AZ
"19. APPOINTMENT STANDARDS...
The Contractor shall have procedures in place that ensure the following
standards are met:
a. Emergency PCP
appointments - same day of request...
For specialty referrals,
the Contractor shall be able to provide:
a. Emergency appointments
- within 24 hours of referral." Arizona Contract, page 29.
AZBH
"7. SCREENING AND EVALUATION,
SERVICE PLAN DEVELOPMENT...
Emergency referrals shall
be accepted twenty-four (24) hours a day, seven (7) days a week and screening
and/or evaluation must be performed within 24 hours of referral or request
for service. This shall include responding within 24 hours of receipt of
a referral to evaluate a hospitalized member who is not yet enrolled with
ADHS." Arizona Behavioral Health Contract, page 14.
"12. APPOINTMENT STANDARDS...
ADHS shall ensure its subcontracted
RBHAs provide appointments as follows:
a. Emergency screening and
evaluation - (including responding to hospitalized, non-ADHS enrolled members)
within 24 hours of referral or request for services...
"XIV. SERVICE DELIVERY. 3.
24 hour Availability of Services: ...
a. Emergency services must
be available 24 hours per day, 7 days per week;
b. The Contractor shall
have a comprehensive plan for Triage of requests for services on a 24 hour
7 day per week basis, including:
(1) immediate Medical
Screening Exam by the Primary Care Physician or hospital emergency room;
(2) access to a qualified
health care practitioner via live telephone coverage either on-site, call-sharing,
or answering service; and
(3) practitioner
back-up covering all specialties." Colorado Contract, pages 46-47.
CT
"3. FUNCTIONS AND DUTIES
OF THE MCO The MCO agrees to the following duties.
3.1 Provision of Services...
b. The MCO shall provide
24-hour accessibility to qualified medical personnel to Members in need
of urgent or emergency care." Connecticut Contract, pages 15-16.
"3.5 Emergency Services a) The MCO shall provide all emergency services 24 hours each day, 7 days a week or arrange for the provision of said services 24 hours each day, 7 days a week through its provider network." Connecticut Contract, page 18.
"3.13 PCP and PCD Scheduling
and Capacity
a. The MCO shall ensure
that the PCPs and PCDs in its network adhere to the following PCP scheduling
practices:
1. Emergency cases
shall be seen immediately or referred to an emergency facility." Connecticut
Contract, page 23.
DE
"9.3.1 General Procedures
The MCO shall have procedures in place that ensure:
(a) Emergency services are
available twenty-four (24) hours a day, seven (7) days a week
(b) Emergency primary care
provider appointments are available the same day (e.g., high temperature,
persistent vomiting or diarrhea, symptoms which are of sudden or severe
onset but which do not require emergency room services)" Delaware
RFP, page II.59.
DC
"2. Service Timelines
a. In furnishing care under
this contract Provider shall adhere to the following timelines:
(1) emergency services,
as defined in Article XXII, shall be furnished immediately and without
prior authorization." District of Columbia Contract, page 29.
FL
"B. Manner Of Service Provision
1. Availability/Accessibility
of Services...
Emergency medical care as
required by this agreement shall be available on a 24 hours a day, seven
days a week basis...
2. Minimum Standards. Plans
shall provide the following: ...
h. A designated emergency
services facility, within 30 minutes typical travel time, providing care
on a 24 hours a day, seven days a week basis..." Florida Contact, pages
10-11.
FLMH
"2.5 Minimum Staffing and
Access Standards...
A.3. The maximum amount
of time between an enrollee's request for mental health services and the
first point of service shall be as follows:
a. For emergency mental
health services as defined in section 1.1 BB., service shall be immediate..."
Florida Mental Health RFP, page 28.
HI
"30.430 Availability of Providers...
The health plan shall have
a sufficient network to ensure members can obtain needed health services
within the acceptable wait times. The acceptable wait periods are:
* Immediate care for true
emergency medical situations." Hawaii RFP, page 10.
