AZ
"SECTION D:
PROGRAM REQUIREMENTS
1. SCOPE OF
SERVICES…
Dental: …Members
under the age of 21 may request dental services without referral and may
choose a dental provider from the Contractor's provider network…"
Arizona Contract, pages 10- 11.
GA
"SECTION 3
SCOPE OF SERVICES...
3.010
Offeror Responsibilities
The following
identify the responsibilities to be performed by the Offeror...
1. Evaluate
provision of unrestricted access to emergency services and family planning
services for recipients enrolled in GBHC…" Georgia RFP, page 7-8.
IN
"4.4.2.4
Self-Referral Services
Capitation
amounts include payment for the following services known as 'self-referral
services':
*
Services rendered for the treatment of an emergency…
*
Chiropractic services
*
Podiatric services
*
Eye Care services (except eye care surgical services)
*
HIV/AIDS targeted case management services
*
Diabetes self-management training services…" Indiana RFP, pages 4-7
- 4-8.
KY
"The Member
Services staff shall be responsible for the following services and tasks:
...
•
Facilitating direct access to primary care vision services; primary care
vision services; primary dental and oral surgery services and evaluations
by orthodontist and prosthodontists…childhood immunizations; sexually transmitted
disease screening, evaluation and treatment; tuberculosis screening, evaluation
and treatment; and testing for HIV, HIV-related conditions and other communicable
diseases, as described in Attachment VIII of this RFA..." Kentucky
RFA, page 53.
"7.9.3
Direct Access Services
The
Partnership shall ensure direct access and may not restrict the choice
of a qualified provider by a Member for the following services within The
Partnership's Network:
•
Primary care vision services, provided by ophthalmologists, optometrists
and opticians,
including
the fitting of eye-glasses;
•
Primary dental and oral surgery services and evaluations by orthodontists
and prosthodontists." Kentucky RFA, page 72.
MD
"Chapter 62
Maryland Medicaid Managed Care Program: Definitions
.01 Definitions…
(156)
'Self-referral services' are the health care services listed in COMAR 10.09.67.28
for which, under specified circumstances, the MCO is required to pay, without
any requirement of referral by the PCP or MCO, when the enrollee accesses
the service through a provider other than the enrollee's PCP." Maryland
COMAR 10.09.62.01.
"10.09.64.06...
.06 Access
and Capacity: Benefits and Appointments.
An MCO applicant
shall include in its application the following information or descriptions:
…
E. Documentation
of the applicant's preparedness to collaborate with providers of self-referral
services, and reimburse at the Department's established fee-for-service
rate, for permissible self-referred services, including: ...
(2) School-based
clinic services as specified in COMAR 10.09.68...
(4) Initial
medical examination services to children in State-supervised care;
(5) Annual
diagnostic and evaluation services (DES) for individuals diagnosed with
HIV/AIDS; and
(6) Renal
dialysis services…" Maryland COMAR 10.09.64.06.
"10.09.65.20...
(6) An
MCO may require enrollees to utilize in-plan providers for pharmacy and
laboratory services ordered by out-of-plan providers of self-referral services,
except as provided in §A(7) of this regulation.
(7) An
MCO shall reimburse out-of-plan providers at the Medicaid rate for medically
necessary and appropriate pharmacy and laboratory services when the pharmacy
or laboratory service is provided:
(a)
In connection with a self-referred service specified in §A(1) of this
regulation; and
(b)
On-site by the out-of-plan provider at the same location that the self-referred
service specified in §A(1) of this regulation was delivered to the
MCO's enrollee." Maryland COMAR 10.09.65.20.
"10.09.67.28...
.28 Benefits-Self-Referral
Services...
B. Services
performed by school-based health centers, as provided in COMAR 10.09.68...
D. Initial
medical examination for children in State custody...
