Medicaid Contract Purchasing Specifications

Part 2. Service Delivery and Health Care Quality Improvement and Measurement

Table of Contents

§201. Enrollment and Disenrollment
§202. Provider Selection
§203. Provider Network
§204. Delivery of Care and Access to Covered Services
§205. Public Health Reporting
§206. Memoranda of Understanding (Reserved)
§207. Quality Improvement and Measurement
§208. Confidentiality of Enrollee HIV Status
§209. Information for Enrollees
§210. Information for Purchaser

The following section offers illustrative language for Purchasers to consider related to enrollment and disenrollment of individuals with HIV/AIDS.

§201. Enrollment and Disenrollment⁶¹

^K (a) Safeguards against the interruption of care for individuals receiving services related to HIV/AIDS at the time of enrollment - In the case of an individual who at the time of enrollment is receiving services for the prevention or medical management of HIV/AIDS, Contractor shall continue to cover and pay for such services furnished by enrollee's current providers without interruption, to the extent that such services are covered under this Agreement, until the primary care provider selected by the enrollee has:

(1) assessed the enrollee;

(2) reviewed the enrollee's care, and

(3) prescribed or arranged for uninterrupted treatment in accordance with the standards enumerated in §110 (relating to coverage), and in consideration of the individual's need for case management services defined in §108.⁶²

^L,K (b) Safeguards against the interruption of care at the time of disenrollment for individuals receiving HIV/AIDS services - In the case of an individual who ceases to be an enrollee, who has other third party coverage, and who, at the time of disenrollment, is receiving services enumerated under Part 1 for HIV/AIDS, Contractor shall:

^K (1) continue to provide the services to the individual until the earlier of:

(A) the last day of the enrollee's enrollment period under the terms of this Purchasing Agreement ends; or

(B) the day on which another provider or managed care organization assumes responsibility for the care of the individual; and

^L,K (2) transfer the individual's medical records in a confidential manner to the responsible provider or managed care organization.

^L,K (c) Safeguards against the interruption of care for individuals without third party coverage who are receiving HIV/AIDS services at the time of disenrollment - In the case of an individual who ceases to be an enrollee, who has no other third party coverage, and who, at the time of disenrollment, is receiving medical management services for HIV/AIDS, Contractor shall:

^K (1) continue to provide the services to the individual until the end of enrollee's enrollment period under the terms of this Purchasing Agreement;

^K (2) assist the enrollee identify alternative sources of payment, including the state AIDS Drug Assistance Program (ADAP) under the Ryan White CARE Act and find alternative sources of care if enrollee requests such help; and

^L,K (3) transfer enrollee's records in a confidential manner to a new provider who has enrollee's consent to obtain such records.

^K (d) Medical management of enrollees whose treating providers leave the network - In the event that the enrollee's primary care provider or other professional involved in the medical management of enrollee's case terminates membership in Contractor's network, Contractor shall assist enrollee to identify another provider (either within the network or on a contractual, non-network affiliation basis) who is willing and able to immediately assume care of the enrollee on an uninterrupted basis.

The following section presents illustrative language related to the selection of providers by enrollees with HIV/AIDS.

§202. Provider Selection⁶³

^G,K (a) Selection of Primary Care Provider - Contractor shall permit enrollees with HIV or HIV-related conditions to select one of the following types of primary care providers:

(1) an experienced HIV provider, as defined in §112, who is a member of Contractor's provider network and who has entered into a written agreement with the Contractor to perform the functions required of a primary care provider;

(2) a primary care provider who has entered into a written consultation agreement with an experienced HIV provider, as described in subsection (b), which:

(A) sets forth the terms of the consultation arrangement; and

(B) includes a standing order that provides the member with direct access to the consultation services offered by an experienced HIV provider as specified in §110(c)(3), as well as other consulting specialists; or

(3) a specialist, as defined in §112, who is a member of Contractor's provider network and who, with respect to the member, has entered into a written agreement with the Contractor to perform the functions required of a primary care provider.

