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Medicaid Contract Purchasing Specifications

Access to Services

Part A2.
Elements of an Accessible MCO33

A Technical Assistance Document
June, 2000

Table of Contents

§A2-1. Provider Network
§A2-2. Access to Network Primary Care Providers
§A2-3. Access to Network Specialists
§A2-4. Access to Out-of-Network Providers
§A2-5. 24/7 Availability of Services
§A2-6. Geographic Access
§A2-7. In-Office Waiting Times
§A2-8. First Appointments for New Enrollees
§A2-9. Prior Authorization
§A2-10. Collecting and Reporting Access Data
§A2-11. Focus Studies on Access

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A2-1. Provider Network 34

(a) In General

(1) Basic Duty - Contractor shall maintain a provider network (as defined in subsection (d)) through which Contractor furnishes items and services covered under [drafter insert reference to coverage provisions in Purchasing Agreement] to enrollees that complies with the requirements of:

(A) subsection (c); and

(B) §A4-1 (relating to ADA compliance).

(2) Delegation - Contractor may delegate duties under [drafter insert name of Purchasing Agreement] to providers (or other subcontractors) only if the following requirements are met:

(A) Written Agreement - The delegation of any duty from Contractor to providers (or other subcontractors) is effective only to the extent that the delegation is set forth in a written agreement under subsection (b).

(B) Contractor's Ultimate Responsibility - Notwithstanding any delegation of a duty of Contractor under subparagraph (A), Contractor shall maintain ultimate responsibility for adhering to, and otherwise fully complying with, the requirements, terms, and conditions of [drafter insert name of Purchasing Agreement].

(b) Written Agreements with Providers35

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(1) In General - Contractor shall enter into and maintain an enforceable written agreement with each provider participating in Contractor's provider network that:

sets forth the provider's duties:

(i) to make covered items and services accessible to enrollees under:

(I) [drafter insert applicable service duties (emergency, urgent care, preventive, routine, or specialty services) under Part A1];

(II) [drafter insert applicable network duties (primary care providers, specialists) under §§A2-2, A2-3];

(III) §A2-5 (relating to 24/7 availability of services);

(IV) §A2-7 (relating to in-office waiting times); and

(V) §A2-8 (relating to first appointments for new enrollees);

(ii) to submit accurate and complete data to Contractor as required under [drafter insert reference to reporting provisions of Purchasing Agreement];

(iii) under other provisions of [drafter insert name of Purchasing Agreement]; and

(iv) under applicable federal and state law;

(B) requires performance of such duties as a condition of participation in Contractor's provider network; and

(C) requires Contractor to comply with the requirements of §1932(f) of the Social Security Act, 42 U.S.C. §1396u-2(f), relating to timely payment of claims for payment to providers for items and services which are covered under [drafter insert reference to coverage provisions in Purchasing Agreement] and are furnished to enrollees under [drafter insert name of purchasing agreement].

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(c) Requirements for Provider Network - Contractor shall comply with [drafter insert references to provisions in Purchasing Agreement relating to provider network composition and organization, including credentialing requirements and profiling, and cultural competence of practitioners].

(d) Provider Network - The set of providers that have entered into enforceable written agreements with Contractor to furnish covered items and services to enrollees.

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

(1) all provider manuals, protocols, memoranda and other materials relating to the establishment and operation of Contractor's provider network;

(2) the credentialing rules and other criteria for selection of providers participating in Contractor's provider network, and all records relating to credentialing or selection decisions;

(3) the name, area of practice, provider number, address (including zip code) at which the provider offers services, current office telephone number(s), office hours of each practice site, of each provider participating in Contractor's provider network; and

(4) written agreements with participating providers.

a2-2. Access to Network Primary Care Providers36

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(a) Sufficient Number of Primary Care Providers

(1) Duty - Contractor shall include in its provider network a sufficient number (as described in paragraph (2)) of primary care providers (as defined in subsection (e)).

(2) Measures of Sufficiency37

- In determining the sufficiency of the number of primary care providers (as defined in subsection (e)) participating in Contractor's provider network under paragraph (1), the following measures shall apply:

(A) Office Hours38 - Contractor shall ensure that primary care services are available from primary care providers participating in Contractor's provider network at locations that, consistent with subsection (c)(1), are geographically accessible to enrollees under §A2-6 between the hours of [ ] a.m. and [ ] p.m. at least [ ] days per week; and

(B) Provider/Enrollee Ratio - Contractor shall ensure that the ratio of (i) the total number of primary care providers participating in Contractor's provider network to (ii) the total number of enrollees shall at all times equal or exceed [ ]39; and

(C) [drafter insert other measures of sufficiency].

