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Medicaid Contract Purchasing Specifications

Access to Services

A Technical Assistance Document
June, 2000

Table of Contents

§A1-1. Access to Emergency Services
§A1-2. Access to Urgent Care Services
§A1-3. Access to Preventive Services
§A1-4. Access to Routine Services
§A1-5. Access to Specialty Services
§A1-6. Access to Public Health Services
§A1-7. Access to Pharmacy Services

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A1-1. Access to Emergency Services 3

(a) Duty of Contractor --Contractor shall:

(1) ensure that emergency services are accessible to each enrollee 24 hours per day, 7 days per week, through providers participating in Contractor's provider network;

(2) comply with the requirements of §1932(b)(2)(A) of the Social Security Act, 42 U.S.C. §1396u-2(b)(2)(A) relating to:

(A) coverage without prior authorization of emergency services furnished by the provider (whether or not participating in Contractor's provider network); 4and

(B) coordination of post-stabilization care services; and

(3) ensure that:5

(A) in [drafter insert name of urban area(s) within Contractor's service area] at least [ ] providers qualified in the medical management of childbirth are available (either on-site or within [ ] minutes travel time) at the emergency room facilities through which Contractor furnishes or arranges for the furnishing of emergency services under this section; and

(B) in [drafter insert name of rural area(s) within Contractor's service area] at least [ ] providers qualified in the medical management of childbirth are available (either on-site or within [ ] minutes travel time) at the emergency room facilities through which Contractor furnishes or arranges for the furnishing of emergency services under this section.

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(b) Emergency Services Defined6 -- For purposes of subsection (a), emergency services are items and services covered under [drafter insert reference to coverage provisions of Purchasing Agreement] that are:

(1) needed to evaluate or stabilize an emergency medical condition (as defined in subsection (c)); and

(2) furnished by a provider qualified to furnish such services.

(c) Emergency Medical Condition Defined -- For purposes of subsection (b), an emergency medical condition is a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(1) the placement of the enrollee's health in serious jeopardy (or with respect to a pregnant enrollee, the health of the enrollee or her unborn child);

(2) serious impairment of a bodily function; or

(3) serious dysfunction of any bodily organ or part.

(d) Post-stabilization Care Services Defined -- For purposes of subsection (a), as provided under §1852(d)(2) of the Social Security Act, 42 U.S.C.§1395w-22(d)(2), 63 Fed. Reg. 34986 (June 26, 1998), post-stabilization care services are medically necessary, non-emergency services needed to ensure that an enrollee who has been determined to be stabilized remains stabilized and that are provided from the time that the treating hospital requests authorization from Contractor until:

(1) the enrollee is discharged;

(2) a physician participating in Contractor's provider network assumes responsibility for the enrollee's care; or

(3) the treating physician and Contractor agree to another arrangement.

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Compliance Measures: Contractor shall make available to Purchaser on request:

(1) all Provider manuals, protocols, memoranda, contracts and other materials used by Contractor to inform providers about Contractor's duties relating to emergency services or the circumstances under which emergency services must be furnished to enrollees;

(2) all enrollee handbooks, handouts, and other materials used by Contractor to inform enrollees about the availability of emergency services; and

(3) records of enrollee grievances and complaints relating to emergency services received by Contractor.

A1-2. Access to Urgent Care Services 7

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(a) Duty of Contractor

(1) 24/7 Availability-- Contractor shall ensure that urgent care services (as defined in subsection (b)) are accessible to each enrollee 24 hours per day, 7 days per week, through providers participating in Contractor's provider network or, to the extent required under §A2-4(d)(2) through providers not participating.

(2) Prior Authorization -- Prior authorization requirements, if any, imposed by Contractor upon urgent care services (as defined in subsection (b)) shall be imposed in a manner that complies with §A2-9.

(b) Urgent Care Services Defined 8-- For purposes of subsection (a), urgent care services are items and services covered under [drafter insert reference to coverage provisions of Purchasing Agreement] that are:

(1) needed to evaluate or treat an urgent medical condition (as defined in subsection (c)); and

(2) furnished by a provider qualified to furnish such services.

(c) Urgent Medical Condition -- For purposes of subsection (b), an urgent medical condition is a condition in an enrollee manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention within [ ] 9hours of the manifestation of the condition to result in:

(1) placement of the enrollee's health (or with respect to a pregnant enrollee, the health of the enrollee or her unborn child) in serious jeopardy;

(2) serious impairment of a bodily function; or

(3) serious dysfunction of any bodily organ or part.