^K (b) Default assignment to a primary care provider - In the case of an individual whose HIV/AIDS status is known to the Contractor at the time of enrollment and provider selection and who fails to select a primary care provider, Contractor, in assigning such individual to a primary care provider, shall make an assignment only to a provider described in subsection (a) of this section.

^K (c) Consultation arrangements with experienced providers - In order to meet the requirements of this Agreement, Contractor shall:

(1) identify experienced HIV providers (either within Contractor's provider network or outside of the network) who agree to furnish consultation services to network providers;

(2) enter into written Agreements with such experienced providers that specify their obligation to make consultation services available to both primary care providers and patients with HIV/AIDS who request such services;

(3) provide a level of compensation for such consultation services that is sufficient to ensure the availability of consultation services required as defined in this Agreement;

(4) furnish the names, addresses and telephone numbers of experienced HIV providers who have entered into such consultation Agreements to enrollees who request it and to all primary care providers in Contractor's provider network; and

(5) require as a condition of participation in Contractor's provider network that a primary care provider who is not an experienced provider as defined in §112:

(A) enter into written consultation arrangement with an experienced provider identified by Contractor, and

(B) permit patients with HIV/AIDS for whom the primary care provider is responsible direct access to the consulting provider for consultation services described in subsection (a)(2)(B) of this section under a standing order without prior authorization.

^K (d) Consultation defined - For purposes of this Agreement, the term consultation shall mean the following:

(1) oral communication with either a primary care provider or an enrollee under the care of such provider, on either a face-to-face basis or by telecommunication, and within a reasonable time period after a request for oral consultation services is made;

(2) review of medical records;

(3) at least one face-to-face medical consultation (including physical examinations and diagnostic procedures that the experienced HIV provider considers to be medically necessary) annually with members who are under the care of primary care providers to whom the provider furnishes consulting services;

(4) provision of timely and ongoing written and oral advice regarding the management of HIV/AIDS; and

(5) when requested by Contractor, a primary care provider, or an enrollee, a written opinion regarding the medical necessity of items and services furnished under this Agreement that sets forth the factual basis on which such opinion is based.

^K (e) Changing primary care providers - Contractor shall permit an enrollee who is diagnosed with HIV/AIDS following his or her enrollment into Contractor's plan to switch to a primary care provider described in subsection (a)

(1) at the time that the diagnosis is initially made;

(2) at least once during the 90-day period following such selection and at least annually thereafter; and

(3) at any time for cause.

^L,K (f) Self-referral for testing and counseling - Contractor shall:

^L,K (1) at least ___ times per year,⁶⁴ allow an enrollee to obtain HIV testing and counseling as defined in §103(b)(1) and (2)(A) on a covered basis from the agency or entity within Contractor's service area that receives funding under the Ryan White CARE Act, a CDC HIV prevention grant, or other public funding dedicated to HIV testing and counseling, sexually transmitted disease or family planning services or prenatal care , regardless of the entity's or agency's network status;

^K (2) reimburse such provider or agency for testing and counseling services that are furnished regardless of provider's network status at rates that are at least as favorable as those under which the Contractor would make payment to a participating provider in Contractor's network; and

^K (3) include in its member handbook and marketing materials a clear statement of each enrollee's right to self-refer on a covered basis ___ times per year to such agency for HIV testing and counseling services.

^L (g) Access to HIV prevention and medical management services by minor enrollees: consent to services - In the case of an enrollee with HIV/AIDS who is a minor as defined in §112, Contractor shall permit the enrollee to consent to receive HIV prevention or medical management services to the extent permitted under state and federal law.⁶⁵

The following subsection offers illustrative language for Purchasers' consideration regarding the composition, capabilities and selection of provider networks competent to treat HIV/AIDS.

§203. Provider Network

^K (a) In general - Contractor shall establish a provider network:⁶⁶

(1) that includes the types of providers described in subsection (b);

(2) that is of sufficient size, range and skill to be able to furnish the care and services that are enumerated in this Agreement in a manner that is consistent with accepted standards of health care practice for persons with HIV/AIDS; and

(3) whose members are accessible to persons with HIV/AIDS in accordance with the Americans with Disabilities Act and §504 of the Rehabilitation Act of 1973 which, in the case of primary care providers, shall be measured by the maintenance of a consulting agreement with an experienced HIV provider.

