"26. FEDERALLY
QUALIFIED HEALTH CENTERS (FQHC)
The Contractor
is encouraged to use FQHCs in Arizona to provide covered services and must
comply with the federal mandates in OBRA 89 and OBRA 90...
The following
FQHCs are currently recognized by HCFA:
Clinical
Adelante, Inc.
El Rio
Health Center
Lake
Powell Medical Center
Mariposa
Community Health Center, Inc.
Mountain
Park Health Center
Sun
Life Family Health Center
United
Community Health Center, Inc.
Sunset
Community Health Center (formerly Valley Health Center, Inc.)
Inter-Tribal
Health Care Center
Native
American Community Health Center, Inc.
Native
Americans for Community Action Family Health Center
Chiricahua
Community Health Centers, Inc.
Marana
Health Center
North
Country Community Health Center
Any other clinics
that subsequently become FQHCs will be subject to the reimbursement methodology
described above upon electing reasonable cost reimbursement from AHCCCSA."
Arizona Contract, pages 34-35.
"64. KIDSCARE
On November
1, 1998, AHCCCSA implemented a Title XXI Children's Health Insurance Program,
referred to as 'KidsCare'. KidsCare provides health care coverage
statewide to eligible children 18 and younger and is provided through the
existing AHCCCS health plans, state employee HMOs that elect to participate,
and tribal facilities or Indian Health Service for Native Americans who
elect to receive services through them. Services will also be directly
provided by participating community health clinics and hospitals which
predominantly serve low income children." Arizona Contract, page
54.
CA
"ARTICLE II
- DEFINITIONS...
E2. Rural Health
Clinic (RHC) means an entity defined in Title 22, CCR, Section 51115.5."
California Contract, pages 2, 12.
"3.28.6 Federally
Qualified Health Centers/Rural Health Clinics
Contractor
shall not enter into a Subcontract with a Federally Qualified Health Center
(FQHC) or a Rural Health Clinic (RHC) unless DHS approves the provisions
regarding rates, which shall be subject to the standard that they be reasonable,
as determined by DHS, in relation to the services to be provided in accordance
with Article VI, Section 6.6.20, FQHC and RHC Contracts. In Subcontracts
where the FQHC or RHC has made the election to be reimbursed on a reasonable
cost basis by the State, provisions shall be included that require the
subcontractor to keep a record of the number of visits by plan Members
separate from Fee-For-Service Medi-Cal beneficiaries, in addition to any
other data reporting requirements of the Subcontract.
Subcontracts with FQHCs shall also meet Contract requirements of Article VI, Sections 6.6.19, FQHC Services, and 6.6.20, FQHC and RHC Contracts. Subcontracts with RHCs shall also meet Contract requirements of Article VI, Section 6.6.20." California Contract, pages 38-39.
"6.6.9 Traditional
and Safety-Net Providers Participation
The Contractor
will ensure the participation and broad representation of traditional and
safety-net providers within the county. Federally Qualified Health
Centers meet the definitions of both traditional and safety-net providers.
6.6.10
Traditional and Safety-Net Provider Capacity
The Contractor
will maintain the percentage of traditional and safety-net provider capacity
submitted and approved by DHS." California Contract, page 106.
"6.6.21 Indian
Health Service Facilities
Contractor
shall reimburse out-of-plan Indian Health Service Facilities for services
provided to Members who are qualified to receive services from an Indian
Health Service Facility. Contractor shall reimburse the out-of-plan
Indian Health Service Facility at the approved Medi-Cal rate for that Facility."
California Contract, page 110.
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: ...
HH. 'Essential
Community Provider' shall mean a health care provider that:
(a) has historically
served medically needy or medically indigent patients and demonstrates
a commitment to serve low-income and medically indigent populations who
make up a significant portion of its patient population or, in the case
of a sole community provider, serves the medically indigent patients within
its medical capability; and
(b) waives
charges or charges for services on a sliding scale based on income
and does not restrict access or services because of a client’s financial
limitations, pursuant to 26-4-114 (3)(a)(b), C.R.S. In order to qualify
as an Essential Community Provider (which includes site and staff), a health
care provider must provide services to the populations, and through at
least one of the delivery systems, specified in 10 CCR 2050-10, §
8.206.31...
AL. 'Federally Qualified Health Center' or 'FQHC' shall mean an entity which provides ambulatory medical care services and is recognized by the United States Department of Health and Human Services as entitled to be an FQHC and is enrolled with the Department as an FQHC." Colorado Contract, pages 5-6.
"X. SUBCONTRACTS...
J. For
purposes of assuring network adequacy and continuity of care, the Contractor
shall make a good faith effort to enter into subcontracts with Essential
Community Providers operating in counties served by the Contractor, as
required in 10 CCR 2050-10, § 8.206.31. The Department shall provide
the Contractor with an updated listing of ECPs operating in counties within
the Contractor’s Service Area upon request." Colorado Contract, pages 39-40.
CT
"3.14
Family Planning Access and Confidentiality
a… The MCO
shall make a reasonable effort to subcontract with all local family planning
clinics and providers, including those funded by Title X of the Public
Health Services Act…" Connecticut Contract, page 24.
DE
"8.2.3 FQHCs/RHCs
MCOs will be
required to contract with FQHCs, unless they can demonstrate that the MCOs
have adequate capacity and will provide an appropriate range of services
for vulnerable populations and if the FQHCs are willing to contract with
them. The State would be hard pressed to contract with an MCO that claimed
it could provide the care in several areas of Delaware without contracting
with an FQHC. See Chapter 2 section 7.2.4...