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Compliance Measures: Contractor shall make available to Purchaser on request:

(1) all Provider manuals, protocols, memoranda, contracts, and other materials used by Contractor to inform providers about Contractor's duties relating to urgent care services or the circumstances under which urgent care services must be furnished to enrollees;

(2) all enrollee handbooks, handouts, and other materials used by Contractor to inform enrollees about the availability of urgent care services; and

(3) records of enrollee grievances and complaints relating to urgent care services received by Contractor.

A1-3. Access to Preventive Services 10

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(a) Pediatric Preventive Services 11

(1) Basic Duty -- Contractor shall ensure that pediatric preventive services (as defined in paragraph (3)) are accessible to each enrollee who is a child under the age of 21, through providers participating in Contractor's provider network (or, to the extent required under §A2-4(d)(2), through providers not participating), as specified in paragraph (2).

(2) Access to EPSDT Services by Enrolled Children Under 21

(A) Periodic Services -- Contractor shall ensure that each enrolled child under 21 who is eligible for [drafter insert reference to state Medicaid program] and who has been enrolled for more than [ ] 12days receives an EPSDT periodic service (as defined in paragraph (3)(A)) at the earlier of:

(i) within [ ] 13 calendar days of a request by an enrolled child under 21 (or the child's family or caregiver) for an appointment for a periodic service; or

(ii) at the time that such service is scheduled to occur in order to comply with the EPSDT periodicity schedule set forth in [drafter insert reference to state Medicaid plan provision].

(B) Interperiodic Services -- Contractor shall ensure that each enrolled child under 21 who is eligible for [drafter insert reference to state Medicaid program] receives an EPSDT interperiodic screening service (as defined in paragraph (3)(E)):

(i) at a time other than the applicable periodic EPSDT screening services referenced in paragraph (1); and

(ii) at the request of an enrolled child's family or caregiver or by an individual who comes into regular contact with the child and who suspects the existence of a physical, mental or developmental health problem (or possible worsening of a preexisting physical, mental or developmental health condition).

(C) Young Adults -- The requirements of this subsection shall not be construed to require an enrollee who is over the age of [ ] but under the age of 21 to receive pediatric preventive services through a pediatrician.

(3) Pediatric Preventive Services -- To the extent the services are covered under [drafter insert reference to coverage provisions in Purchasing Agreement], pediatric preventive services for children under age 21 are the following EPSDT services:

(A) screening services described in §1905(r)(1) of the Social Security Act 14 and §5123 of the Medical Assistance Manual, http://www.hcfa.gov/pubforms/stmcaid/mcaidtoc.htm;

(B) vision services described in §1905(r)(2) of the Social Security Act and §5123.2F.1. of the Medical Assistance Manual, http://www.hcfa.gov/pubforms/stmcaid/mcaidtoc.htm;

(C) dental services described in §1905(r)(3) of the Social Security Act and §5123.2G of the Medical Assistance Manual, http://www.hcfa.gov/pubforms/stmcaid/mcaidtoc.htm;

(D) hearing services described in §1905(r)(4) of the Social Security Act and §5123.2F.2. of the Medical Assistance Manual, http://www.hcfa.gov/pubforms/stmcaid/mcaidtoc.htm; and

(E) interperiodic screening services required under §5140.B. of the Medical Assistance Manual, http://www.hcfa.gov/pubforms/stmcaid/mcaidtoc.htm.

(b) Clinical Preventive Services for Adults

(1) Basic Duty -- Contractor shall ensure that clinical preventive services for adults (as defined in paragraph (3)) are accessible to each enrolled adult, through providers participating in Contractor's provider network (or, to the extent required under §A2-4(d)(2), through providers not participating), as specified in paragraph (2).

(2) Access to Clinical Preventive Services for Adults [Back To Top]

(A) Basic Duty -- Contractor shall ensure that each enrolled adult receives an appointment for clinical preventive services (as defined in paragraph (3)):

(i) the day that is within [ ]15 days of a request by an enrolled adult for an appointment for a clinical preventive service; or, if earlier,

(ii) the day that such appointment must be scheduled to occur in order to comply with the requirement for a periodic health visit under subparagraph (B).