HIBH
"30.420 Availability and
Accessibility of Providers
The BHMC plan shall have
a sufficient provider network statewide to ensure members can access needed
behavioral health services consistent with the member's degree of risk,
as set forth below:
"(8) Emergency Services
(A) The Contractor shall
assure that Emergency Services are available as Covered Services for all
Beneficiaries on a 24-hour basis, 7 days a week, at the closest appropriate
facility and provided until the beneficiary is stabilized and may be either
safely discharged or transferred, as is medically appropriate.
(B) The Contractor shall
not impose any requirements for prior approval of Emergency Care." Illinois
HMO Contract, page 22.
IN
"4.6.2 Provider Network in Hoosier Healthwise The MCO will be solely responsible for arranging for and administering covered services to enrollees. Covered services shall be medically necessary, administered by, and arranged for, under the direction of a designated Primary Medical Provider (PMP). MCOs must ensure that this delivery system shall provide available, accessible and adequate numbers of facilities, locations and personnel for the provision of covered services. MCOs must ensure that emergency services are available seven days a week, 24-hours per day. The MCO must demonstrate that it can maintain a delivery system of sufficient size and resources to offer quality care that can accommodate the needs of the enrollees within each enrollment area. MCOs must ensure that contracted PMPs are required to provide or arrange for coverage of services 24 hours a day, 7 days a week. MCOs must also ensure that PMPs are available to see patients a minimum of 20 hours over a 3-day period per practice location per week. The 3-day requirement can be fulfilled by more than one PMP in a group practice...
4.6.3 Provider Network and
Access to Care Requirements and Reporting Standards The MCO must meet the
following provider network and access to care requirements: ...
* The MCO must have a reliable
method and system for providing 24-hour access to care and emergency services.
Direct contact with a qualified clinical staff person must be available
through a toll-free member services voice and telecommunication device
for the deaf telephone number...." Indiana RFP, pages 4-17 - 4-18, 4-20
- 4-21.
IABH
"Accessibility Standards...
For mental health services,
the access shall be measured by:
* acuity of need: enrollees
with emergency needs must be seen within 15 minutes of presentation at
a service delivery site.
For substance abuse treatment
services, the access shall be measured by:
1. Acuity of need: Eligible
persons with emergency needs must be seen within 15 minutes of presentation
with provider..." Iowa Behavioral Health Contract, page 88.
KS
"Appointment Standards.
The HMO shall have procedures
in place that ensure:
"D. Services to Be Provided...
2. Accessibility The Contractor
shall make services, service locations, and services sites available and
accessible to Members as specified in Section 7.7.2 and Attachment V of
the RFA." Kentucky Contract, page 21.
"7.7.2 Provider Program Capacity Demonstration The Partnership shall assure that all covered services are as accessible to Members (in terms of timeliness, amount, duration, and scope) as the same services are available to commercial insurance recipients in The Partnership Region; and that no incentive is provided, monetary or otherwise, to providers for the withholding from Members of medically-necessary services. The Partnership shall make available and accessible facilities, service locations, and personnel sufficient to provide covered services consistent with the requirements specified in Attachment V. Emergency medical services shall be made available to Members 24 hours a day, seven days a week. Urgent care services by any provider in The Partnership's Program shall be made available within 48 hours of request. The Partnership shall provide the following: ...
(c) Immediate care for emergency conditions or illnesses as defined in 907 KAR 1:705 at a health facility that is most suitable for the type of injury, illness or condition, regardless of contracts." Kentucky RFA, page 48.
MA
"Section 2.6 Access...
B. Waiting Time 1. The Contractor
shall ensure that Enrollees have access to MCO Covered Services provided
below: a. Emergency Services - immediately upon Enrollee presentation at
the service delivery site including non-network and out-of-area facilities.