8.3.2 Existing
Community Providers
The State strongly
encourages MCOs to contract with providers of essential community services
who would normally contract with the State as well as other public agencies,
such as the Division of Public Health, the Division of Alcohol, Drug Abuse
and Mental Health, the Division of Child Mental Health and the Department
of Education. Many of these providers serve the Medicaid population. In
order to maintain continuity of care, the state considers the special expertise
of these providers to be important, especially in the area of Children
with Special Health Care Needs (CSHCN)
Should the method of reimbursement for these services be capitation, the State expects the MCO to risk adjust the capitation to reflect the serious and chronic nature of the necessary services for these children." Delaware RFP, pages II.54-II.55.
HI
"30.440
FQHCs and RHCs...
The HCFA terms
and conditions for QUEST specify that the State shall require health plans
to contract with FQHCs unless the health plan can demonstrate to the U.S.
Department of Health and Human Services and DHS that the plan has both
adequate capacity and an appropriate range of services for vulnerable populations…"
Hawaii RFP, page 11.
"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:
* Clinics
(clinics must list all of their physician and non-physician PCPS)"
Hawaii RFP, Appendix B, page 1.
"b) Are health plans required to contract with both FQHCs and RHCs or just FQHCs?...
ANSWER...
The health
plan is required to contract with FQHCs and look alike, and RHCs unless
it can demonstrate that it is able to meet the requirements to providing
medical services to a vulnerable population…" Hawaii RFP, Q&A, page
6.
HIBH
"30.440
Department of Health Adult Mental Health Division (DOH-AMHD)
The Adult Mental
Health Division (AMHD), through its Community Mental Health Centers (CHMC).,
provides case management and outpatient behavioral health services to persons
who are seriously mentally ill (SMI)...
The BHMC plan is encouraged to include the AMHD CMHCs in its provider network. The AMHD will contract for its CHMCs with the BHMC plan to make the CMHCs part of the plan's provider network. No individual CHMC will contract independently with BHMC plan...
30.450
Department of Health Child and Adolescent Mental Health Division (DOH-CAMHD)
The Department
of Health, through its and Child and Adolescent Mental Health Division-Family
Guidance Center Branches (FGCBs), provides behavioral health services to
children and youth who are severely emotionally disturbed (SED)...
The BHMC plan is encouraged to include the CAMHD centers in its provider network. The CAMHD will contract for its FGCBs with the BHMC plan to make the FGCBs part of the plan's provider network…" Hawaii Behavioral Health RFP, pages 18-19.
IN
"4.4.2.5
Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs)
Since FQHCs
and RHCs are essential community providers, MCOs are strongly encouraged
to contract with FQHCs and RHCs and will be evaluated on the use of FQHCs
and RHCs in their network. MCOs must identify in their proposal the
FQHCs and RHCs with which they intend to contract and must specify the
contractual arrangements that assure that reimbursement to FQHCs and RHCs
for services is not less than the level and amount of payment the MCO would
make for the services if the services were furnished by a provider which
is not a FQHC or RHC. Prior to contract signature, the MCO must notify
OMPP of the type of financial arrangement selected with FQHCs and RHCs.
OMPP endorses the following two types of contractual arrangements:
*
The FQHC or RHC accepts a full capitation (i.e. for primary care, specialty
care, and hospital care).
*
The FQHC or RHC accepts a partial capitation or other method of payment
at less than full risk for patient care (i.e. primary care capitation,
fee-for-service)." Indiana RFP, pages 4-8 - 4-9.
IA
"4.2.5.3.
Contracts with Federally Qualified Health Clinics (FQHC) and Rural Health
Clinics (RHC)
The HMO is
encouraged to contract with RHCs and FQHCs in their Enrollment Area who
meet the HMO's credentialing criteria and who meet the DEPARTMENT's RHC
or FQHC Medicaid enrollment criteria as outlined in IAC 441--7721 ad 77.35
respectively. The HMO's payments for services provided by a RHC or
FQHC shall be no less than the HMO's customary payment for any other Provider
of similar services in the same geographic area." Iowa Contract,
pages 24-25.
KS
"D. LOCAL
HEALTH DEPARTMENTS
The Kansas
Department of Health and Environment provides funding to Local Health Departments
for the provision of health care services to low income individuals. The
HMO shall make a reasonable effort to subcontract with any local health
care provider receiving funds from Titles V and X of the Social Security
Act. Close cooperation with these entities is strongly encouraged...
F. RURAL
HEALTH CLINICS
The HMO shall
make a reasonable effort to subcontract with any rural health clinic located
within its service area. Close cooperation with these entities is strongly
encouraged.
G. FEDERALLY
QUALIFIED HEALTH CENTERS (FQHCs)
The HMO shall
make a reasonable effort to subcontract with each Federally Qualified Health
Center located within its service area. Close cooperation with these entities
is strongly encouraged...
H. INDIAN
HEALTH SERVICES
The HMO shall
coordinate with any Indian Health Services or tribally operated facilities
if applicable. Documentation of such coordination is required before contract
signature." Kansas Contract, pages 10-12.
"L. FAMILY
PLANNING SERVICE ACCESS AND CONFIDENTIALITY...