(B) Periodic Health Visit -- Contractor shall ensure that each enrolled adult receives an appointment for a periodic health visit that is administered at a frequency and in a manner appropriate to the age and health status of the adult consistent with the Guide to Clinical Preventive Services described in paragraph (3)(D).

(3) Clinical Preventive Services for Adults 16

(A) Adults Age 21 Through 24 -- In the case of an enrolled adult age 21 through 24, clinical preventive services are the interventions recommended for the general population for the periodic health examination in "Table 2" of the Guide described in subparagraph (D).

(B) Adults Ages 25 Through 64 Years -- In the case of an enrolled adult age 25 through 64, clinical preventive services are the interventions recommended for the general population for the periodic health examination in "Table 3" of the Guide described in subparagraph (D).

(C) Adults Age 65 and Older -- In the case of an enrolled adult age 65 and older, clinical preventive services are the interventions recommended for the general population for the periodic health examination in "Table 4" of the Guide described in subparagraph (D).

(D) Guide to Clinical Preventive Services -- The Guide described in this subparagraph is U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd Ed., 1996, www.dphp.osophs.dhhs.gov/pubs/GUIDECPS/.

(c) Services for Pregnant Women 17

(1) Basic Duty -- Contractor shall ensure that preventive services for pregnant women (as defined in paragraph (3)) are accessible to each enrolled pregnant woman, through providers participating in Contractor's provider network (or, to the extent required under §A2-4(d)(2), through providers not participating), as specified in paragraph (2).

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(2) Access to Preventive Services by Enrolled Pregnant Women

(A) Prenatal Care -- Contractor shall ensure that each enrolled pregnant woman receives an appointment for preventive services for pregnant women (described in paragraph (3)) with a primary care provider (as defined in §A2-2(e)) participating in Contractor's provider network (including, under §A2-3(b), an obstetrician/gynecologist or certified nurse midwife):

(i) within [ ] 18calendar days of a request by an enrolled woman for an appointment; or, if earlier

(ii) at the time a prenatal care visit is indicated under the Guidelines for Perinatal Care, 4th Ed., American Academy of Pediatrics and American College of Obstetricians and Gynecologists, http://www.sales.acog.com.19

(B) Post-partum Care -- Contractor shall ensure that each enrolled woman who has given birth while enrolled receives:

(i) an appointment with a primary care provider participating in Contractor's provider network (including, under §§A2-3(b), an obstetrician/gynecologist or certified nurse midwife) for a post-partum visit consistent with clause (ii) at the earlier of:

(I) within [ ]20 calendar days of a request by an enrolled woman for an appointment; or

(II) at the time a postpartum visit is indicated under the Guidelines for Perinatal Care, 4th Ed., American Academy of Pediatrics and American College of Obstetricians and Gynecologists, www.sales.acog.com; and

(ii) items and services during the post-partum visit consistent with the Guidelines for Perinatal Care, 4th Ed., American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, www.sales.acog.com.

(3) Preventive Services for Pregnant Women -- In the case of an enrolled pregnant woman, preventive services for pregnant women are the interventions recommended for the general population for the periodic health examination in "Table 5" of U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd Ed., 1996, www.dphp.osophs.dhhs.gov/pubs/GUIDECPS/.

Compliance Measures: Contractor shall make available to Purchaser on request:

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(1) all Provider manuals, protocols, memoranda, and other materials used by Contractor to inform providers about Contractor's duties relating to the delivery of pediatric preventive services, clinical preventive services for adults, and preventive services for pregnant women;

(2) the enrollee handbook and other materials used by Contractor to inform enrollees about the availability of pediatric preventive services, clinical preventive services for adults, and preventive services for pregnant women;

(3) records of enrollee grievances and complaints relating to preventive services received by Contractor; and (4) data relating to access to preventive services required to be reported under §A2-10.

A1-4. Access to Routine Services 21

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(a) Duty of Contractor -- Contractor shall ensure that routine services (as defined in subsection (c)) are accessible to each enrollee, through providers participating in Contractor's provider network or, to the extent required under §A2-4(d)(3), through providers not participating, as specified in subsection (b).

(b) Access Requirements 22

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(1) Appointment Scheduling23 -- Contractor shall ensure that an appointment for a routine service (as defined in subsection (c)) shall be made for an enrollee with the enrollee's primary care provider or other appropriate provider participating in Contractor's provider network within [ ]24 days of a request by an enrollee for an appointment for such a service.