F. Renal
dialysis services performed in a Medicare-certified facility;
G. Initial
medical examination of a newborn when the:
(1)
Examination is performed in a hospital by an on-call physician, and
(2)
MCO failed to provide for the service before the newborn's discharge from
the hospital; and
H. Medical
services directly related to a child's medical condition, such as physical
therapy, occupational therapy, or speech therapy for a child with a special
health care need who at the time of initial enrollment was receiving these
services as part of a current plan of care…" Maryland COMAR 10.09.67.28.
MN
"B. Provider Access Changes. The HEALTH PLAN shall not make any substantive changes in its method of provider access during the term of this Contract, unless -approved in advance by the STATE… Examples of methods of provider access include but are not limited to: Enrollee has open access to all Primary Care Providers; Enrollee may self-refer to a physician specialist…" Minnesota Contract, page 29.
"Section 6.20. Services Received at Indian Health Service and Tribal Providers. This Section applies when the STATE begins enrollment of American Indians under Section 3.1.1.C.(14). American Indian PMAP and PGAMC Enrollees -- living on or off a reservation -- shall have direct access to services provided at Indian Health Service (IHS) facilities and facilities (also known as 638 facilities or providers) operated by a tribe or tribal organization… The HEALTH PLAN shall not require any Prior Approval or impose any condition for an American Indian to access services at such facilities...
Section 6.20.1. Referrals from IHS and 638 Providers. When a physician in a facility described in Section 6.20. refers an American Indian PMAP or PGAMC Enrollee to a Participating Provider for services covered under this Contract, the HEALTH PLAN shall not require the Enrollee to see a Primary Care Provider prior to the referral…" Minnesota Contract, page 69.
MO
"p. At
a minimum, the member handbook shall include: ...
12) Notice
that a member with a condition which requires ongoing care from a specialist
may request a standing referral to such a specialist and the procedure
for requesting and obtaining such a standing referral…" Missouri
RFP, pages 42-43.
MT
"2.4.2
Participating Providers:...
B
Providers Contracts Must be Extended to or Contractor Must Allow Access
to:...
2) Federally
Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): ...
At a minimum,
the CONTRACTOR must reimburse an FQHC or RHC PARTICIPATING PROVIDER either
the Medicaid interim rate for each medically necessary ENROLLEE visit to
the FQHC or RHC or the same payment per ENROLLEE or service offered to
the CONTRACTOR'S other PRIMARY CARE PROVIDERS. The DEPARTMENT is
responsible for paying the shortfall to the FQH/RHC or recouping the excess
from the FQHC/RHC for the difference between the amount reimbursed by the
CONTRACTOR and the reasonable cost to the FQHC or the RHC to provide the
covered service.
1) If a recipient is mandated in to an HMO which has no FQHC or RHC on its panel and chooses to go to an FQHC or RHC then the recipient does not have to obtain prior approval, but under the state requirements the recipient must inform their HMO before receiving the FQHC services...
3) If there is more than one FQHC in the area and one is on the HMO panel and the other is not, then the recipient may only go to the FQHC or RHC on the provider panel without requiring HMO prior authorization. If the recipient chooses to go to the FQHC or RHC not on the HMO panel then the recipient is responsible to pay for services received from the FQHC or RHC.
3) Public
Health Clinic Access
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...
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 HIS is responsible
for billing the service fee-for-service to the state." Montana Contract,
pages 36-37.
NE
"4.1.22 The term 'Family Planning Services' means...Treatment for sexually transmitted diseases (STD) pursuant to this contract shall be reimbursed by the plans in the same manner as family planning services, without referral or authorizations by the Primary Care Physician(PCP)/plan…" Nebraska Contract, page 9.
"13.22 Provision
of Services: The plan shall coordinate activities with the Department,
other NHC contractors, and other providers for services outside the Basic
Benefits Package, as appropriate, to meet the needs of the client, and
ensure that systems are in place to promote well managed patient care,
including, but not limited to...