The HMO shall
make a reasonable effort to cooperate and communicate with all local family
planning clinics and centers, including those funded by Title X of the
Public Health Services Act." Kansas Contract, page
17.
"Federally Qualified Health Center (FQHC) - an entity which provides ambulatory medical care services and is certified as an FQHC by the Department of Health and Human Services." Kansas Contract, Appendix E, page 3.
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: ...
•
have a provider Program representing the complete array of provider types
including primary care providers; primary care centers, including Federally
Qualified Health Centers and rural health clinics; the Commission for Children
with Special Health Care Needs and local health departments serving the
appropriate Partnership Region, See Attachment XII..." Kentucky RFA,
pages 10-11.
"The Partnership
shall include at least the specified providers in its Program as follows:
...
(b)
Children's Hospitals providing services under traditional Medicaid that
practice outside of the commonwealth. In the case where a traditional
out-of-state provider does not contract with The Partnership, The Partnership
shall provide a plan for assuring continuity of care for children served
by these providers as described in section 7.9.2 of this application.
(c)
Primary care centers, including FQHCs and rural health clinics, that serve
The Partnership region.
(d)
The Kentucky Commission for Children with Special Health Care Needs.
(e)
Public health departments that serve The Partnership region...
The Partnership's Program shall also include any charitable providers, such as free clinics or Shriner's Hospital for Children, which serve Members in the Partnership Region, provided that they meet credentialing standards. The Partnership is encouraged to enter into contracts with any existing school-based health care provider within its region.
The Partnership shall demonstrate the extent to which its Program has incorporated providers who have traditionally provided a significant level of care to Medicaid clients within the geographic Partnership Region." Kentucky RFA, pages 49-50.
ME
"3.4 SERVICE
DELIVERY
A. PROVIDER
NETWORKS...
The Contractor
shall ensure that, at a minimum, its provider networks are comprised of…FQHCs...
and other providers in sufficient numbers to make available all covered
services in a timely, effective and efficient manner...
C. FEDERALLY
QUALIFIED HEALTH CENTERS
The Contractor
shall subcontract with any and all Federally Qualified Health Centers (FQHCs)
offering to negotiate in good faith to enter into a contract for the provision
of services within this Initiative. The Contractor must reimburse FQHCs
in a manner described in Exhibit H." Maine Contract, pages 25-26.
MD
"I. THE
MCO AGREES: ...
C. To
enter into a contract with any historic provider assigned to the MCO by
the Department in accordance with COMAR 10.09.65.16." Maryland Contract,
page 1.
"Chapter 62
Maryland Medicaid Managed Care Program: Definitions
.01 Definitions…
(57)
'Federally qualified health center (FQHC)' means a clinic which either:
(a) Receives
a grant under §329, 330, or 340 of the Public Health Services Act,
42 U.S.C. §254c; or
(b) Meets
the requirements for a grant under §329, 330, or 340 of the Public
Health Services Act, 42 U.S.C. §254c; or
(c) Qualifies
as a FQHC pursuant to a waiver from the Secretary of the U.S. Department
of Health and Human Services of one or more of the requirements for receiving
a grant under §329, 330, or 340 of the Public Health Services Act,
42 U.S.C. §254c...
(65) 'Historic Provider' means a health care provider, as defined in Health-General Article, §19-4A-01, Annotated Code of Maryland, who, on or before June 30, 1995, had a demonstrated history of providing health care services to Program recipients and otherwise meets the requirements of COMAR 10.09.65.16." Maryland COMAR 10.09.62.01.
"10.09.65.16...
.16 Historic
Providers.
A. Conditions
of Eligibility.
(1) A
health care provider or residential service agency is an historic provider
if the provider or agency meets the:
(a)
Definition of:
(i) 'Health care provider' set forth in Health-General Article, §19-1501(d),
Annotated Code of Maryland, or
(ii) 'Residential service agency' as defined in Health-General Article,
§19-4A-01, Annotated Code of Maryland; and
(b)
Criteria for establishing a demonstrated history of providing health care
services to Program recipients if the provider has, between July 1, 1994,
and June 30, 1995:
(a)
Provided 1,000 units of service to program recipients;
(b)
Earned $25,000 in Medicaid payments based on services delivered to Program
recipients; or
(c)
Served as a PMP to 100 Program recipients…
(4) A provider or residential service agency has a demonstrated history of providing health care services to Program recipients if the provider or residential service agency has, during any calendar year between 1991 and 1994, inclusive, had a practice consisting of at least 5 percent Program recipients.
(5)c To qualify
for participation in the Maryland Medicaid Managed Care Program, an historic
provider shall meet and maintain the following standards, as applicable:
(a)
Be in compliance with all applicable State laws under Health-General and
Health Occupations Articles, Annotated Code of Maryland;
(b)
Meet the general Medical Assistance Provider participation criteria set
forth in COMAR 10.09.36;
(c)
Be in compliance with 42 CFR Part 489, Subpart I, Advance Directives;
(d)
Be appropriately licensed, certified, or otherwise legally authorized,
and in good standing, under Health Occupations Article or Health-General
Article, Annotated Code of Maryland;
(e)
Meet all COMAR Medical Assistance provisions applicable to the provider's
license type;
(f)
If the provider is a physician or an advanced practice nurse whose certification
type authorizes prescribing, have an unrestricted current DEA and CDS license;
(g)
If a physician, have:
(i) An unrestricted current license to practice medicine, and
(ii) Completed an approved resiliency program, or 10 years continuous
experience in practicing medicine;
(h)
If an advanced practice nurse, have an unrestricted current nursing license
and advanced practice certification;
(i) If a practitioner, provide an attestation of good health and
absence of substance abuse;
(j)
Have no sanctions imposed by either the Department or the Health Care Financing
Administration in the past 10 years...