^L,K (b) Network membership - Contractor's provider network shall contain the following providers:

^K (1) primary care providers who maintain consultative relationships with experienced HIV providers;

^K (2) experienced HIV providers as defined in §112 on either a full membership or consultative status in accordance with the requirements of §202;

^K (3) specialty medical and health care providers representing the full range of physical and mental health, substance abuse, dental, and clinical subspecialties that are required in order to furnish the care and services enumerated in Part 1 of this Agreement in a manner that is appropriate to the prevention, treatment and management of HIV/AIDS;

^K (4) pharmacies (both retail and mail order);⁶⁷

^L (5) laboratories that are certified under the Clinical Laboratory Improvement Act (CLIA), §353 of the Public Health Service Act, (42 U.S.C. §263a) to perform the tests described in §105 of this Agreement;

^K (6) one or more hospitals (either as part of the network or under special arrangements) that have demonstrated experience in furnishing care to individuals with HIV/AIDS as demonstrated by:

(A) the establishment and operation of a comprehensive program of care for individuals with HIV/AIDS;

(B) the provision of regular training to hospital medical and non-medical staff relating to the treatment of individuals with HIV/AIDS; or

(C) the granting of admitting privileges to experienced HIV providers.

^L,K (7) centers of excellence in the care and management of persons with HIV/AIDS that are recognized under state law;.⁶⁸

^K (8) medical nutritionists on a direct care or consultative basis with demonstrated experience in counseling patients with HIV/AIDS; and

^K (9) trained HIV counselors, educators and case managers on either a direct or consultative basis.⁶⁹

^K (c) Ryan White CARE Act providers - Contractor shall use its best efforts to enter into network Agreements with any provider in Contractor's service area that receives funding under the Ryan White CARE Act and that furnishes or arranges for one or more of the types of care and services enumerated in Part 1 of this Agreement.⁷⁰

^K (d) Provider materials - Contractor shall furnish each network provider, as well as non-network providers, with the following materials:

a standard agreement form for use in entering into written consultation agreements with experienced HIV providers, as required in §202(c), that addresses the elements specified in such section; and

1.a provider manual that is updated as needed, describes the coverage, service, confidentiality, reporting, access, enrollment, and network requirements of this Agreement, instructs providers on the required elements of the experienced provider consultation program described in §202(c) and the procedures for developing such a consultation arrangement, and identifies experienced hospitals in the network as described in §203(b).

^K (e) Prohibited use of resource consumption measures in selecting or retaining providers⁷¹ - Contractor shall not exclude or disenroll a provider from Contractor's provider network solely on the grounds that the provider:

(1) Conducts or orders to be conducted HIV tests consistent with §103 of this contract;

(2) prescribes drugs and biologicals consistent with §106 of this contract; or

(3) provides medical care to persons with HIV/AIDS.

^K (f) Compensation of providers participating in Contractor's provider network - Contractor shall not reduce compensation to, withhold compensation from, or otherwise impose financial penalties upon a provider participating in Contractor's provider network solely on the basis of a provider's use of resources in connection with the prevention, or medical management of HIV/AIDS.

^K (g) Training of providers⁷² - Contractor shall certify that each primary care provider participating in Contractor's provider network receives information or training on at least an annual basis on the following topics:

(1) the incidence and prevalence of HIV/AIDS in the Contractor's service area and the population groups at risk of HIV residing in the area;

(2) risk factors for HIV and information about preventing transmission of HIV;

(3) universal precautions;

(4) diagnosis of primary HIV infection;

(5) in the case of primary care providers, risk assessment, testing and counseling duties as described in §103; (6) provisions related to confidentiality under §208; and

(7) applicable HIV referral and reporting requirements under the laws of the state of [drafter insert name of state].

The following section offers illustrative language for Purchasers' consideration related to delivery and access of HIV/AIDS services.

§204. Delivery of Care and Access to Covered Services ⁷³

^K (a) In general - Contractor shall ensure that in furnishing services covered under this Agreement, network and affiliated providers comply with the performance standards in this section.