(b) Provider Capacity to Accept Enrollees as Patients

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(1) Duty - Contractor shall ensure that at all times there are at least [ ] primary care providers (as defined in paragraph (e)) participating in Contractor's provider network that have the capacity to accept enrollees as new patients under paragraph (4).

(2) Notification of Purchaser

(A) If at any time there are less than [ ] primary care providers participating in Contractor's provider network that have the capacity to accept enrollees as new patients under paragraph (4), Contractor shall, within [ ] business days, notify Purchaser of the lack of capacity.

(B) If Contractor has notified Purchaser under subparagraph (A), Purchaser shall not, after the date of notification, enroll any additional individuals eligible for [drafter insert name of state Medicaid program] in Contractor until Contractor notifies Purchaser that there are at least [ ] primary care providers participating in Contractor's provider network that have the capacity to accept enrollees as new patients under paragraph (4).

(3) Suspension of Enrollment - Contractor understands and agrees that Purchaser, upon receipt of the notification described in paragraph (2), may suspend new enrollment of enrollees under [drafter insert name of Purchasing Agreement] until Contractor has secured additional primary care provider capacity in its provider network.

(4) Capacity to Accept New Patients - For purposes of this subsection, a primary care provider shall be considered to have the capacity to accept an enrollee as a new patient if the number of patients (whether or not enrollees) for whose medical management the provider is responsible does not exceed [drafter insert maximum panel size limit].

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(c) Standards of Accessibility

(1) Geographic Access - Contractor shall comply with the requirements of §A2-6 with respect to primary care providers.

(2) In-Office Waiting Times - Contractor shall ensure that the primary care providers participating in Contractor's provider network comply with the requirements of §A2-7.

(d) Enrollee Selection of, or Assignment to, a Primary Care Provider - Contractor shall comply with:

(1) [drafter insert reference to provisions of Purchasing Agreement relating to selection of, or assignment to, a primary care provider; see for example Part 4 of CHSRP's Optional Specifications: Medicaid Managed Care for Pediatric Services.]; and

(2) the requirements of §A2-3(b) and (c) relating to selection of specialists as primary care providers.

(e) Primary Care Provider Defined40 - A primary care provider is defined in [drafter insert reference to applicable section of Purchasing Agreement].

A2-3. Access to Network Specialists41

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(a) In General - Contractor shall ensure access by enrollees to specialists (as defined in subsection (g)) participating in Contractor's provider network by complying with the requirements of:

(1) subsections (b) and (c) relating to selection of specialists as primary care providers;

(2) subsections (d) and (e) relating to direct access to specialists; and

(3) subsection (f) relating to standards of accessibility of specialists.

(b) Selection of an Obstetrician/Gynecologist or Certified Nurse Midwife as a Primary Care Provider - Contractor shall offer each enrolled woman (including an adolescent) the option of choosing as her primary care provider a provider from among the following providers participating in Contractor's provider network:

(1) a primary care provider (as defined in §A2-2(e)) who is willing and has the capacity (as described in §A2-2(b)(4)) to accept the enrolled woman as a patient;

(2) an obstetrician/gynecologist who is willing and has the capacity to carry out the responsibilities of a primary care provider for the enrolled woman; or

(3) a certified nurse midwife who is willing and has the capacity to carry out the responsibilities of a primary care provider for the enrolled woman.

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(c) Selection of a Specialist as a Primary Care Provider by Enrollees with Special Health Care Needs - Contractor shall offer each enrollee with special health care needs (as defined in §A2-8(f)) the option of choosing as the enrollee's primary care provider either of the following providers:

(1) a primary care provider (as defined in §A2-2(e)) participating in Contractor's provider network who is willing and has the capacity (as described in §A2-2(b)(4)) to accept the enrollee as a new patient; or

(2) a specialist (as defined in subsection (g)) participating in Contractor's provider network who:

(A) has expertise and experience in the treatment of the enrollee's special health care needs; and

(B) is willing and has the capacity (as described in §A2-2(b)(4)) to accept the enrollee as a primary care patient.

(d) Direct Access by Enrolled Women to Obstetrician/Gynecologists - Contractor agrees that each enrolled woman (including an adolescent) has the right, without the prior authorization of Contractor or a referral or other authorization from the enrolled woman's primary care provider, to schedule an appointment with, and to receive services covered under [drafter insert reference to coverage provisions in Purchasing Agreement] directly from an obstetrician/gynecologist participating in Contractor's provider network.42

(e) Direct Access to Specialists other than Obstetrician/Gynecologists by Enrollees43

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(1) Duty of Contractor - Contractor shall ensure that each enrollee has the opportunity, without a referral or other authorization from the enrollee's primary care provider, to schedule an appointment with, and to receive services covered under [drafter insert reference to coverage provisions in Purchasing Agreement] directly from a specialist described in paragraph (2) participating in Contractor's provider network.