B. Certification
and Assignment.
(1) An
historic provider that satisfies the requirements of §A of this regulation
is guaranteed initial participation in at least one MCO.
(2) If the historic provider is unable to secure a position on any MCO's provider panel serving the service area of the provider's practice, the historic provider may petition the Department, in writing, for certification and assignment to an MCO...
(4) The
Department shall review the historic provider applicant's qualifications
to determine whether the requirements of §A of this regulation are
met...
(b)
Qualifies as an historic provider who meets the quality standards for Maryland
Medicaid Managed Care Program participation, the Department shall certify
the historic provider applicant as an historic provider eligible for mandatory
assignment to an MCO.
(5) Assignment.
(a)
The Department shall identify all MCOs operating in the area served by
the certified historic provider, and select an MCO to which the certified
historic provider will be assigned.
(b)
Except as provided in §B(5)(c) of this regulation, the Department's
assignment of historic providers to specific MCOs shall be done on a rotation
basis, intended to result in all MCOs in the region having comparable numbers
of assigned historic providers.
(c)
In determining to which MCO an historic provider will be assigned, the
Department may consider:
(i) Which MCO in the area has the largest number of the historic
provider's Medicaid patients enrolled; and
(ii) Whether the historic provider's past contractual or employment
affiliation with the MCO or its predecessor entity, if any, resulted in
the historic provider's termination, for cause, from the MCO's provider
network.
(6) Historic
Provider Contract.
(a)
Subject to the reimbursement requirement for FQHCs in Regulation .21 of
this chapter, upon the historic provider's assignment to an MCO, the MCO
shall offer the historic provider a contract with terms that are substantially
equivalent to the MCO's contracts with similarly qualified nonassigned
providers in the same or similar practice categories." Maryland COMAR
10.09.65.16.
MI
"II-I
SPECIAL COVERAGE PROVISIONS...
5. Federally
Qualified Health Centers (FQHCs)
The Contractor
agrees to provide Enrollees with access to services provided through a
Federally Qualified Health Center (FQHC) if the Enrollee resides in the
FWHC's service area and if the Enrollee requests such services…"
Michigan Contract, pages 22, 25.
MN
"Section 9.2.7. FQHCs and RHCs Contracting Requirements… The STATE may require the HEALTH PLAN to offer to contract with any FQHC or RHC in the HEALTH PLAN's Service Area...
Section 9.2.8. Community Clinic, Community Mental Health Centers, and Community Health Services Agencies Subcontracting Requirements. The HEALTH PLAN shall contract with nonprofit community clinics, community mental health centers, or community health services agencies to provide services to Enrollees who choose to receive services from the clinic or agency, if the clinic or agency agrees to payment rates that are competitive with rates paid to other HEALTH PLAN providers for the same or similar services… The STATE will provide the HEALTH PLAN with a list of all nonprofit community clinics, community mental health centers, and community health services agencies within the Service Area within one week of the effective date of the Contract… The HEALTH PLAN must submit a written invitation to contract to each nonprofit community health clinic, community mental health center or community health services agency within the Service Area within 30 days of the effective date of this Contract…" Minnesota Contract, pages 84-85.
MO
"i. Federally Qualified Health Centers and Rural Health Clinics: The health Plan must include Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in its network unless it can demonstrate that it has both adequate capacity and an appropriate range of services to provide care for the expected enrollment in a service area without contracting with Federally Qualified Health Centers or Rural Health Clinics (a description of Federally Qualified Health Center/Rural Health Clinic) services is included...
j. Tile X and Title V Family Planning Providers: Although the health plan is encouraged to include Title X and Title V Family Planning and sexually transmitted disease treatment providers in its network to serve individuals covered under the comprehensive and extended family planning, women's reproductive health, and sexually transmitted diseases benefit packages, full freedom of choice must be available for the provision of these services…" Missouri RFP, page 27.
MT
"COMMUNITY BASED ORGANIZATIONS- local governmental and nonprofit organizations providing programs of preventive and other health related services. Community based organizations provide services that include but are not limited to: child immunizations, health education, case management, health screening, nutrition, poison prevention, developmental outpatient and health support services and health tracking programs." Montana Contract, page 26.
"2.4.1
Choice of Primary Care Providers (PCP)...
Primary Care
Providers (PCPs) may include: ...
-clinics:
-Federally Qualified Health Clinics(FQHCs)
-Rural Health Clinics (RHCs)...
2.4.2 Participating Providers:...
2) Federally
Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs):
The CONTRACTOR
shall offer Federally Qualified HEALTH CENTERS (FQHCs) or Rural Health
Clinics (RHCs) which serve RECIPIENTS in the enrollment area terms and
conditions, excluding reimbursement, at least as favorable as those offered
to other PRIMARY CARE PROVIDERS, providing the FQHC or RHC substantially
meets the same access and credentialling criteria as the CONTRACTOR's other
PRIMARY CARE PROVIDERS, as specified in Appendix 2, 2.4.3 and 2.6.4, respectively.
The HMO must have signed contracts with interested FQHCs and RHCs in the
enrollment area of proof that the FQHC/RHC did or could not meet the terms.