(2) Telephone Access to Appointments25 -- Contractor shall ensure that enrollees may make appointments, either through Contractor or through providers participating in Contractor's provider network, for routine services between the hours of [ ] and [ ] Monday through [ ]:

(A) by telephone; and

(B) in person.

(c) Routine Services Defined -- Routine services are items or services that are covered under [drafter insert reference to coverage provisions in Purchasing Agreement] that are not:

(1) emergency services (as defined under §A1-1(b));

(2) urgent care services (as defined under §A1-2(b)); and

(3) preventive services under §A1-3.

Compliance Measures: Contractor shall make available to Purchaser on request:

(1) all Provider manuals, protocols, memoranda, and other materials used by Contractor to inform providers about Contractor's duties relating to routine services;

(2) the enrollee handbook and other materials used by Contractor to inform enrollees about the availability of routine services; and

(3) records of enrollee grievances and complaints relating to routine services received by Contractor.

A1-5. Access to Specialty Services 26

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(a) Duty

(1) Specialist Available in Provider Network - Contractor shall ensure that each enrollee has access to specialty items and services (as defined in subsection (c)) covered under [drafter insert reference to coverage provisions of Purchasing Agreement] from specialists who participate in Contractor's provider network, except as provided in paragraph (2).

(2) Specialist Not Available in Provider Network - In the case that there is no specialist participating in Contractor's provider network who has the expertise and experience appropriate to the enrollee's illness or condition and who has the capacity (in light of other patient demands) to treat the enrollee within [ ] 27 days of the enrollee's request for or referral to specialty care, Contractor shall comply with the requirements of subsection (b) (relating to out-of-network specialists).

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(b) Specialists Not Participating in Provider Network - Contractor shall ensure that, in the case described in subsection (a)(2), the specialist to whom the enrollee is referred either has an ongoing referral agreement under paragraph (1) or complies with the requirements of paragraph (2).

(1) Ongoing Referral Agreement - Contractor shall be considered to have an ongoing referral agreement with a specialist only if there is in effect an enforceable written agreement between Contractor (or a provider participating in Contractor's provider network) and the specialist under which the specialist agrees:

(A) in furnishing items or services to an enrollee,

(i) to comply with the treatment guidelines that would apply under [drafter insert name of Purchasing Agreement] if the items or services were furnished by a specialist participating in Contractor's provider network; and

(ii) to furnish the items or services in the same setting that the specialist would furnish such items or services to commercially-insured patients with same illnesses or conditions; and

(B) to furnish, within [ ]28 days after referral, services to a specified minimum number of enrollees who are referred to the specialist by primary care providers or specialists participating in Contractor's provider network; and

(C) to charge enrollees referred by primary care providers or specialists participating in Contractor's provider network no more than the amounts (if any) that specialists participating in Contractor's provider network are permitted to charge beneficiaries under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., and the [drafter insert reference to state Medicaid plan] and the provisions of [drafter insert name of Purchasing Agreement]. 29

(2) Alternative Requirements for Specialists Not Participating in Contractor's Provider Network - If Contractor refers an enrollee to a specialist who does not participate in Contractor's provider network and who does not enter into an ongoing referral agreement under paragraph (1), Contractor shall ensure that the specialist:

(A) complies with the treatment guidelines that would apply under [drafter insert name of Purchasing Agreement] if the items or services were furnished by a specialist participating in Contractor's provider network; and

(B) charges the enrollee no more than the amounts (if any) that a specialist participating in Contractor's provider network would be permitted to charge the enrollee under the [drafter insert reference to state Medicaid plan] and the provisions of [drafter insert name of Purchasing Agreement].