^L,G,K (b) Prevention, testing and counseling services - In delivering services enumerated in §103, Contractor shall ensure that consistent with §103 (relating to prevention services), network providers:⁷⁴

(1) conduct an HIV risk assessment:

^L,G (A) as part of the initial visit and regularly thereafter as part of any covered routine health exam (including, for Medicaid enrollees under age 21, periodic and interperiodic screens furnished pursuant to the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT)); and

^G,K (B) during an encounter related to pregnancy, reproductive health, mental illness or addiction disorder, sexually transmitted disease, tuberculosis, bacterial pneumonia in persons under 50, cervical intra epithelial neoplasia, or any other conditions suggestive of HIV infection;⁷⁵

^G,K (2) conduct HIV antibody tests and pre- and post-test counseling in the case of an enrollee who:

^G (A) has one or more HIV risk factors as defined in §112;

^G (B) is a woman who is pregnant or considering becoming pregnant;

^G (C) has experienced occupational exposure to HIV; or

^K (D) requests a test;

^K (3) dispense a reasonable number of condoms at the time of testing and counseling an enrollee at risk for HIV; and

^G (4) make a reasonable effort to contact an enrollee who tests positive for HIV infection but who does not return for the test results.

^K (c) Case management services⁷⁶ - Contractor shall ensure that:

(1) the case management plan described in §108:

(A) is developed by a case manager participating in Contractor's provider network in consultation with the enrollee and, with the written consent of the enrollee, the enrollee's primary care physician, other treating providers, a member of the enrollee's family, or other caregiver; and

(B) includes a description of all services for which the periodic assessment under subsection (a)(1) indicates a need (whether or not such services are covered under this Agreement);

(2) covered case management services are delivered at alternative sites such as an enrollee's home, shelter or other locations indicated by the enrollee's health.

^K,L (d) Service timelines - In furnishing services covered under this Agreement Contractor shall ensure that:

^K (1) testing and counseling occurs within___calendar days of the time of request;⁷⁷

^K (2) positive results of HIV tests are communicated to enrollees on a face-to-face basis within___calendar days following the date on which the patient's blood is drawn;⁷⁸

^K (3) drugs in the prescribed dosage and form are dispensed and received within ___ hours of the time that enrollee presents the prescription;⁷⁹

^L (4) a 72-hour supply of any drug is immediately made available to an enrollee during the time period that a full prescription is pending;⁸⁰

^K (5) a case management plan is:

(A) developed within ___ calendar days ⁸¹after an individual whose HIV/AIDS status is known at the time of enrollment enrolls under this Agreement or within ___ calendar⁸² days after an enrollee is diagnosed with HIV infection or an HIV-related condition; and

(B) modified within ___ calendar days⁸³ after a significant change in the medical condition or housing status of an enrollee with a written case management plan; and

^K (6) in the case of an HIV infected enrollee who is pregnant and who has an addiction disorder, treatment is arranged within __ hours of request;⁸⁴

^K (7) appointments for newborns are made with the infant's primary care provider within ___ calendar days of hospital or birthing center discharge;⁸⁵

^K (8) appointments for urgent medical conditions are provided within ___ hours of request; ⁸⁶and

^L (9) no prior authorization is required for the case of enrollees when the Contractor or a member of Contractor's network has a reasonable basis for suspecting an emergency medical condition.

(e) Language access (Reserved).

The following section provides illustrative language related to the reporting of data required for public health surveillance purposes.

§205. Public Health Reporting⁸⁷

^L,K (a) Case and test result reporting by providers including clinical laboratories -- Contractor shall ensure that, regardless of their location in or outside of [drafter insert name of state], each provider (including clinical laboratories)that has entered into a service agreement with the Contractor reports cases of HIV and AIDS to the [drafter insert name of state] public health agency, in accordance with the laws and regulations of such state, and in a form, timeline, and manner prescribed by the [drafter insert name of state health agency], in any case in which the test sample is drawn in [drafter insert name of state] or the care is furnished in [drafter insert name of state]. ⁸⁸

^L,K (b) Access to data for case surveillance - Contractor and each clinical laboratory, and other provider participating in Contractor's provider network shall:

^L,K (1) make available to [drafter insert name of public health agency with HIV/AIDS monitoring responsibilities in the area served by the Contractor] upon request and in a manner consistent with the confidentiality provisions of this Agreement individual medical and other information with respect to an enrollee with HIV/AIDS necessary to enable the Agency to:

^L (A) carry out its HIV/AIDS case surveillance responsibilities under [drafter insert applicable state law or regulation]; and

^L (B) conduct HIV-related investigations of public health importance under [drafter insert applicable state law or regulation].