If a new FQHC/RHC is available in the enrollment area after the contract
is in effect, the DEPARTMENT will notify the CONTRACTOR and the CONTRACTOR
will have six (6) months from notification to subcontract with or prove
the FQHC/RHC did or could not meet the terms...
3) Public
Health Clinic Access
Give each ENROLLEE,
including adolescents, the opportunity to go to any public health clinic
for immunization and blood lead testing (but not well-child screens) without
requiring a referral. The CONTRACTOR shall also make a reasonable
effort to contract with all county public health clinics. At a minimum
the CONTRACTOR shall reimburse such public health clinics to submit claims
or reports in specified formats before reimbursing services.
4) Indian
Health Services (HIS):
If a recipient
is eligible for Indian Health Services and chooses to receive services
within an HIS clinic then prior approval is not required and the HIS is
responsible for billing the service Fee-for-service to the state.
If the HIS clinic refers the recipient to services outside the HIS clinic, approval is required from the recipient PCP. If authorization is not acquired then HIS is responsible for paying for the services received." Montana Contract, pages 35-37.
2.5.1 (B)
Family Planning Service Access and Confidentiality
The CONTRACTOR
shall make a reasonable effort to contract with family planning clinics
funded by Title X of the Public Health Services Act…" Montana Contract,
page 43.
NE
"13.50 Federally
Qualified Health Centers (FQHC): Each plan shall contract with any FQHC
located within the designated coverage area or otherwise arrange for the
provision of FQHC services...
13.50.1 Client
Choice: In the NHC, the client chooses to participate with the FQHC by
selecting the physician as his/her PCP.
13.50.2 Availability
of FQHC Facilities: Currently, the following facilities are in the designated
coverage areas and meet the definition of an FQHC:
(a) Nebraska
Urban Indian Health Center - Lincoln; and
(b) Charles
Drew - Omaha.
The Panhandle Community Services Health Center in Gering is also considered a FQHC but is not included in the designated coverage areas.
13.50.3 Rural Health Clinics: No Rural Health Clinics exist in the designated coverage areas. The same reasonable efforts that are applied to the FQHC, apply to the Rural Health Clinics.
13.50.4 Tribal
Clinics: The following are considered clinics/hospitals under tribal authority:
(a) Ponca Health
and Wellness Dental Clinic in Omaha;
(b) Winnebago
Dental Health Clinic in Winnebago;
(c) Carl T.
Curtis Health Center in Macy; and
(d) Santee
Health Center in Niobrara." Nebraska Contract, pages 99-100.
NEBH
"11.56 Federally Qualified Health Centers (FQHC): If MH/SA services are provided by the FQHC, the PHP shall contract with an FQHC or otherwise arrange for the provision of FQHC services…" Nebraska Behavioral Health Contract, page 69.
NV
"U. Essential
Community Providers. The Contractor is required to negotiate in good
faith with all of the following providers who are located in the plan's
geographic service area(s):
1) A Federally
Qualified Health Center to provide health care services;
2) University
Medical Center of Southern Nevada to provide inpatient and ambulatory services;
3) University
of Nevada School of Medicine to provide primary care; and
4) Any health
provider designated by DHCFP as an essential community provider.
An essential
community provider is defined as a provider:
1.
Which accepts patients on a sliding scale fee determined on the income
of the patient and;
2.
Does not restrict access or services due to financial limitations of a
patient and;
3.
Can demonstrate to DHCFP that at least 10% of the previous years income
was from Medicaid and as such, the restriction of patient base from this
provider would cause access problems for either Medicaid or low income
patients.
DHCFP will notify Contractor of providers designated by DHCFP as essential community providers.
Negotiating in good faith requires, at a minimum, offering contracts which are at least as beneficial to the provider as contracts with other providers in the same geographic area for similar services." Nevada Contract, page 37.
NJ
"ARTICLE 3
COMPENSATION/CAPITATION...
3.9 The
contractor shall contract with at least one Federally Qualified Health
Center (FQHC) located in its enrollment area based on the availability
and capacity of the FQHCs in that area…" New Jersey Contract, pages
30-31.
"ARTICLE 7
ENROLLMENT...
7.20
The contractor shall offer as an enrollment choice or assign (as needed)
enrollees to its subcontracted FQHC primary care providers in the same
manner, numbers and case-mix as for any other participating primary care
provider in the contractor's network." New Jersey Contract, pages
40-43.
NM
"2.C.8
Federally Qualified Health Centers (‘FQHCs'):
Federally qualified
health Centers (FQHCs) are federally-funded Community Health Centers, Migrant
Health Centers and Health Care for the Homeless Project that receive grants
under sections 329,330 and 340 of the US Public Health Services Act.
Current federal regulations {SSA 19002(a)(13)(E)} specify that states must
guarantee assess to FQHCs and RHCs under Medicaid managed care programs;
therefore the CONTRACTOR must provide access to FQHCs and RHCs to the extent
that access is required under federal law. The CONTRACTOR must contract
with as may FQHCs and RHCs as necessary to permit beneficiaries access
to participating FQHCs and RHCs without having to travel a significant
distance..." New Mexico Contract, page 29.
"2.C.10 Local
Department of Health Offices:
The CONTRACTOR
shall contract with public health providers for services as described in
Section MAD-606.A.6., BENEFITS PACKAGE, and those defined as public health
services under State law, NMSA (1978) Sections 24-1-1, et, seq.
