providers
in HMO network must meet the following qualifications: …
Physician
- An individual who is licensed to practice medicine as an M.D. or
a D.O. in the State of Texas either as a primary care provider or in the
area of specialization under which they will provide medical services under
contract with HMO; who is a provider enrolled in the Medicaid program;
and who has a valid Drug Enforcement Agency registration number and a Texas
Controlled Substance Certificate, if either is required in their practice...
Non-Physician Practitioner Provider - An individual holding a license issued by the applicable licensing agency of the State of Texas who is enrolled in the Texas Medicaid Program or an individual properly trained to provide behavioral health support services who practices under the direct supervision of an appropriately licensed professional...
School Based Health Clinic (SBHC) - Clinics located at school campuses that provide on-site primary and preventive care to children and adolescents.
7.8 PRIMARY
CARE PROVIDERS...
7.8.2
HMO must maintain a primary care provider network in sufficient numbers
and geographic distribution to serve a minimum of forty-five percent (45%)
of the mandatory STAR eligibles in each county of the service area.
HMO is required to increase the capacity of the network as necessary to
accommodate enrollment growth beyond the forty-fifth percentile (45%)…
7.8.7 HMO’s primary care provider network may include providers from any of the following practice areas: General Practitioners; Family Practitioners; Internists; Pediatricians; Obstetricians/Gynecologists (OB/GYN); Pediatric and Family Advanced Practice Nurses (APNs) and Certified Nurse Midwives Women Health (CNMs) practicing under the supervision of a physician; Physician Assistants (PAs) practicing under the supervision of a physician specializing in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a PCP under this contract; or Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and similar community clinics; and specialists who are willing to provide medical homes to selected Members with special needs and conditions (see Article 7.9.4).
7.8.8 The PCP for a Member with disabilities or chronic or complex conditions may be a specialist who agrees to provide PCP services to the Member. The specialty provider must agree to perform all PCP duties required in the contract and PCP duties must be within the scope of the specialist’s license..." Texas Contract, pages 62-64.
UT
"3. Enrollees
with Special Health Care Needs...
b. Choosing
a Primary Care Provider...
The
CONTRACTOR will have primary care providers with skills and experience
to meet the needs of Enrollees with special health care needs..."
Utah Contract, Attachment B, pages 16-17.
VA
"ARTICLE I -
DEFINITIONS...
Primary Care
Provider (PCP)… PCPs in Medallion II may include pediatricians, family
and general practitioners, internists, obstetrician/gynecologists, and
specialists who perform primary care functions, such as surgeons.
Clinics such as health departments, Federally Qualified Health Centers
(FQHCs), and Rural Health Clinics (RHCs) may also qualify as PCPs."
Virginia Contract, page 11.
"12. Choice
of Health Professional...
a. Providers
Qualifying as PCPs
The following
types of specialty physicians may perform as PCPs:
i.
Pediatricians:
ii.
Family and General Practitioners;
iii.
Internists:
iv.
Obstetrician/Gynecologists:
v.
Specialists who perform primary care functions, e.g. Surgeons:
vi.
Federally Qualified Health Centers, Rural Health Clinics, and similar community
clinics; or
vii.
Other providers approved by the Department.
b. Specialists
as PCPs
Enrollees with
disabling conditions or chronic illnesses may request that their PCP be
a specialist. The Contractor shall have in place procedures for ensuring
access to needed services for these enrollees or shall grant these PCP
requests, as is reasonably feasible and in accordance with Contractor's
credentialing policies and procedures." Virginia Contract, page 28.
WA
"1.13 Primary Care Provider (PCP) means a participating medical provider who has the responsibility for supervising, coordinating, and providing primary health care to members, initiating referrals for specialist care, and maintaining the continuity of member care. A PCP shall have, or be eligible for, a Medical Assistance Administration care provider agreement. PCPs include, but are not limited to Pediatricians, Family Practitioners, General Practitioners, Internists, Physician Assistants (under the supervision of a physician), or Advanced Registered Nurse Practitioners (ARNP), as designated by the Contractor." Washington Contract, page 3.
WV
"3.1.1
Network Capable of Full Array of Services
The MCP must
establish and maintain provider networks in geographically accessible locations
for the populations to be served. These networks must be comprised of hospitals,
primary care providers (PCPs) and specialty care providers (SCPs) in sufficient
numbers to make available all covered services in a timely manner…"
West Virginia RFA, page 14.
"3.6.4
Primary Care Centers
DHHR will provide
financial incentives for the MCP to contract with state-designated primary
care centers to provide services including Right from the Start services.
See Appendix H.
3.6.5
School-Based-Health-Centers (SBHCs)
School-based
health centers (SBHCs) provide general, primary health care services to
school-aged children. The State recognizes these centers as increasingly
important providers of primary health care, especially in rural communities
which face shortages of primary care physicians. DHHR encourages the MCP
to contract with or develop cooperative agreements with SBHCs. Such agreements
would recognize the MCP as the medical home for the child, define the process
for referring students to MCP network providers, spell out procedures for
sharing medical information between the SBHCs and the MCP, and provide
for reimbursement of the SBHC by the MCP." West Virginia RFA, page
23.
"3.2.4
Types of Primary Care providers
The MCP may
designate the following providers as PCPs, as appropriate:
* Certified
nurse midwives;
* Advanced
practice nurses; and
* Physicians
with the following specialties:
* General
practice
* Family
practice
* Internal
medicine
* Obstetrics/gynecology
* Pediatrics.
The MCP will be allowed to designate physicians outside of these specialties as PCPs for specific individuals - including those within the disabled population - whose underlying health conditions are best managed by specialists.
3.2.5 PCP Team
in Teaching Settings
If the MCP's
primary care network includes institutions with teaching programs, PCP
teams, comprised of residents, physicians assistants and a supervising
faculty physician, may serve as a PCP. The MCP must organize its PCP teams
so as to ensure continuity of care for enrollees and must identify a lead
physician within the team for each enrollee. The lead physician must be
an attending physician and not a resident." West Virginia RFA, pages
16-17.
WI
"III.
FUNCTIONS AND DUTIES OF THE HMO
In consideration
of the functions and duties of the Department contained in this Contract
the HMO shall: ...
B. PROVISION
OF CONTRACT SERVICES...
9. The
following provision refers to payments made by the HMO...Primary care providers
are defined as nurse practitioners, nurse midwives, physician assistants,
and physicians who are Medicaid certified with specialties of general practice,
OB-GYN, family practice, internal medicine, or pediatrics…" Wisconsin
Contract, pages 5, 9-10.
"Y. QUALITY
IMPROVEMENT (QI)...
4. Access
a… Primary
care providers are defined to include, but are not limited to, Physicians
and Physician Clinics with specialties in general practice, family practice,
internal medicine, obstetrics and gynecology, and pediatrics, FQHCs, RHCs,
Nurse Practitioners, Nurse Midwives, Physician Assistants, and Tribal Health
Centers. HMOs may define other types of providers as primary care
providers. If they do so, the HMOs must define these types of primary
care providers during the pre-contract review phase of the HMO Certification
process." Wisconsin Contract, pages 21, 24-25.