^L,K (c) Perinatal exposure - Contractor shall ensure that providers caring for pregnant women with HIV report cases of infants exposed perinatally to HIV to the local public health agency consistent with [drafter insert applicable state law or regulation].

§206. Memoranda of Understanding (Reserved)

The following section offers illustrative language for Purchasers' consideration related to quality measures in the area of HIV/AIDS.

§207. Quality Improvement and Measurement

^K (a) Clinical performance studies - Contractor shall conduct, or arrange for the conduct of, one or more clinical studies to measure the timeliness, accessibility to enrollees, or effectiveness of [drafter insert agreed-upon topics from the following options]:

(1) HIV testing of all pregnant enrollees no later than the second prenatal encounter;

(2) HIV testing, with counseling of enrollees diagnosed with a sexually transmitted disease;

(3) antiretroviral therapy for enrollees diagnosed with HIV as recommended in the guidelines enumerated in §109;

(4) prophylactic treatment of enrollees diagnosed with HIV for Pneumocystis carinii pneumonia or other opportunistic infections;

(5) viral load testing and CD4 monitoring of enrollees diagnosed with HIV;

(6) assessment of adolescent enrollees for HIV risk factors;

(7) assessment of adult enrollees for HIV risk factors;

(8) compliance by providers participating in Contractor's provider network with the requirements relating to the timeliness of provision of the HIV prevention and medical management services specified in [drafter insert reference comparable to the illustrative language in §103 and §104 of Part 1] of the Agreement;

(9) measures of satisfaction among members who have HIV/AIDS.

^K (b) Performance reporting⁹⁰ - Contractor shall make the results of performance studies related to HIV/AIDS available to the Purchaser and, upon request, to the state public health agency and enrollees without charge.

^K (c) Study plan - Prior to commencing its study, Contractor shall submit its study plan to Purchaser for review and approval.

The following section offers illustrative language for Purchasers' consideration related to patient and enrollee confidentiality.

§208. Confidentiality of Enrollee HIV Status

^L (a) Compliance with legal requirements - Contractor shall comply with applicable state and federal law regarding the confidentiality of enrollee HIV status in carrying out the terms of this Agreement.

The following section offers illustrative language for Purchasers' consideration related to information that should be furnished to enrollees.

§209. Information for Enrollees

^L,K (a) Member handbook - Contractor shall include in its member handbook the following information⁹¹

(1) a statement that patient medical information relating to the provision of HIV services is confidential and that it may be disclosed only in a manner consistent with state and federal law;

(2) a statement of rights of minors, in accordance with state and federal law, to confidentiality of all encounters or communications relating to services covered under this Agreement for HIV/AIDS;

(3) a complete and accurate description of all care and services related to HIV/AIDS that are covered under this Agreement as well as the conditions under which the Contractor may pre-authorize care and services;

(4) complete and accurate information regarding the ability of enrollees with HIV/AIDS to select PCPs who are experienced providers, as defined in §112 of this Agreement, or who are affiliated with such providers; and

(5) complete and accurate information regarding the ability of enrollees to self-refer for services identified as described in §202 of this Agreement.

^K (b) Confidential information - Contractor shall ensure that an enrollee or prospective enrollee may obtain the following information on a confidential basis through member services and through enrollment forms or other written materials:

(1) a description of procedures available to enrollees and their treating providers to protect the confidentiality of enrollee medical information;

(2) a list of services that are covered under this Agreement; and

(3) a list of participating experienced HIV providers and specialists and primary care providers who have consultative relationships with experienced HIV providers as described in §202(a)(2).

The following section provides illustrative language regarding information for Purchasers.