The Contractor shall, in accordance with 42 USC 1396u-2(b)(2) and 42 CFR
434.30, provide coverage for Emergency Services to Enrollees 24 hours a
day and 7 days a week without regard to prior authorization or the Emergency
Service provider's contractual relationships with the Contractor." Massachusetts
Contract, pages 47-48.
"Section 2.12 Behavioral
Health Program Services...
D. BH Program Access and
Availability The Contractor shall: ...
3. Ensure that Enrollees'
access to BH Services is consistent with the degree of urgency, as set
forth below:
a. Emergency Services care
- must be provided immediately." Massachusetts Contract, pages 68-73.
"Section 2.12 Behavioral
Health Program Services...
F. BH Program Emergency
Screening, Emergency Services, and Short Term Crisis Stabilization Services
The Contractor shall: ...
3. Ensure Enrollees unrestricted
access to BH Emergency Services, as described in Appendix C, Exhibit 2.C
to this Contract, on a twenty-four (24) hour basis, seven (7) days a week."
Massachusetts Contract, pages 68-80.
MABH
"5.03 Service Authorization
and Utilization Review The Contractor shall: ...
5.03.07 Develop Emergency
Services, Emergency Screening Services, and Short Term Crisis Stabilization
Services policies and procedures for Emergency Services, Emergency Screening
Services, and Short Term Crisis Stabilization Services, to be submitted
to the Division for prior review and approval, implement them on the Full
Service Start Date, and ensure that these policies and procedures shall,
at a minimum, satisfy the following requirements: ...
d. require that the response time for face-to-face evaluations in Emergency situations does not exceed one hour from notification of the Emergency by telephone from the referring party or from the time of presentation by the Enrollee for Emergency Services." Massachusetts MH/SAP Contract, Appendix B, pages 34, 37-38.
MI
"II-M CONTRACTOR ORGANIZATIONAL
STRUCTURE, ADMINISTRATIVE SERVICES, FINANCIAL REQUIREMENTS AND PROVIDER
NETWORKS...
6. Provider Network in the
CHCP (a) General... The Contractor must ensure that the provider network:
...
*Guarantees that emergency
services are available seven days a week, 24-hours per day.
(i) PCP Standards...
The Contractor will ensure
that there is a reliable method and system for providing 24 hour access
to. emergency services 7 days a week. Emergency Services must always be
available." Michigan Contract, pages 32, 35, 39.
MN
"Section 6.1.13. Medical Emergency, Post-Stabilization Care, and Urgent Care Services. Medical Emergency Services, Post-Stabilization Care Services and Urgent Care Services must be available 24 hours per day, seven days per week, including a 24-hour per day number for Enrollees to call in case of a Medical Emergency. The HEALTH PLAN shall not require Prior Authorization as a condition of providing a Medical Emergency Service. Nor shall the HEALTH PLAN require an Enrollee to receive a Medical Emergency or Post-Stabilization Care Service within the HEALTH PLAN's network. See Section 6.22.1." Minnesota Contract, pages 48-49.
MO
"2.13.4 Appointment Standards:
...
a. The health plan shall
have procedures in place that ensure:
1) Emergency services must
be available at all times.
2) Emergency primary care
provider appointments are available the same day (e.g. high temperature,
persistent vomiting or diarrhea, symptoms which are of sudden or severe
onset but which do not require emergency room services)." Missouri RFP,
page 65.
"d. For behavioral health
services to non-serious mentally ill members, the health plan shall be
able to provide appointments as follows:
1) Emergency appointments
within twenty-four (24) hours of request." Missouri RFP, page 69.
NEBH
"12.3 Goal: To provide the
NHC client an `adequate' network of MH/SA providers...
At a minimum, the PHP shall
meet the following requirements to demonstrate `adequacy': ...
3. Immediate access for
clients with urgent, symptomatic conditions for triage and crisis intervention.."
Nebraska Behavioral Health Contract, pages 74, 76.
NJ
"ARTICLE 10 COVERED HEALTH
CARE SERVICES...