2.C.10a
The CONTRACTOR shall contract with local and district public health offices
for the provision of the following services:..
2.c.10.a.iii
In addition the MCO may contract with local and district health offices
for other clinical preventive services not otherwise available in the community
such as prenatal care or prenatal case management." New Mexico Contract,
page 30.
"2.C.13
Indian Health Services (IHS) & Tribal Health Centers:
The CONTRACTOR
shall allow members who are native American to seek care from any IHS.
Tribal Provider or Urban Indian Program Provider defined in the Indian
Health Care Improvement Act (25 U.S.C. 1601 et seq.) whether or not the
provider participates in the CONTRACTOR provider network.
The CONTRACTOR
may not prevent members who are IHS beneficiaries from seeking care from
IHS, Tribal or Urban Indian Providers, and network providers due to their
status as native Americans.
The CONTRACTOR
must track IHS expenditures by members for those native Americans who voluntarily
enroll in the MCO. The MCO shall reimburse these providers.
The CONTRACTOR
must track reimbursement to these providers by member.
The CONTRACTOR
must submit this report quarterly. IHS is entitled to be reimbursed
by the CONTRACTOR rates set by the Federal Officer of Management and Budget
or an alternative rate, if agreed to and accepted by these providers."
New Mexico Contract, page 32.
NY
"21. PARTICIPATING
PROVIDERS...
21.20
Federally Qualified Health Centers (FQHCs)
In voluntary
counties, the Contractor is not required to contract with FQHCs...
In mandatory counties, the Contractor shall contract with FQHCs operating in its Service Area. However, the Contractor has the option to make a written request to the SDOH for an exemption from the FQHC contracting requirement, if the Contractor can demonstrate, with supporting documentation, that it has adequate capacity and will provide a comparable level of clinical and enabling services (e.g., outreach, referral services, social support services, culturally sensitive services such as training for medical and administrative staff, medical and non-medical and case management services) to vulnerable populations in lieu of contracting with an FQHC in its Service Area…
When the Contractor is participating in a county where an MCO that is sponsored, owned and/or operated by one or more FQHCs exists, the Contractor is not required to include any FQHCs within its network in that county…" New York Contract, pages 21-1-21-10.
ND
"2.5 Public
Health Clinic Access
The Contractor
shall give each enrollee, including adolescents, the opportunity to go
to any public health clinic for immunizations and blood lead testing, but
not well-child screens, without requiring a referral. The Contractor
shall also make a reasonable effort to contract with all county public
health clinics for these and other services…" North Dakota Contract,
Attachment C, page 11.
"2.10
Enrollment Limits and Guarantees...
(2)… Additionally,
the Contractor must have signed contracts with interested FQHCs and RHCs
in the enrollment area or prove that the FQHC/RHC did not or could not
meet the terms. If a new FQHC/RHC is available in the enrollment
area after the contract is in effect, the Department will notify the Contractor
and the Contractor will have six months from notification to subcontract
with or prove the FQHC/RHC did or could not meet the terms…" North
Dakota Contract, Attachment C, page 14.
"2.21
Participating Providers...
The Contractor
shall offer federally qualified health centers (FQHCs) or rural health
clinics (RHCs) which serve recipients in the enrollment area terms and
conditions, excluding reimbursement, at least as favorable as those offered
to other primary care providers, providing the FQHC or RHC substantially
meets the same access and credentialing criteria as the Contractor's other
primary care providers, as specified in Sections 2.9 and 2.22 respectively.
At a minimum, the Contractor must pay an FQHC or RHC participating provider
either the Medicaid interim rate for each medically necessary enrollee
visit to the FQHC or RHC or make the same capitation payment per enrollee
offered to the Contractor's other primary care providers…" North
Dakota Contract, Attachment C, pages 22-23.
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: … federally qualified
health centers (FQHCs)…" Ohio RFP, page 24.
"Federally Qualified Health Center (FQHC) Services...
In order to
receive a provider agreement, the applicant will be required during the
proposal documentation phase to either
(1) contract
with an FQHC in each county in the service area or
(2) demonstrate
that it will provide a comparable range of services without contracting
with an FQHC." Ohio RFP, pages 27-28.
OK
"2.7.10
Essential Community and Special Needs Providers
Health Plan
must contract with at least one Federally Qualified Health Center (FQHC)
in each service area in which it operates…" Oklahoma RFP Contract,
page 39.
PA
"H. COORDINATION
WITH OUT-OF-PLAN SERVICES
1. General
The Department
strongly encourages the HMO to enter into written agreements with public
health entities and community-based social services including but not limited
to:
• State
and County/Municipal Health Clinics/CLPPPs
• Regional
Health Resource Centers
• Family
Planning Clinics
• AIDS
Service Organizations
• Community
Service Providers…" Pennsylvania RFP, page 51.
"I. PROVIDER
NETWORKS...
5. FQHCs
The HMO should
contract with a sufficient number of FQHCs to ensure access to FQHC services,
If the HMO's primary care network includes FQHCs, these sites may be designated
as PCP sites…" Pennsylvania RFP, pages 63-66.
RI
"2.08.07 FQHCs/RHCs
Contractor shall include
FQHCs and RHCs in its network unless it can demonstrate that it has both adequate
capacity and an appropriate range of services for vulnerable populations to
serve the expected enrollment in a service area without contracting with FQHCs
or RHCs (a description of FQHC services is included in Attachment G)."