(2) Direct Access Specialists - The specialists to whom an enrollee has the right to direct access under paragraph (1) are:

(A) [drafter insert types of specialists other than obstetrician/gynecologists, if any, for which direct enrollee access is a state law requirement or Purchaser policy priority].

(f) Standards of Accessibility44

(1) Geographic Access - Contractor shall comply with the requirements of §A2-6(a)

(2) with respect to specialists. (2) In-Office Waiting Times - Contractor shall ensure that the specialists participating in Contractor's provider network comply with the requirements of §A2-7.

(g) Specialist Defined45 - A specialist is defined in [drafter insert reference to applicable section of Purchasing Agreement].

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§A2-4. Access to Certain Services Out-of-Network

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(a) Emergency Services - Contractor shall ensure that enrollees have access to emergency services in compliance with §A1-1.

(b) Specialty Services - Contractor shall ensure that enrollees have access to specialty services in compliance with §A1-5(b).

(c) Public Health Services

(1) Right to Self-Referral - Contractor agrees that an enrollee is entitled to elect to receive the following items and services covered under [drafter insert reference to coverage provisions in Purchasing Agreement] from any provider of such services with a valid provider number under [drafter insert name of state Medicaid program], whether or not the provider participates in Contractor's provider network or is otherwise designated or approved by Contractor:

(A) as required under §1902(a)(23)(B) of the Social Security Act, 42 U.S.C. §1396a(a)(23)(B), family planning services and supplies;

(B) items and services relating to diagnosis and treatment of sexually transmitted diseases not described in subparagraph (A); and

(C) [drafter insert reference to other public health services to which Purchaser seeks to promote access through enrollee self-referral].

(2) Construction - Paragraph (1) shall not be construed to authorize Contractor to:

(A) require an enrollee to obtain an item or service covered under [drafter insert reference to coverage provisions in Purchasing Agreement] from a publicly-funded provider; or

(B) deny payment to a publicly-funded provider for the furnishing of an item or service covered under [drafter insert reference to coverage provisions in Purchasing Agreement] to an enrollee who has elected under paragraph (1) to receive a covered item or service from the provider.

(d) Other Services

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(1) Scope46 - The provisions of this subsection shall apply with respect to the following services covered under [drafter insert reference to coverage provisions in Purchasing Agreement]:

(A) urgent care services under §A1-2;

(B) preventive services under §A1-3; and

(C) routine services under §A1-4.

(2) Duty - If Contractor is unable to furnish (or arrange for the furnishing of) an item or service described in paragraph (1) to an enrollee through its provider network, Contractor shall, within [ ] days of the request for an item or service by or on behalf of the enrollee:

(A) arrange for the furnishing of such items and services to the enrollee through a provider not participating in Contractor's provider network that meets the requirements described in paragraph (3); and

(B) notify the enrollee of the arrangements that Contractor has made under subparagraph (A).

(3) Requirements for Out-of-Network Providers47 - A provider meets the requirements of this paragraph if the provider:

(A) has the expertise or experience needed to furnish the item or service required by the enrollee;

(B) meets the Contractor's reporting requirements with respect to the item or service furnished to the enrollee; and

(C) meets the requirements for participation in [drafter insert name of state Medicaid program] as evidenced by possession of a valid Medicaid provider number or otherwise.

(e) Reimbursement of Out-of-Network Providers - Contractor shall comply with [drafter insert reference to provisions in Purchasing Agreement relating to payment for covered services furnished by out-of-network providers in the cases specified in the preceding subsections].48

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

(1) all provider manuals, protocols, memoranda, and other materials used by Contractor to inform providers about Contractor's duties relating to enrollee use of out-of-network providers; and

(2) all enrollee handbooks, handouts, and other materials used by Contractor to inform enrollees about their rights to use of out-of-network providers.

§A2-5. 24/7 Availability of Services49 Top

(a) Emergency and Urgent Care Services

(1) Duty of Contractor -- Contractor shall comply with the requirements of:

(A) §A1-1(a)(1) relating to accessibility of emergency services 24 hours per day, 7 days per week; and

(B) §A1-2(a) relating to accessibility of urgent care services 24 hours per day, 7 days per week.

(2) Toll-free Telephone Line for Enrollees50

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(A) In General-- In order to carry our the duty described in paragraph (1), Contractor shall maintain and staff, on a 24-hour per day, 7-day per week basis, a toll-free telephone number to receive calls from or on behalf of enrollees regarding emergency services (as defined in §A1-1(b)) or urgent care services (as defined in §A1-2(b)) or emergency transportation under §A3-1(a).