§210. Information for Purchaser

^K(a) Submissions required - Contractor shall make available to Purchaser upon request a copy of the following documents:

(1) Contractor's provider manual and any other directives, guidelines, or protocols relating to the provision or coverage of items or services under this Agreement;

(2) the subcontract or other written agreement between Contractor and participating laboratories, pharmacies, providers and case managers;

(3) Contractor's enrollee handbook or other written information given to enrollees regarding items and services covered under this Agreement; and

(4) Contractor's directives, coverage and treatment guidelines, and instructions to network and affiliated providers relating to the prevention, diagnosis and management of HIV and related conditions.

Endnotes

Commentary: The guidelines in §109 do not address the issue of enrollment and disenrollment. This section has been drafted to provide Purchasers with illustrative specifications regarding issues that arise in the development of enrollment and disenrollment specifications. Purchasers might wish to pay particular attention to the recommendation of HIV experts regarding the obligations of Contractors in situations involving new enrollees with HIV as well as the disenrollment of persons receiving HIV-related care. Of special interest is the sample specification regarding continuation of treatment until the treatment has been reviewed and any necessary adjustment been made by the individual's new primary care provider.
Commentary: The guidelines set forth in §109 do not address the issue of adherence to medical management plans. Several states do include provisions in their contracts regarding the effect of existing case plans on subsequent Contractor conduct. See, e.g., State of New Jersey entry, Table 3.1, in Negotiating the New Health System (2d Ed.), op cit.
Commentary: This section has been drafted to provide Purchasers with illustrative specifications regarding issues that arise in the development of provider selection standards. Particular attention should be paid to the recommendation of HIV experts, as set out in guidelines, that patients with HIV/AIDS have the option of selecting either an experienced provider or a provider that maintains a consultative relationship with an experienced provider.The specification explains what is meant by a consultative relationship and sets forth the duties of Contractors to assist in the development of such relationships. The complexity and rapid evolution of HIV treatment options and the risk of inadequate treatment resulting in treatment failure and emergence of drug-resistant strains of HIV have resulted in recommendations that "[w]hen possible, the treatment of HIV-infected patients should be directed by a physician with extensive experience in the care of these patients. When this is not possible, the physician treating the patient should have access to such expertise through consultations." (Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, at §109 (i)). Investigators have reported the death rates of AIDS patients with the most experienced physicians to be nearly one-third lower than death rates of patients whose physicians had the least experience in treating the condition: Kitihata MM et al. Physician's experience with the acquired immunodeficiency syndrome as a factor in patients' survival. NEJM. 1996; 334(11):701-706. 97:323-330; Strathdee S et al. "HIV+ IDUs eligible for antiretrovirals: what are the barriers to receiving therapy despite universal access?." Fifth conference on Retroviruses and Opportunistic Infections 1998, Abstract 132. Laine C et al. "The relationship of clinic experience with advanced HIV and survival of women." AIDS . 1998;12(4):417-424. Markson, LE et al., "Repeated emergency department use by HIV-infected persons: effect of clinic accessibility and expertise in HIV Care." Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology. 1998; 17(1):35-41.
Commentary: Self-referral is recommended by HIV experts to minimize barriers to early identification of HIV infection. No specific number of out-of-network encounters with local health agencies that are not members of Contractor networks is specified in the guidelines in §109. Experts in HIV prevention recommend permitting at least one self-referral annually.Commentary for Medicaid purchasers: Certain state Medicaid agencies have elected to define family planning services, in their managed care contracts, to include HIV counseling and testing and to permit Medicaid managed care enrollees to refer themselves for these services. See Rosenbaum S et al., Negotiating the New Health system: A Nationwide Study of Medicaid Managed Care Contracts (2d ed.)(The George Washington University, Washington D.C., 1998). These provisions are consistent with the statutory requirement that managed care organizations permit Medicaid enrollees to self-refer for family planning services. (42 U.S.C. 1396a(a)(23)(B), 42 U.S.C. 1396d(a)(4)(C)). More generally, the Balanced Budget Act of 1997 requires each Medicaid managed care organization to provide assurances that the organization "offers an appropriate range of services and access to preventive and primary care services for the population expected to be enrolled..." (42 U.S.C. §13969-2(b)(5)(A)).