Rhode Island RFP, page 37.
"FQHC - A South Carolina licensed health center is certified by the Health care Financing Administration and receives Public Health Services grants. A FQHC is eligible for state defined cost based reimbursement from the Medicaid fee-for-service program. A FQHC provides a wide range of primary care and enhanced services in a Medically under served Area." South Carolina Contract, Appendix A, page 4.
"RHC - A South Carolina licensed rural health clinic is certified by the Health care Financing Administration and receives Public Health Services grants. A RHC is eligible for state defined cost based reimbursement from the Medicaid fee-for-services program. A RHC provides a wide range of primary care and enhanced services in a medically under served area." South Carolina Contract, Appendix A, page 8.
"Provider Certification and Licensing...
Federally Qualified Health Clinics
(FQHC) - Clinics must have a Notice of Grant Award under 319, 330, or 340
or the Public Health Services Act and be certified by the Health Care Financing
Administration (HCFA). Providers billing laboratory procedures must
have a clinical Laboratory Improvement Amendment (CLIA) certificate.
Rural Health Clinics (RHC) - Clinics
must be surveyed and licensed by the Department of Health and Environmental
control (DHEC) and certified by the Health care Financing Administration (HCFA).
Providers billing laboratory procedures must have a Clinical Laboratory Improvement
Amendment (CLIA) Certificate. Laboratories can only provide services
that are consistent with their type of CLIA certification." South Carolina
Contract, Appendix C, Tab 3, page 2.
TN
"2-3.
Benefit/Service Requirements and Limitations...
q. Federally
Qualified Health Centers (FQHCs) and Other Safety Net Providers
The
CONTRACTOR is encouraged to contract for the provision of primary care
services, preventive care services and/or specialty/referral services with
Federally Qualified Health Clinics (FQHCs) and other safety net providers
in the CONTRACTOR'S service area to the extent possible and practical.
In addition, where FQHCs are not utilized, the MCO must demonstrate to
the U.S. Department of Health and Human Services, the Tennessee Department
of Human Services and to TENNCARE that both adequate capacity and an appropriate
range of services for vulnerable populations exist to serve the expected
enrollment in a service area without contracting with FQHCs…" Tennessee
Contract, pages 7-26.
TX
"FQHC means a Federally Qualified Health Center that has been certified by HCFA to meet the requirements of 1861(aa)(3) of the Social Security Act as a federally qualified health center and is enrolled as a provider in the Texas Medicaid program." Texas Contract, page 7.
"Rural Health Clinic (RHC) means an entity that meets all of the requirements for designation as a rural health clinic under §1861(aa)(1) of the Social Security Act and approved for participation in the Texas Medicaid Program." Texas Contract, page 11.
"7.7 PROVIDER
QUALIFICATIONS - GENERAL...
The providers
in HMO network must meet the following qualifications: …
Rural Health
Clinic (RHC) - An institution which meets all of the criteria for
designation as a rural health clinic, and enrolled in the Texas Medicaid
Program.
Local Health
Department - A local health department established pursuant
to Health and Safety Code, Title 2, Local Public Health Reorganization
Act §121.031ff." Texas Contract, page 62.
"7.13
SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
HMO must seek
participation in its provider network from:
7.13.1
Each health care provider in the service area who has traditionally provided
care to Medicaid recipients;
7.13.2
Each hospital in the service area that has been designated as a disproportionate
share hospital under Medicaid; and
7.13.3
Each specialized pediatric laboratory in the service area, including those
laboratories located in children’s hospitals.
7.14 RURAL
HEALTH PROVIDERS
7.14.1
In rural areas of the service area, HMO must seek the participation in
its provider network of rural hospitals, physicians, home and community
support service agencies, and other rural health care providers who:
7.14.1.1
are the only providers located in the service area; and
7.14.1.2
are Significant Traditional Providers…
7.15 FEDERALLY
QUALIFIED HEALTH CENTERS (FQHCS) AND RURAL HEALTH CLINICS (RHCS)
7.15.1
HMO must make reasonable efforts to include FQHCs and RHCs (Freestanding
and hospital-based) in its provider network.
7.15.2
FQHCs or RHCs will receive a cost settlement from TDH and must agree to
accept initial payments from HMO in an amount that is equal to or greater
than HMO’s payment terms for other providers providing the same or similar
services...
7.16 COORDINATION
WITH PUBLIC HEALTH
7.16.1
Reimbursed Arrangements. HMO must make a good faith effort to enter
into a subcontract for the covered health care services as specified below
with TDH Public Health Regions, city and/or county health departments or
districts in each county of the service area that will be providing these
services to the Members (Public Health Entities), who will be paid for
services by HMO, including any or all of the following services or any
covered service which the public health department and HMO have agreed
to provide:
7.16.1.1
Sexually Transmitted Diseases (STDs) Services (see Article 6.15);
7.16.1.2
Confidential HIV Testing (see Article 6.15);
7.16.1.3
Immunizations;
7.16.1.4
Tuberculosis (TB) Care (see Article 6.12);
7.16.1.5
Family Planning Services (see Article 6.7);
7.16.1.6
THSteps checkups (see Article 6.8); and
7.16.1.7
Prenatal services (see Article 6.9).
7.16.2
HMO must make a good faith effort to enter into subcontracts with public
health entities in the service area…" Texas Contract, pages 70-72.
UT
"5. Maternity
Stays...
c.