(B) Staffing -- Contractor shall ensure that the toll-free telephone line described in subparagraph (A) shall be staffed at all times by individuals who are:

(i) qualified to answer the types of questions generally asked by enrollees regarding emergency or urgent care services;

(ii) proficient in English and, except as provided in subparagraph (E), a language other than English that is spoken as a primary language by at least [ ] of Contractor's enrollees; and

(iii) authorized by Contractor to approve requests by or on behalf of enrollees for emergency transport.

(C) Response Time -- Contractor shall ensure that each call to the toll-free telephone line:

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(i) requesting ambulance or other emergency transportation, or emergency services, is answered within [ ] minutes of initial placement of the call;51 and

(ii) requesting urgent care services (as defined in §A1-2(b)) is answered within [ ] of initial placement of the call.

(D) Noncompliance with Emergency Response Time -- In any case in which Contractor does not comply with the requirement of subparagraph (C)(i), Contractor shall be liable for the cost of items and services related to the treatment of the illness or injury that was the subject of the call, whether the items or services are furnished by a provider participating in Contractor's provider network or otherwise.

(E) Language Interpreter Services -- Contractor shall not be considered to be out of compliance with the requirement of subparagraph (B)(ii) if Contractor ensures that a language-appropriate interpreter (as described in [drafter insert reference to relevant provisions in Purchasing Agreement]) is available on a 24-hour per day, 7-day per week basis for immediate interpretation of calls received by staff of the toll-free telephone line under this subsection.

(b) Routine Services -- Contractor shall comply with the requirement of §A1-4(b)(2) relating to appointments for routine services.

§A2-6. Geographic Access52

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(a) Travel Time in Urban Areas53 - In the case of an enrollee living in [drafter insert name of urban area(s) within Contractor's service area], Contractor shall ensure that:

(1) Primary Care Providers54 - at least [ ] primary care providers (as defined in §A2-2(e)) participating in Contractor's provider network are located within [ ] minutes travel time (using ground transportation) of each enrollee;

(2) Specialists - at least [ ] specialists (as defined in §A2-3(g)) of the following types participating in Contractor's provider network are located within [ ]56 minutes travel time (using ground transportation)57 of each enrollee:

(A) providers of family planning services who are not primary care providers (as defined in §A2-2(e));

(B) providers of obstetrical services who are not primary care providers (as defined in §A2-2(e));

(C) pharmacists; and

(D) [drafter insert additional categories of specialists]; and

(3) Hospitals - at least [ ] hospitals with the capacity to furnish the acute care inpatient hospital services covered under [drafter insert name of Purchasing Agreement] are located within [ ] minutes travel time (using ground transportation) or [ ]58 miles of each enrollee.

(b) Travel Time in Rural AreasTop

(1) Emergency Services - In the case of an enrollee living in [drafter insert name of rural area(s) within Contractor's service area], Contractor shall ensure that at least one provider participating in Contractor's provider network that furnishes emergency services (as defined in §A1-1(b)) is located within:

(A) [ ] travel time of the enrollee using ground transportation;59 and

(B) [ ] travel time of the enrollee using air transport.

(2) Non-Emergency Physician Services60 - In the case of an enrollee living in [drafter insert name of rural area(s) within Contractor's service area], Contractor shall ensure that at least [ ] physicians participating in Contractor's provider network are:

(A) located at a practice site within [drafter insert travel time]61 of the enrollee using ground transportation; or

(B) accessible to the enrollee's primary care provider via telemedicine.

If Contractor elects to use telemedicine under subparagraph (B), Contractor shall not impose copayments or other charges on an enrollee that Contractor does not impose under [drafter insert name of Purchasing Agreement] upon enrollees who do not use telemedicine.

(3) Non-Emergency Hospital Services - In the case of an enrollee living in [drafter insert name of rural area(s) within Contractor's service area], Contractor shall ensure that at least [ ] community hospital62 with the capacity to furnish, or arrange for the furnishing of, the inpatient hospital services covered under [drafter insert name of Purchasing Agreement] is located within [ ]63 minutes travel time (using ground transportation) or [ ]64 miles of each enrollee.

Compliance Measures: In the case of a Contractor with less than [ ] enrollees, Contractor shall make available upon request to the Purchaser a map65 showing:[Back To Top]

(1) the practice site of each provider participating in Contractor's provider network;

(2) the location of public transportation stops in Contractor's service area; and

(3) the zip codes in Contractor's service area in which at least [drafter insert minimum number] of the enrollees reside.

a2-7. In-Office Waiting Times66

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(a) Scheduled Appointments for Preventive, Routine, or Specialty Services - Contractor shall ensure that an enrollee who has a scheduled appointment with a provider participating in Contractor's provider network for a service that is not an emergency service (as defined in §A1-1(b)) or an urgent care service (as defined in §A1-2(b)) begins an encounter with the provider within [ ]67 minutes of the time the appointment is scheduled to begin.