Commentary: All states by law permit minors to consent to diagnosis and treatment of an STD although not all states classify HIV infection as an STD. At least 13 states by law specifically permit adolescents to consent to HIV testing; and seven states also by statute expressly permit minors to consent to treatment. K. Hein, Annotation: adolescent HIV testing - who says who signs? AJPH 1997; 87:1277-1278. Other types of services to which minors may consent, which could reasonably include HIV services, are prenatal care and delivery (27 states and the District of Columbia) and contraceptive services (23 states and the District of Columbia). Allan Guttmacher Institute, Teenagers' Right to Consent to Reproductive Health Care (http://www.agi-usa.org/pubs/ib21.html)
Commentary: The guidelines in §109 do not address the issue of provider network. This section has been drafted to provide Purchasers with illustrative specifications regarding issues that arise in the development of a provider network. Purchasers may wish to pay particular attention to the manner in which the issue of consulting experienced providers and hospitals with special capabilities is handled. Contractors may either include such providers in their network or develop special consulting arrangements with both classes of providers.
Commentary: Certain enrollees with HIV infection for whom drug treatment is prescribed may need or elect to receive covered drugs, vitamin supplements and biologicals by mail because they live in rural or underserved areas without pharmacies within a reasonable distance, because they are homebound, because of confidentiality concerns about receiving HIV drugs at a pharmacy in their neighborhood or for other reasons. Note that both retail and mail order services are included; it is not intended that enrollees be limited to mail-order pharmacy services
Commentary: Purchasers and Contractors, particularly with regard to rural areas with few or no experienced HIV providers may also wish to consider the Tennessee HIV "Centers of Excellence" voluntary model, which was developed through a consensus process involving medical providers specializing in HIV/AIDS care, consumers, advocates, managed care organizations and the state Health Department. MCOs are encouraged but not required to enter into fee-for-service contracts under which the Centers would serve as primary care physicians for individuals with HIV infection. Criteria for designation as a Center include an actively managed patient base of at least 50 individuals with HIV, a commitment to furnish provider AIDS education and medical and non-medical service capacity. The development and other elements of this model are described in J Rawlings-Sekunda and N. Kaye, op cit. New York State will require its MCOs to contract with designated AIDS centers, a hospital designation that has been in existence in the state since 1985.
Commentary: In areas where CDC prevention grantees or Ryan White CARE Act providers offer these services, Contractor may consult with such providers to identify such specialists.
Commentary: Medicaid agencies are directed to the November 25, 1998 letter from Sally Richardson that encourages use of Ryan White CARE Act providers in managed care network. See note 20 supra, for website address. Contractors should contact their state health agencies to obtain the names and locations of Ryan White CARE Act grantees in their service areas.
Commentary: Subsections (e) and (f) are intended to minimize disincentives for providers to furnish appropriate HIV services or for providers to accept individuals with HIV/AIDS into their practices.
Commentary: The Contractor may wish to consult with CDC-funded HIV prevention programs (in local or state public health agencies) and Ryan White CARE Act grantees to identify appropriate clinical training opportunities (materials, personnel, programs) as well as the availability of epidemiological data and other types of information on which provider training is recommended.
Commentary: The guidelines in §109 do not address the issue of access. These specifications have been developed because of the importance under the Balanced Budget Act of 1997 (P.L. 105-33) of including access measures in purchasing specifications as part of the state's quality assurance system. These access standards address both prevention and treatment requirements in order to ensure maximum plan involvement in prevention activities.
For applicable Medicaid law, see Commentary 3.
Commentary: Experts note that conditions such as unexplained weight loss, thrush, chronic fatigue and chronic diarrhea may be suggestive of HIV infection.
Commentary: See Commentary on case management at §108.
Commentary: The guidelines in §109 do not address timelines for requested testing and counseling from request. Experts in the field suggest that the test should occur within 5 calendar days of request.
Commentary: The guidelines in §109 do not specify timelines for reporting test results. Experts in the field recommend that individuals receive positive test results within 14 days of the date on which blood is drawn. Negative results also can be communicated by telephone.