(c) Specialty Items and Services - For purposes of subsection (a), specialty items and services are:

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(1) in the case of an enrollee at high risk for complications of pregnancy, labor, or delivery, the medical management of the enrollee and the newborn;

(2) in the case of an enrollee who is not described in paragraph (1) and who is not in need of emergency or urgent care services:30

(i) [drafter insert other types of items and services for which access is a policy priority].31

Compliance Measures: Contractor shall make available to Purchaser on request:

(1) a listing of specialists, by specialty, participating in Contractor's provider network;

(2) a listing of specialists, by specialty, not participating in Contractor's provider network to whom Contractor refers enrollees;

(3) all Provider manuals, protocols, memoranda, and other materials used by Contractor to inform providers about Contractor's duties relating to specialty services;

(4) the ongoing referral agreement entered into by Contractor with specialists not participating in Contractor's provider network;

(5) Contractor's records reflecting referrals of enrollees to specialists (whether in the form of referral logs or payment records or otherwise);

(6) the enrollee handbook and other materials used by Contractor to inform enrollees about the availability of specialty services; and

(7) records of enrollee grievances and complaints relating to specialty services received by Contractor.

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A1-6. Access to Public Health Services 32

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(a) Access to Childhood Lead Poisoning ServicesSee §204 of CHSRP, Sample Purchasing Specifications for Childhood Lead Poisoning Services, www.gwu.edu/~chsrp.

(b) Access to HIV/AIDS Services See §204 of CHSRP, HIV/AIDS Sample Purchasing Specifications.

(c) Access to Immunization Services See §007 of CHSRP, Sample Purchasing Specifications: Immunizations.

(d) Access to Asthma Services [Sample purchasing specifications under development].

(e) Access to Dental Care See §201 of CHSRP, Sample Purchasing Specifications For Medicaid Pediatric Dental And Oral Health Services, www.gwu.edu/~chsrp.

(f) Access to Diabetes Services [Sample purchasing specifications under development].

(g) Access to Reproductive Health Services See §201 of CHSRP, Sample Purchasing Specifications for Reproductive Health Services.

(h) Access to Sexually Transmitted Disease Services See §201 of CHSRP, Sample Purchasing Specifications For Services For Sexually Transmitted Diseases.

(i) Access to Tuberculosis Services See §204 of CHSRP, Tuberculosis Services Sample Purchasing Specifications.

A1-7. Access to Pharmacy Services

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[Sample purchasing specifications under development].

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Endnotes:

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  1. Commentary: The Medicaid statute speaks specifically to the coverage of emergency services by MCOs. Under §1932(b)(2)(A) of the Social Security Act, 42 U.S.C. §1396u-2(b)(2)(A), each risk contract with a Medicaid MCO must require the MCO "to provide coverage for emergency services§without regard to prior authorization or the emergency care provider's contractual relationship with the MCO§." The statute further requires that Medicaid MCOs comply with the Medicare+Choice guidelines relating to the coordination of post-stabilization care. Note that emergency services are also addressed in §A2-4 (Access to Out-of-Network Services), as well as §A2-5, (24/7 Availability of Services). For language in state Medicaid MCO contracts relating to access to emergency services, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3.
  2. Commentary: This illustrative language clarifies that Contractor must make timely payment for emergency services furnished to enrollees by hospitals not participating in Contractor's provider network. It is assumed the hospitals have a duty under the Medicare program to provide stabilizing medical treatment to all patients seeking emergency services, including managed care enrollees. For additional information, see OIG/HCFA Special Advisory Bulletin on the Patient Anti-Dumping Statute, 64 Fed Reg 61353 (November 10, 1999).
  3. The ranges of numbers of providers includes: 1 ob/gyn per 7100 covered lives (NJ, App. N, pp. 2-3); 14.7 ob/gyn per 100,000 resident population (1 per 6803) (American Medical Association, Physician Characteristics and Distribution in the U.S. (1999), Table A-22); 1 ob/gyn for each 2000 non-pregnant women between 18-44 and 1 ob/gyn for each 300 pregnant women enrollees (IL, p. 24-25). The travel-time-to-providers requirement in state contracts ranges from 30 to 60 minutes for urban and rural areas with some states allowing for a waiver of travel time requirements in rural areas.
  4. For additional information on this definition from the BBA, see HCFA, Letter to State Medicaid Directors (April 18, 2000), http://www.hcfa.gov/medicaid/smd41800.htm.
  5. For language in state Medicaid MCO contracts relating to definitions of emergency services, see Table 2.6, Negotiating the New Health System, 3rd Ed., Volume 2, Part 2.
  6. For language in state Medicaid MCO contracts relating to access to urgent services, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3. There is no single definition of urgent care that is universally accepted by states and managed care organizations. Some states, such as Wisconsin in its 1997 contract, use a definition of urgent care very similar to the illustrative definition set forth in subsection (c). Other states, like Ohio in its contract, use a different definition of urgent care: "services provided for conditions due to illness or injury which are not life-threatening but require prompt attention and/or treatment to prevent complication to, or deterioration of, the enrollee's condition." For these and other definitions of urgent care in state MCO contracts, see Table 2.6, Negotiating the New Health System, 3rd Ed., Volume 2, Part 2 www.gwu.edu/~chsrp.
  7. The 1997 Wisconsin contract specifies that the test for urgent care be the need for "immediate" medical attention.
  8. Commentary: Some MCOs and their providers have tried to encourage the use of preventive services by offering "freebies," for example free food or clothing to encourage women to come in for prenatal visits or mammograms. A recent regulation issued by the DHHS Office of Inspector General (OIG) clarifies that, in the case of Medicare, Medicaid, or SCHIP beneficiaries, such "freebies" are not illegal remuneration that would subject either the plan or the provider to civil money penalties. 42 C.F.R. §1003.102(b)(13), 65 Fed. Reg. 24400 (April 26, 2000), http://www.access.gpo.gov/su_docs/fedreg/a000426c.html. For this purpose, the IG defines a preventive service as a "prenatal service or a post-natal well-baby visit or ... a specific clinical service described in the current U.S. Preventive Services Task Force's Guide to Clinical Preventive Services .§" 42 C.F.R. §1003.101. For language in state Medicaid MCO contracts relating to access to preventive services, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3.
  9. Commentary: Note that under the illustrative language in §A2-9, these preventive services (and the clinical services for adults, and services for pregnant women preventive services described in this section) would be excluded from prior authorization requirements. Purchasers seeking to limit the number of preventive services excluded from prior authorization may wish to adjust the scope of the exclusion under §A2-9.
  10. Commentary: This time frame should correspond to the time frame selected under §A2-6(a), which specifies the date on which an initial assessment must be scheduled for a new enrollee. The effect of linking these two timeframes would be to avoid duplication between the initial assessment and the EPSDT screening requirements as well as to give the MCO a sufficient amount of time to integrate newly enrolled children into their delivery systems. The Pennsylvania RFP provides that EPSDT screens should be furnished within 45 days of enrollment.
  11. State contract provisions specify a range from 2 weeks to 6 months (see CA, DC, FL, NE, WI).
  12. Commentary: Under §1905(r)(1), screening services are: (1) a comprehensive health and developmental history; (2) comprehensive unclothed physical exam; (3) appropriate immunizations; (4) laboratory tests to assess health and nutritional status, including assessment of blood lead levels; and (5) health education, including anticipatory guidance. For illustrative language on purchase of immunization services, see CHSRP, Sample Purchasing Specifications: Immunizations (May 1998).
  13. One state contract provision for clinical preventive services specifies within 2 weeks of an appointment (NV); five specify within 3 weeks (AZ, DE, OK, PA, TN); twelve specify within 4 weeks (DC, FL, GA, KY, MS, MO, MT, NJ, NM, NY, UT, VT); six specify within 8 weeks (HI, IL, MA, NE, NH, SC); and two specify beyond 8 weeks (CO, NC). For language in state Medicaid MCO contracts relating to access time to covered services and providers, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3