(b) Unscheduled Appointments for Preventive, Routine, or Specialty Services - In the case of an enrollee who has not scheduled an appointment with a provider participating in Contractor's provider network an presents at the provider's practice site for a service that is not an emergency service (as defined in §A1-1(b)) or an urgent care service (as defined in §A1-2(b)), Contractor shall ensure that:

(1) the enrollee receives, within [ ]68 minutes of the time the enrollee presents at the practice site, an appointment for an encounter with the provider or another appropriate provider that is scheduled to occur within [ ] days of the day on which the enrollee presents at the practice site.

(c) Documentation - Contractor shall ensure that each provider participating in Contractor's provider network maintains in the regular course of business the documentation necessary to evaluate compliance with the requirements of subsections (a) and (b).

(d) Written Agreements with Participating Providers - As required by §A2-1(b)(1)(A), Contractor shall include provisions in Contractor's written agreements with providers participating in Contractor's provider network requiring compliance on the part of such providers with the requirements of subsections (a), (b), and (c).

Compliance Measures: Contractor shall make available upon request to Purchaser:Top

(1) all provider manuals, protocols, memoranda and other materials used by Contractor to inform providers about service waiting time requirements with respect to emergency medical conditions, urgent medical conditions, and all other illnesses or conditions;

(2) copies of written agreements between Contractor and providers participating in Contractor's provider network; and

(3) the documentation prepared by providers participating in Contractor's provider network relating to compliance with service waiting time requirements.

a2-8. First Appointments for New Enrollees69

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(a) New Enrollees Who are Pregnant - Contractor shall ensure that each new enrollee known or identified70 to Contractor as a pregnant woman receives an appointment consistent with §A1-3(c)(2) within [ ] days of the effective date of enrollment.

(b) New Enrollees with Special Health Care Needs71 - Contractor shall ensure that each new enrollee known or identified72 to Contractor as having special health care needs (as defined in subsection (f)) receives an assessment under subsection (e) within [ ] days of the effective date of enrollment.

(c) Other New Enrollees - Contractor shall ensure that each new enrollee (who is not a pregnant woman or an enrollee with special health care needs) receives an appointment for an assessment under subsection (e) within [ ]73 days of the effective date of enrollment.

(d) Enrollees Who do Not Present - In the case of a new enrollee who does not present for an encounter (for emergency care or otherwise) with a provider participating in Contractor's provider network within [ ] consecutive months of the effective date of enrollment, Contractor shall notify Purchaser of the name and identification number of the enrollee.74

(e) Assessment - An assessment is an encounter between an enrollee and a primary care provider participating in Contractor's provider network at which [ ].75

(f) Enrollee with Special Health Care Needs Defined - An enrollee with special health care needs is defined in [drafter insert reference to applicable section of Purchasing Agreement].76

a2-9. Prior Authorization77

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(a) Telephone Access for Treating Providers78

(1) Duty - Contractor shall maintain, and staff with qualified individuals, on a [ ] hour per day, [ ] day per week basis, a toll-free telephone number to receive requests from providers for authorization for the furnishing to an enrollee of a covered item or service that is not excluded from prior authorization under subsection (b).

(2) Separate Line - Contractor shall maintain and staff the toll-free telephone number described in paragraph (1) separately from the toll-free telephone number described in §A2-5(a)(2) for emergency or urgent care services.

(b) Items and Services Excluded from Prior Authorization - Contractor shall not require prior authorization for the following items and services:

(1) Emergency Services - emergency services described in §A1-1;

(2) Preventive Services - pediatric preventive services, clinical preventive services for adults, and services for pregnant women described in §A1-3; and

(3) [drafter insert other items and services, if any, excluded from prior authorization].

Compliance Measure: Contractor shall make available upon request to Purchaser copies of provisions of Contractor's operating manual, provider manual, protocols, memoranda and other materials relating to utilization management and prior authorization of services.

a2-10. Collecting and Reporting Access Data80

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(a) In General - Contractor shall collect and report, in such form and manner as Purchaser specifies under subsection (b), the data necessary to enable Purchaser to determine whether enrollees have access to items and services covered under [drafter insert reference to coverage provisions in Purchasing Agreement].

(b) Data Collection and Reporting Requirements - Contractor shall comply with [drafter insert reference to provisions in Purchasing Agreement relating to data collection and reporting requirements].81

(c) Enrollee Satisfaction82 - Contractor shall facilitate the administration of the following enrollee surveys by [drafter insert name of vendor selected by Purchaser]:

(1) CAHPS 2.0, Adult Medicaid Managed Care Questionnaire; and

(2) CAHPS 2.0, Child Medicaid Managed Care Questionnaire.