(d) Unrestricted
access to 'protected' services such as emergency room services...tribal
clinics, etc., according to 471 NAC…" Nebraska Contract, page 85.
"13.34 Medical Specialists: ...Clients with chronic or severe medical conditions, e.g., HIV/AIDS, may be allowed to go directly to a qualified specialist within the plan’s network pursuant to Section 13.5.3 and 13.5.4." Nebraska Contract, page 87.
"13.44.3 Unrestricted Services: The plan shall not require authorization for...emergency services, and Native Americans seeking tribal clinic or Indian Health hospital services. The plan shall allow the client to access these services from any Medicaid-enrolled provider s/he chooses, and is not limited to providers within the plan’s network. The plan shall allow the client to access these services without a referral, even if the plan contracts with Medicaid to provide these services.
13.44.4 Emergency Services: The plan shall provide all covered emergency services...The plan shall allow the client to access these services without a referral, even if the plan provides these services." Nebraska Contract, page 93.
NEBH
"11.26 Coordination
of Services: The PHP shall coordinate activities with the Department,
other NHC contractors, other providers for services, and others involved
with the client, as appropriate, to meet the needs of the client, and ensure
systems are in place to promote well managed patient care, including, but
not limited to: ...
(e) Unrestricted
access to protected services such as emergency room services, tribal clinics,
etc., according to 471 NAC…" Nebraska Behavioral Health Contract,
pages 58-59.
"11.52.4
Native Americans: The PHP shall ensure that Native Americans seeking
tribal clinic or Indian Health hospital services do not require prior authorization
or provision by the PHP.
11.52.5
Emergency Services: The PHP shall ensure that: ...
(c) The client may access these services without a referral, even if the PHP contracts with Medicaid to provide these services." Nebraska Behavioral Health Contract, pages 64-65.
NV
"H. Out-of-Plan
Services…
4. Federally Qualified Health Centers and Rural Health Clinics. The
Contractor must pay for services provided by a Federally Qualified Health
Center (FQHC) or a rural health clinic…" Nevada Contract, pages 25-26.
NJ
"1.95
'Referral Services'...
Exception B: An enrollee may access services at a Federal Qualified
Health Center (FQHC) in a specific enrollment area without the need for
a referral when neither the contractor nor any other HMO has a contract
with the Federally Qualified Health Center in that enrollment area and
the cost of such services will be paid by the Medicaid fee-for-service
program." New Jersey Contract, page 20.
NM
"2.A.1.e.ii
The CONTRACTOR shall provide each member with written information that
instructs members about how to obtain primary and specialty care, including:
(A)
a list of providers, by provider type and specialty, available through
the CONTRACTOR and how to access them; such list, at the option of CONTRACTOR,
may be limited to primary care providers and those providers to whom members
may self-refer, including, but not limited to… urgent and emergency care
providers, HIS and other Indian providers, and pharmacies…" New Mexico
Contract, page 5.
"2.C.13 Indian
Health Services (HIS) & 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 ... 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."
New Mexico Contract, page 33.
NY
"10. BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES…
10.16
Services for Which Enrollees Can Self-Refer...
b) Vision
Services
The Contractor
will allow its Enrollees to self-refer to any participating provider of
vision services (optometrist or opthalmologist) for refractive vision services...
c) Diagnosis
and Treatment of Tuberculosis
Enrollees may
self-refer to public health agency facilities for the diagnosis and/or
treatment of TB...
e) Sexually
Transmitted Disease (STD) Services
Enrollees may
self refer to any qualified Medicaid provider for STD services as described
in Section 10.19(c) of this Agreement...
"10.19
Public Health Services
a) Tuberculosis
Screening, Diagnosis and Treatment; Directly Observed Therapy(TB\DOT):
i) ...It
is the State's preference that the Contractor's Enrollees receive TB diagnosis
and treatment through the Contractor's plan, to the extent that providers
experienced in this type of care are available in the Contractor's network
of Participating Providers, although Enrollees may self-refer to public
health agency facilities for the diagnosis and/or treatment of TB... "
New York Contract, pages 10-1-10-10.