  14. Commentary: The following illustrative language draws upon the 1996 recommendations of the U.S. Preventive Services Task Force as set forth in the 2nd Ed. of the Guide to Clinical Preventive Services. In recommending specific interventions within each age-specific group (e.g., adults 25 - 64), the Task Force distinguished between the general population and high-risk populations. The recommended interventions for high-risk populations are more extensive than those for the general population. While the following language specifies the interventions recommended for the general population, purchasers may wish to add interventions applicable to high-risk populations as well. See also the illustrative language relating to preventive services in the CHSRP purchasing specifications relating to specific public health conditions (e.g., HIV/AIDS, lead poisoning, sexually transmitted diseases, tuberculosis) enumerated in Table 1.
  15. For illustrative language relating to access to additional reproductive health services, including family planning services, see CHSRP, Sample Purchasing Specifications for Reproductive Health Services (May 2000), www.gwu.edu/~chsrp.
  16. State contract provisions specify: within 2 (VT) or 3 (NH) weeks of positive pregnancy test. Other states specify: within 3 weeks during first trimester, 2 weeks during second trimester, and 1 week for third trimester.
  17. Commentary: The ACOG guidelines state that "[t]he content and timing of prenatal care should vary according to the risk status of the mother and the fetus." Guidelines for Perinatal Care, 4th Ed. (1997), p. 2.
  18. State contract provisions specify: 6-8 weeks after delivery (TN, VT) or 60-90 days. Some states also address the scheduling of a home visit, ranging from contact after 4 weeks after notification of discharge or within 10 working days or the arranging of 2 visits within 48 days of discharge.
  19. For language in state Medicaid MCO contracts relating to access to routine services, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3
  20. Commentary: For purposes of identifying facilities having a shortage of primary care providers, DHHS regulations specify, as one criterion, that "waiting time for appointments is more than 7 days for established patients or more than 14 days for new patients, for routine health services." 42 C.F.R. Part 5, Appendix A, Part III -- Facilities, B. Public or Nonprofit Medical Facilities, 2. Methodology, (b) Insufficient capacity to meet primary care needs, (iii).
  21. Commentary: For purposes of §1915(b) Medicaid managed care waivers, HCFA queries States whether they have established standards for appointment scheduling for MCO enrollee access to primary care providers, specialists, and other providers. HCFA defines appointment scheduling as "the time before an enrollee can acquire an appointment with his or her provider for both urgent and routine visits." HCFA, Proposal for a Section 1915(b) Capitated Waiver Program Initial Application Preprint, April 30, 1999, p. 27, http://www.hcfa.gov/medicaid/smd50699.htm.
  22. Four state contract provisions for routine appointments specify within 48 hours of request (MA, NE, NH, SC); four specify within 3 days (NY, NC, NV, OK); four specify within 1 week (FL, GA, ME, MS); five specify within 2 weeks (CO, OR, PA, TX, VT); four specify within 3 weeks (AZ, DE, IL, KY); seven specify within 1 month (DC, MT, NJ, NM, ND, RI, UT); and one specifies within 45 days (HI). For language in state Medicaid MCO contracts relating to access time to covered services and providers, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3.
  23. State contract provisions specify a range from 40 hours per week to M-F between 7 am and 7 pm. Other state contract provisions include additional hours, such as 8 hours weekly consisting of at least 2 evenings between 6 and 11 pm, or one evening or one weekend day.
  24. Commentary: Note that the following language does not address the issue of direct access by enrollees to specialists without a referral from a primary care provider. For illustrative language on this issue, see §A2-3. For language in state Medicaid MCO contracts relating to enrollee access to specialists in an MCO's network, see Tables 3.1, 3.7 and 3.8, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3 www.gwu.edu/~chsrp.
  25. State contract provisions in 18 states had standards for access time to routine, non-urgent specialist care. Six states specified 30 days from a request for an appointment (AZ, ME, MD, NV, RI, UT ) and other states specify a longer time period (NJ and NY: 4-6 weeks, NC: 90 days). Three states specify a timeframe for a particular specialty service (e.g., MA, NE, and TN specify dental services).
  26. An alternative option would be to vary the number of days within which referrals must be seen by the type of specialty service. State contract provisions range from 24 hours to over 45 days of referral. An alternative option would be to require the furnishing of specialty services within a time frame that is specific to the illness or condition for which the enrollee is referred.
  27. Commentary: Under current law, providers serving Medicaid beneficiaries must accept as payment in full the rates that Medicaid programs pay for covered items and services. Providers are only permitted to charge beneficiaries the amounts of any co-payments or other types of cost-sharing that the State Medicaid Plan imposes on particular services for particular populations. This illustrative language clarifies that this mandatory assignment policy applies to specialists treating Medicaid MCO enrollees whether the specialist is in- or out-of-network.
  28. Commentary: Note that in cases where enrollees need emergency or urgent care services, enrollee access to the needed specialty emergency or urgent care services is governed by §§A1-1 and A1-2.
  29. For example, the 1996-97 Arizona RFP provides: "If outpatient specialty services (OB/GYN, family planning, if provided, internal medicine, and pediatrics) are not included in the primary care provider contract, at least one subcontract is required for each of these specialties in the service sites specified." Table 3.8, Negotiating the New Health System, 3rd Ed., Vol. 2, Part 3.
  30. Commentary: The purchasing specifications enumerated in this section refer to documents produced or under development by CHSRP for the Centers for Disease Control and Prevention.

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