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§A2-11. Focus Studies on Access83 - Contractor shall conduct and report, no later than [ ], the results of [ ] of the following studies:

(a) the accessibility of preventive health services to enrolled adults under §A1-3(b)(2);

(b) the accessibility of primary care providers to enrollees under §A2-2;

(c) the accessibility of immunization services to enrolled children under §A1-3(a)(3);

(d) the accessibility of prenatal care to enrolled pregnant women under §A1-3(c)(2)(A);

(e) the percentage of enrollee telephone calls relating to emergency or urgent care services under for the period [ ] to which Contractor did not respond within the response time requirements under §A2-5(a)(2)(C)(i) (relating to emergency services) and §A2-5(a)(2)(C)(ii) (relating to urgent care services);

(f) the accessibility of care coordinators to enrollees with treatment plans under §A3-2

(a)(2); and

(g) [drafter insert additional or alternative focus study topics].84

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Endnotes:Top

  1. Commentary: A number of the elements described in this Part will not be meaningful to MCO enrollees unless they are informed of their rights under each element selected by Purchaser. For illustrative language relating to duties of Contractors to inform their enrollees, see §A3-3.
  2. Commentary: The following illustrative language relates exclusively to access to a provider network. For illustrative language addressing other issues affecting provider networks, see Part 5 of CHSRP's Optional Specifications: Medicaid Managed Care for Pediatric Services, www.gwu.edu/~chsrp. For language in state Medicaid MCO contracts relating to network composition, see Tables 3.1 and 3.6, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3, www.gwu.edu/~chsrp.
  3. Commentary: For an example of a written agreement between an MCO and a physician, see American Academy of Pediatrics, Model Managed Care Agreement (1998). Top
  4. For language in state Medicaid MCO contracts relating to access to primary care providers in MCO provider networks, see Tables 3.1 and 3.6, Negotiating the New Health System, 3rd Ed. Volume 2, Part 3, www.gwu.edu/~chsrp.
  5. Commentary: Note that this aggregate test of sufficient capacity differs from the individual provider test of capacity set forth in subsection (b). State contract provisions specify ranges from 40 hours/week to M-F between 7 am and 7 pm.
  6. Commentary: State contract provisions specify ranges from 40 hours/week to M-F between 7 am and 7 pm.
  7. One state contract provision for primary care provider/adult enrollee ratio specifies 1:1000 (PA); twelve specify 1:1500 (FL, GA, IL, MS, NE, NV, NJ, NM, NY, RI, TX, VT); two specify 1:1800 (AZ, OK); seven specify 1:2000 (CA, DC, MD, ME, MI, NC, OH); and two specify above 1:2000 (DE, SC). For language in state Medicaid MCO contracts relating to provider network standards, see Table 3.1, Negotiating the New Health System, 3rd Ed. Volume 2, Part 3, www.gwu.edu/~chsrp. For purposes of defining an area having a shortage of primary care providers, DHHS regulations specify, as one criterion, that the "ratio of the number of persons in the population group to the number of primary care physicians practicing in the area and serving the population group is at least 3,000:1." 42 C.F.R. Part 5, Appendix A, Part II -- Population Groups, A. Criteria , §1(c).
  8. Commentary: In these sample specifications, the term "primary care provider" is understood to mean physicians practicing in the fields of family and general practice, general internal medicine, and general pediatrics, as well as nurse practitioners acting within the scope of state law. However, the illustrative language allows interested purchasers to tailor this definition to their own policy preferences and the health care marketplace within which contracting MCOs operate. For example, a purchaser and contracting MCO could consider a family medicine subspecialist practicing in geriatrics to be a primary care provider. Top
  9. Commentary: A number of states have enacted legislation that relate to direct access by MCO enrollees to specialists. According to the National Conference of State Legislatures: 34 states have enacted legislation giving women direct access to obstetrician/gynecologists; 19 states have enacted legislation allowing women to designate an obstetrician/gynecologist as their primary care provider; 8 states have enacted legislation giving MCO enrollees direct access to other specialists; and 6 states have enacted legislation allowing MCO enrollees to designate other specialists as a primary care provider. NCSL, 2000 State by State Guide to Managed Care Law, §§2.3 - 2.4, Tables 2-3 - 2-4, pp. 2-28 - 2-35. For states with such legislation, the illustrative language is consistent with the purposes of such legislation. For language in state Medicaid MCO contracts relating to direct access by enrollees to specialists in MCO networks for obstetrical care, family planning services, mental health services, and substance abuse treatment, see Table 3.4, Negotiating the New Health System, 3rd Ed., Vol. 2, Part 3, www.gwu.edu/~chsrp.
  10. An alternative option would be to add the requirement that Contractor must ensure that the enrollee has the option of obtaining direct access to an ob/gyn of a gender of the enrollee's choice.