Post-Delivery Care
Post-delivery
care will be provided to a mother and her newborn child... in (1)
a federally qualified rural health clinic, or a State health
department maternity clinic..." Utah Contract, Attachment B, pages
19-20.
UTMH
"9. The CONTRACTOR must attempt to subcontract with the Federally Qualified Health Center(s) (FQHC) in the CONTRACTOR's area for the provision of outpatient mental health services covered under this Contract…" Utah Mental Health Contract, page 13.
VA
"ARTICLE I -
DEFINITIONS…
Federally Qualified
Health Centers (FQHCs) - Those facilities as defined in 42 C.F.R. 405.240(b),
as amended...
Rural Health Clinic - A facility as defined in 42 C.F.R. 491.2, as amended." Virginia Contract, pages 7, 9-12.
"12. Choice
of Health Professional...
A. Providers
Qualifying a PCPs
The following
types of specialty physicians may perform as PCPs: ...
vi. Federally
Qualified Health Centers, rural Health Clinics, and similar community clinics…"
Virginia Contract, page 28.
WV
"4.5 Incentive-Based
Payments to Managed Care Plan...
The Department
will award up to 2 percent in additional capitation to each Managed Care
Plan in each county in increments of one-half of one percent (0.5%) as
an incentive to contract with certain types of publicly supported providers...
The following
types of providers are considered to be publicly supported for the purposes
of the Mountain Care program:
* Children
with Special Health Care Needs (CSHCN) providers;
* Local
Public Health Departments;
* Primary
Care Centers (State-designated centers that are not FQHCs or RHCs);
* Federally-designated
Critical Access Hospitals; and
* School-based
Health Centers." West Virginia Contract, page 31.
"3.6 Publicly
Supported Providers
3.6.1
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
Federally Qualified
Health Centers (FQHCs) are federally-funded Community Health Centers, Migrant
Health Centers and Health Care for the Homeless Projects...Current federal
regulations specify that states must guarantee access to FQHCs and RHCs
under Medicaid managed care programs; therefore, MCPs must provide access
to FQHCs and RHCs to the extent that access is required under federal law...
The MCP must contract with as many FQHCs and RHCs as necessary to permit beneficiaries access to participating FQHCs and RHCs without having to travel a significantly greater distance past a non-participating FQHC or RHC. The MCP must contract with FQHCs and RHCs in accordance with the 30 minute travel time standards for routinely used delivery sites as specified in Section 3.4.1. An MCP with an FQHC or RHC on its panel which has no capacity to accept new patients will not satisfy these requirements. If an MCP cannot satisfy the standard for FQHC and RHC access at any time while the MCP holds a Medicaid contract, the MCP must allow its Medicaid members to seek care from non-contracting FQHCs and RHCs and must reimburse these providers at Medicaid fees...
3.6.2 . Local
Health Departments
Local governmental
departments administer certain public health programs which are critical
to the protection of the public's health and, therefore, must be available
to Medicaid managed care enrollees. For those services defined as public
health services under State law, the MCP may choose either to provide these
services itself or to contract with local health departments…" West
Virginia RFA, pages 21-22.
"Financial Incentives
DHHR will provide
MCPs with a financial incentive of up to 2 percent in additional capitation
to contract with certain types of publicly supported providers. The
MCP will only receive financial incentives for contracting with public
supported providers that serve those counties where the MCP has a DHHR
Medicaid contract. The following types of providers are considered
to be public supported for the purposes of the Mountain Care program:
* Handicapped
Children's Services (HCS) providers...
* Local
Public Health Departments...
* Primary
Care Centers (State-designated centers that are not FQHCs or RHCs)...
* Rural
Primary Care Hospitals (RPCHs)...
* School-based
Health Center...
DHHR will develop a measure of these providers' capacity in each county and then evaluate each MCP's contract against this capacity…" West Virginia RFA, Appendix H, page H1.
"Federally Qualified
Health Centers (FQHCs) and Rural Heath (RHCs)
The following
lists indicate all of the Federally Qualified Health Centers (FQHCs) and
Rural Health Centers (RHCs) in West Virginia. The MCP must guarantee
access to FQHCs and RHCs within its service area as required by federal
law…" West Virginia RFA, Appendix Q, page Q1.
WI
"DEFINITIONS...
The term 'Community
Based Health Organizations' means non-profit agencies providing community
based health services. These organizations provide important health care
services such as HealthCheck screenings, nutritional support, and family
planning, targeting such services to high risk populations.
The term 'continuing care provider' means (as stated in 42 CFR 441.60(a)) a provider who has an agreement with the Medicaid agency to provide:
A. any reports that the Department may reasonably require, and
B. at
least the following services to eligible HealthCheck recipients formally
enrolled with the provider as enumerated in 42 CFR 441.60(a)(1)-(5):
1. screening,
diagnosis, treatment, and referrals for follow-up services,
2. Maintenance
of the recipient's consolidated health history, including information received
from other providers,
3. physician's
services as needed by the recipient for acute, episodic or chronic illnesses
or conditions,
4. provide
or refer for dental services, and
5. transportation
and scheduling assistance...
The term 'Local Health Department' (LHD) means an agency of local government established according to Chapter 251, Ws. Stats. Local health departments have statutory obligation to perform certain core functions: assessment, assurance, and policy development for the purpose of protecting and promoting the health of their communities." Wisconsin Contract, pages 1-3.