Commentary: The guidelines enumerated in §109 do not prescribe time lines for dispensing prescribed drugs. Experts in the area of HIV suggest a time line of 72 hours. Note that in the case of contracts that permit the use of mail order pharmacies, a Purchaser should indicate maximum time limits for the transmission of mail order prescriptions to a member. Purchasers should consider specifying the use of overnight mail arrangements where necessary to meet the 72- hour timeline.
Commentary for Medicaid Purchasers: Under specialized Medicaid prior authorization rules for prescription drugs, a 72-hour emergency supply of a drug must be dispensed while waiting for a prior authorization (which must be made and transmitted within 24 hours of the request for authorization). (42 U.S.C.?1396r-8(d)(5)).
Commentary: The guidelines listed in §109 do not specify time periods for developing a case management plan following enrollment. Experts in HIV medical management recommend a time period of between 30 and 60 days.
Commentary: The guidelines listed in §109 do not specify time periods for developing a case management plan for persons diagnosed with HIV/AIDS. Experts in HIV medical management recommend a time period of between 60 and 90 days.
Commentary: The guidelines listed in §109 do not specify timelines for such modifications. Experts in HIV medical management recommend a timeline of between 14 and 30 days.
Commentary: The guidelines in §109 do not set forth treatment timelines for treatment of pregnant women with addiction disorders. Experts in the field recommend that treatment should be initiated within 24 hours.
Commentary: While the guidelines listed in §109 do not specifically address services following discharge of an HIV-exposed neonate, they provide guidance on timing of services following birth in order to maximize the opportunity to prevent the onset of HIV infection or opportunistic infection (particularly Pneumocystis carinii pneumonia, PCP) and achieve appropriate treatment outcomes in infants infected at birth. These timelines include provision of an initial HIV test within forty-eight hours of birth, antiretroviral therapy/prophylaxis for the first six weeks of life and initiation of PCP prophylaxis six weeks after birth. In light of these and other considerations, experts in the field recommend that a first post-discharge visit occur at least within seven to fourteen days.
Commentary: The guidelines in §109 do not specify a definition of "urgent" or a timeline for urgent medical conditions. Experts recommend that conditions that require attention within 24 hours be considered urgent and recommend the use of a 24-hour window for urgent care appointments.
Commentary: These public health reporting requirements have been developed by experts to provide Purchasers with illustrative specifications relating to the provision of information to public health authorities regarding HIV. Purchasers may wish to pay particular attention to reporting of the results of laboratory tests, particularly in cases in which Contractors use out-of-state laboratories over which a state may have limited practical control. Frequently laboratories are critical sources of data for public health surveillance activities. Note that public health reporting is distinguished from any Medicaid claims reporting that may be required in a comprehensive or specialty Medicaid services contract.
Commentary: For a fuller explication of public health data and reporting, as well as other data and reporting specifications, see forthcoming data and information specifications, which may be obtained in draft form from CHPR.
Commentary: Performance measures for HIV prevention and care are under development or consideration. The Institute of Medicine (IOM) has recommended the development and adoption of performance measures for prenatal HIV testing. Reducing the Odds, op cit. Field-tested performance measures will be appended to future revisions of these specifications as they become available. Commentary for Medicaid purchasers: State Medicaid agencies must maintain programs to review services covered for benefconsiderations, experts in the field recommend that a first post-discharge visit occur at least within seven to fourteen days. Commentary: The guidelines in §109 do not specify a definition of "urgent" or a timeline for urgent medical conditions. Experts recommend that conditions that require attention within 24 hours be considered urgent and recommend the use of a 24-hour window for urgent care appointments.
Commentary: Note that reporting on performance measures is distinguished from public health reporting which is considered necessary for case surveillance and epidemiological data collection.
Commentary for Medicaid purchasers: The 1997 Balanced Budget Act includes a general requirement that managed care organizations provide specified information to enrollees including covered services and the "identity, locations, qualifications and availability" of the plan's primary care and specialist providers. (42 U.S.C. §1396u-2(a0(5)(B)(ii), (iv)).