  11. Commentary: A number of states that provide enrollees with direct access to specialists still do not allow the enrollees to designate a specialist as a PCP. The providers for whom such direct access is allowed are limited to categories such as primary care eye providers, dermatologists, chiropractic providers, and medical specialists. NCSL, 2000 State by State Guide to Managed Care Law, § 2.4, Table 2-4.
  12. For illustrative language on access to out-of-network specialists, see §A1-5.Top
  13. Commentary: In these sample specifications, the term "specialists" is understood to mean obstetrician/gynecologists and physicians practicing in such specialist fields as cardiovascular disease, dermatology, gastroenterology, neurology, ophthalmology, psychiatry, pulmonary diseases, surgery, and urology. However, the illustrative language allows interested purchasers to tailor this definition to their own policy preferences and the health care marketplace within which the contracting MCOs operate. With respect to specialists appropriate to children with special health care needs, see P. McManus, Institute for Child Health Policy, University of Florida at Gainesville, Evaluating Managed Care Plans for Children with Special Health Needs: A Purchaser's Tool (1998), www.ichp.edu.
  14. An alternative option would be for purchasers to select one, two, all, or none of the types of services listed in this subsection.
  15. Commentary: Interested purchasers should note that the criteria relating to out-of-providers set forth in this subsection differ from those applicable to out-of-network specialists under §A1-5.
  16. For illustrative language on provider reimbursement, see CHSRP's purchasing specifications with respect to children with special health care needs (forthcoming), children with behavioral health needs (forthcoming), and individuals who are homeless, www.gwu.edu/~chsrp.
  17. For language in state Medicaid MCO contracts relating to availability of services, see Table 3.7, Negotiating the New Health System, 3rd Ed., Vol. 2, Part 3, www.gwu.edu/~chsrp.
  18. Commentary: Sections A2-9(a) and A3-3(c) would require Contractor to maintain separate toll-free lines for prior authorization requests and for general information requests, respectively. With respect to emergency and urgent care services, state contract provisions specify a range from 24 hour telephone call services to an after-hours answering service. Top
  19. Commentary: Note that this illustrative language would not require an enrollee to call Contractor's toll-free emergency telephone rather than 911. The language speaks only to the Contractor's duties which arise if an enrollee calls Contractor's line.
  20. Commentary: For purposes of §1915(b) Medicaid managed care waivers, HCFA queries States whether they have established maximum distance and travel time requirements for MCO enrollee access to primary care providers, specialists, and other providers. HCFA, Proposal for a Section 1915(b) Capitated Waiver Program Initial Application Preprint, April 30, 1999, p. 26, www.hcfa.gov/medicaid/smd50699.htm. Some states use a combination of distance and travel as an access standard to primary care providers in urban areas; for example, three states specify a standard of up to 10 miles or 30 minutes (CA, MD, NJ); three states specify a standard of up to 20 miles or 30 minutes (IN, MA, TN); and two states specify a standard of up to 30 miles or 30 minutes (DE, KY). In addition, some states use only travel distance as an access standard to primary care providers in urban areas; for example, three states use up to 20 miles (MO, NH, WI); and two states use up to 30 miles (NV, SC). For language in state Medicaid MCO contracts relating to geographic access to covered services and providers, see Table 3.8, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3, www.gwu.edu/~chsrp.
  21. Commentary: This illustrative language does not specify the geographic access standard with respect to emergency services in urban areas because under §A1-1 enrollees are entitled to access to in- or out-of-network emergency services and protected by the requirements of EMTALA, §1867 of the Social Security Act, 42 U. S.C. §1395dd. See OIG/HCFA Special Advisory Bulletin on the Patient Anti-Dumping Statute, 64 Fed Reg 61353 (November 10, 1999). Top
  22. Commentary: For purposes of designating areas having shortages of primary care providers, DHHS regulations measure these areas using a "travel time greater than 30 minutes." The regulations use the following distances as guidelines in determining distances corresponding to 30 minutes travel time: "(i) Under normal conditions, with primary roads available: 20 miles. (ii) In mountainous terrain or in areas with only secondary roads available: 15 miles. (iii) In flat terrain, or in areas connected by interstate highways: 25 miles. Within inner portions of metropolitan areas, information on the public transportation system will be used to determine the distance corresponding to 30 minutes travel time." 42 C.F.R. Part 5, Appendix A, Part I, Geographic Areas, B. Methodology, 1. Rational Areas for the Delivery of Primary Medical Care Services, (a)(ii), (b)(i) - (iii).
  23. An alternative option would be to reduce this minimum to one so that an enrollee would have access to just one provider of this type within a reasonable travel time.