10.10 Emergency Services...
B. The contractor shall
ensure that all covered services that are required on an emergency basis
are available to enrollees twenty-four (24) hours per day, seven (7) days
per week either in the contractor's own provider network or through arrangements
approved by DMAHS. The contractor shall maintain twenty-four (24) hours
per day, seven (7) days per week on-call telephone coverage to advise enrollees
of procedures for emergency and urgent care and explain procedures for
obtaining non-emergent/non-urgent care during regular business hours within
the enrollment area as well as outside the enrollment area...
10.11 The contractor shall
comply with the appointment availability guidelines below...
A. For emergency services:
immediately upon presentation at a service delivery site." New Jersey Contract,
pages 51-57.
"Provider Network Requirements...
F. Accessibility Measures/
Appointment Scheduling Standards...
4. Scheduling time for emergency
care-immediate." New Jersey Contract, pages 195-199.
"APPENDIX A BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS MEDICAID AND NJ KID CARE - PLANS A, B AND C The health care services listed below shall be provided by the contractor to enrollees as covered benefits rendered under the terms of this contract. Provision of these services shall be equal in amount, duration, and scope as established by the Medicaid program, in accordance with medical necessity without any predetermined limits: .
SERVICES INCLUDED IN THE
CONTRACTOR'S BENEFITS PACKAGE The following services must be provided and
case managed by the contractor...
4. Emergency medical care
- 24 hours/day, 7 days/week..." New Jersey Contract, Appendix A, pages
166-167.
NM
"2.A.4.b.i The CONTRACTOR shall ensure that there is no clinically significant delay caused by MCO utilization control measures." New Mexico Contract, page 13.
NY
"15. ACCESS REQUIREMENTS
15.1 Appointment Availability
Standards The Contractor shall comply with the following appointment availability
standards. a) For emergency care: immediately upon presentation at a service
delivery site." New York Contract, page 15-1.
NC
"6.5 Appointment Availability
The Plan must ensure that appropriate services are available as follows:
a. Emergency - immediately
upon presentation or notification." North Carolina Contract, page 9.
OH
"5101:3-26-031 Managed care
plan: Availability and access to services...
(D) The PCP sites must have
ODHS-approved written triage procedures that address the following:
(1) Enrollees with emergency
care needs must be triaged and treated immediately on presentation at the
PCP site." Ohio RFP, Appendix E, OAC 5101:3-26-031, pages 1-2.
OK
"2.8.3 Emergency Services...
In the event of an emergency,
the Health Plan must allow its members to access emergency services twenty-four
(24) hours a day, seven (7) days a week." Oklahoma RFP, page 42.
OR
"(13) Contractor shall define access requirements in the following way: Members shall be seen the same day for emergency care." Oregon Contract, page 14.
ORMH
"2. In access and continuity of care standards specified in the rules above in Subsection D.1, Contractor shall establish standards for access to Covered Services and Continuity of Care which at a minimum include the following:
a. For Emergency Services, Contractor shall assure that 98% it's OMAP Members receive an initial face-to-face or telephone screening within 15 minutes of contact to determine the nature and the urgency of the situation.
b. For Emergency Services, Contractor shall assure that 100% of it's OMAP Members receive timely Covered Services within time frames identified by the Urgent and emergency response screening or within 24 hours of contact, whichever is shorter." Oregon Mental Health Contract, page 24.
PA
"J. SERVICE AND ACCESSIBILITY
STANDARDS...
3. Appointment Standards
The HMO shall have PCP scheduling procedures in place that ensure:
"5. Service Access
a. The MCO provider network
must to provide face-to-face intervention within one hour for emergencies."
Pennsylvania Behavioral Health RFP, page 63.
RI
"2.09.03 Emergency Medical Services Pursuant to 42CFR 434.30, Contractor agrees to provide emergency services which are available twenty-four (24) hours a day and seven (7) days a week, either in Contractor's own facilities or through arrangement, with other providers. Contractor agrees that services shall be made available immediately for an emergent medical condition including a mental health or substance abuse condition. The provision of emergency services must also conform to RIte Care Program Emergency Medical Services Policy." Rhode Island RFP, page 39.