NC
"6.19
Payment to Out-of-Plan Providers
The Plan shall
reimburse Out-of-Plan Providers for Covered Services, which may be obtained
by Members without prior authorization from the Plan for the following:
...
c. Services provided by a Public Health Department for the screening, diagnosis, counseling, or treatment of STD's, TB, HIV…" North Carolina Contract, page 13.
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…" North Dakota
Contract, Attachment C, page 11.
OH
"Certified Nurse
Midwives (CNMs) and Certified Nurse Practitioners (CNPs)…
MCPs would
be permitted to require a referral from the enrollee's PCP if they so desired,
however, MCPs must allow enrollee's whose pregnancy has been confirmed
by their PCP's office to self-refer to CNMs…" Ohio RFP, pages 28-29.
OK
"2.8.7
Self-Referral for Designated Services
2.8.7.1
General
Except for
the categories described below, Health Plan may require members to obtain
authorization prior to receiving any non-emergent, non-primary care services
included in the pre-paid benefit package...
2.8.7.3
Dental Services
Health Plan
must allow its members who are eligible for dental services to self refer
to a network dental provider for non-emergent dental services, subject
to the Plan's standard utilization management mechanisms.
2.8.7.4
Eye Care Services
Health Plan
must allow its members who are eligible for eye care services to self refer
to any network ophthalmologist or optometrist for non-emergent services
both refractive services and treatment of diseases/injuries of the eye,
subject to the Plan's standard utilization management mechanisms...
2.8.7.6
Immunizations and EPSDT Screens
The Health
Plan must allow the member to self-refer for immunizations and EPSDT screenings,
if the following occurs:
1) a
school-based clinic or health department notifies the Plan that a member
is due for an immunization or EPSDT screen; and
2) the
Plan fails to schedule an immunization or EPSDT screen within three weeks
of notification…" Oklahoma RFP, pages 44-45.
SC
"COMMUNICABLE
DISEASE SERVICES...
A. Communicable
Disease...
Eligible recipients
should be encouraged to receive family planning, TB, STD, and HIV services
through their primary care provider or by appropriate referral to promote
the integration/coordination of these services with heir total medical
care. However, eligible recipients have the freedom to receive family
planning services from any appropriate Medicaid providers without any restrictions.
Eligible recipients have the freedom to receive TB, STD and HIV testing
and counseling services from any public health agency without any restrictions
to services." South Carolina Contract, Appendix C, Tab 1, page 3.
UT
"E. Clarification
of Covered Services
1.
Emergency Services
a.
In General
The
Health Plan must provide coverage for Emergency Services without regard
to prior authorizations or the emergency care provider's contractual relationship
with the MCO. MCOs must inform their enrollees that access to emergency
services is not restricted and that if an enrollee experiences a medical
emergency, he or she may obtain services from a non-plan physician
or other qualified provider, without penalty... The CONTRACTOR must comply
with Medicare guidelines for post-stabilization of care. " Utah Contract,
Attachment B, page 13.
WA
"4.9 Self-Referral to Family Planning Clinics and Health Departments: … Members may self-refer to health departments for the following services: immunizations, sexually transmitted disease screening and follow-up, human immunodeficiency virus (HIV) screening, tuberculosis screening and follow-up… ...In addition, members may self-refer to family planning clinics for… sexually transmitted disease screening and treatment services." Washington Contract, pages 17-18.
"COVERED SERVICES...
Vision Care:
The Contractor shall cover eye examination for visual acuity and refraction
once every twenty-four (24) months for adults and once every twelve (12)
months for children under age twenty-one (21)…Members may self-refer to
participating providers for these services." Washington Contract,
Exhibit 6, Attachment 1, page 2.