SC
"4.10 Twenty-Four (24) Hour Coverage The Contractor's network provider/subcontractor may elect to provide 24 hour coverage by direct access or through arrangement with a triage system. The triae system arrangement must be prior approved by SCDHHS...
4.10.2 Scheduling/Appointment
Waiting Times The Contractor shall ensure that its subcontractors/network
providers have an appointment system for covered core benefits and/or expanded
services which are in accordance with prevailing medical community standards
but shall not exceed the following requirements: ...
4.10.2.3 Emergent or emergency
visits immediately upon presentation at a service delivery site." South
Carolina Contract, page 27.
TN
"2-3. Benefits/Services Requirements
and Limitations...
b. Availability and Accessibility
of Services
1. The CONTRACTOR shall
make services, service locations, and service sites available and accessible
in terms of timeliness, amount, duration, and personnel sufficient to provide
the covered (specialized or otherwise) services. Emergency medical services
shall be available on a twenty-four (24) hours a day, seven (7) days a
week basis." Tennessee Contract, pages 7-11.
"ATTACHMENT IX - TERMS AND
CONDITIONS FOR ACCESS...
Terms and Conditions for
Access In general, contractors shall provide available, accessible, and
adequate numbers of institutional facilities, service locations, service
sites, professional, allied, and paramedical personnel for the provision
of covered services, including all emergency services, on a 24-hour-a-day,
7-day-a-week basis. At a minimum, this shall include: ...
Emergency Care: All emergency care is immediate, at the nearest facility available, regardless of contract. Waiting times shall not exceed 45 minutes." Tennessee Contract, pages 137-138.
UTMH
"B. Performance Standards.
1. The CONTRACTOR will provide
timely Covered Services to Enrollees who seek services in accordance with
the following time frames: a. If based on the Initial Contract it appears
the Enrollee has an Emergency, the CONTRACTOR will respond to the Enrollee
within 30 minutes. If the CONTRACTOR determines that the Enrollee has an
Emergency the CONTRACTOR will provide face-to-face Emergency Services within
one hour or within a time frame mutually agreed on by the Enrollee or his
or her agent and the CONTRACTOR." Utah Mental Health Contract, page 12.
VA
"11. Appointment Standards
a. The Contractor must arrange
to provide care according to each of the following appointment standards:
i. Appointments for emergency
services shall be made available immediately upon the enrollee's request."
Virginia Contract, page 66.
WA
"E. ACCESSIBILITY OF SERVICES
[QI 5] The contractor must establish mechanisms to assure the accessibility
of primary care services, urgent care services, and member services.
3. The contractor must establish
standards for appointments that are no longer than the following: ...
d) emergency medical care
smut be available 24 hours per day, seven days per week." Washington Contract,
QIP-2000 Standards, page 6.
WV
"III-1 AVAILABILITY AND ACCESSIBILITY...
The MCO must have standards
for timelines of access to care and member services that meet or exceed
such standard as may be established by the Bureau for Medical Services,
continuously monitor its provider network's compliance with these standards,
and take corrective action as necessary. Current BMS standard for timeliness
state that:
* Emergency cases must be
seen immediately or referred to an emergency facility." West Virginia Contract,
Exhibit F, page 12.
"3.4.2 Scheduling Standards
3.4.2.1 Appointment Scheduling
MCPs must meet the following appointment scheduling standards:
a) Emergency cases must
be seen immediately or referred to an emergency facility...
Emergency care services include those services provided for conditions which pose a potential threat to the patient of loss of life or limb or significant impairment. These include accidental injury and poison-related problems and vague complaints which may be indicative of serious, life-threatening medical problems, e.g. chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests examination, a nurse triage screening is always allowed." West Virginia RFA, pages 18-19.