  24. Eleven state contract provisions specify 30 minutes travel time (FL, GA, ME, MI, MS, NM, NY, OH, OR, PA, VT). See Table 3.7, Negotiating the New Health System, 3rd Ed. Volume 2, Part 3, www.gwu.edu/~chsrp.
  25. For illustrative language relating to coverage of transportation services, see §A3-1.
  26. The standard for access to inpatient hospital care in urban areas used by the state of Missouri is 20 miles travel distance. Schaller Anderson, Inc., Sample Access Standards Required under Medicaid Managed Care (October 15, 1998). Top
  27. For illustrative language relating to coverage of transportation services, see §A3-1.For language in state Medicaid MCO contracts relating to geographic access to covered services and providers, see Table 3.8, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3, http://www.gwu.edu/~chsrp/contracts.html.
  28. Three state contract provisions specify 60 minutes travel time (NM, OR, PA ). An alternative option would be to extend the application of a travel time standard in rural areas to categories of non-emergency services other than physician services, such as hospital, pharmacy, laboratory, and dental services.
  29. For illustrative language relating to coverage of transportation services, see §A3-1. Some states use a combination of distance and travel as an access standard to primary care providers in rural areas; for example, one state specifies a standard of up to 10 miles or 20 to 25 minutes (NJ); one state specifies a standard of up to 25 miles or 45 minutes (OK); and three states specify a standard of up to 45 miles or 30 minutes (KY, MD, TN). For language in state Medicaid MCO contracts relating to geographic access to covered services and providers, see Table 3.8, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3, http://www.gwu.edu/~chsrp/contracts.html.
  30. Commentary: The term "community hospital" is generally understood to include all non-Federal, short-stay hospitals except facilities for individuals with mental retardation. A short-stay hospital is one in which the average length of stay is less than 30 days. In contrast, a "specialty hospital" is generally understood as hospitals such as psychiatric, tuberculosis, chronic disease, rehabilitation, maternity, and alcoholic or narcotic hospitals that provide a particular type of service to the majority of their patients. National Center for Health Statistics, DHHS, Health United States, 1999, p. 371 Top .
  31. See Bosanac et al., "Geographic Access to Hospital Care: A 30-MinuteTravel Time Standard," Med Care 1976; 14(7):616-24. Top
  32. The standard for access to inpatient hospital care in rural areas used by the state of Missouri is 75 miles travel distance. Schaller Anderson, Inc., Sample Access Standards Required under Medicaid Managed Care (October 15, 1998).
  33. One of the commercially available mapping programs that is used by MCOs and state purchasers is GeoAccess, www.geoaccess.com. This program allows users to map distances between enrollee residences and provider sites.
  34. Commentary: For purposes of §1915(b) Medicaid managed care waivers, HCFA queries States whether they have established standards for in-office waiting times for MCO enrollee access to primary care providers, specialists, and other providers. HCFA, Proposal for a Section 1915(b) Capitated Waiver Program Initial Application Preprint, April 30, 1999, p. 28, www.hcfa.gov/medicaid/smd50699.htm. For language in state Medicaid MCO contracts relating to office waiting times, see Table 3.7, Negotiating the New Health System, 3rd Ed., Volume 2, Part 3, www.gwu.edu/~chsrp.
  35. Many state contract provisions specify a range from 30 minutes to 2 hours. For purposes of identifying facilities having a shortage of primary care providers, DHHS regulations specify, as one criterion, that "the waiting time at the facility is longer than 1 hour where patients have appointments§." 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, (iv). Top
  36. For purposes of identifying facilities having a shortage of primary care providers, DHHS regulations specify, as one criterion, that "the waiting time at the facility is longer than 2 hours where patients are treated on a first-come, first-served basis." 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, (iv).
  37. For language in state Medicaid MCO contracts relating to assessment of new enrollees, see Table 3.7, Negotiating the New Health System, 3rd Ed. Vol. 2, Part 3, www.gwu.edu/~chsrp.
  38. For illustrative language relating to the identification of MCO enrollees who are pregnant, see CHSRP, Optional Purchasing Specifications for Reproductive Health Services (May 2000), www.gwu.edu/~chsrp.
  39. Commentary: On October 5, 1998, HCFA transmitted a guidance to State Medicaid Directors entitled "Key Approaches to the Use of Managed Care Systems for Persons with Special Health Needs," www.hcfa.gov/medicaid/smd-snpf.htm.Top
  40. For illustrative language relating to the identification of one population with special health care needs, see §102 of CHSRP, Optional Purchasing Specifications: Medicaid Managed Care for Children with Special Health Care Needs (forthcoming), www.gwu.edu/~chsrp.
  41. State contract provisions specified a range from 14 days to 180 days from the effective date of enrollment for first appointments for new enrollees: 5 states provide a range under 30 days (ME, PA, HI, RI, WAMH); 7 states provide a range from 45 to 90 days (DC, FL, GA, MD, NY, NC, TX); and 3 states go over 100 days (CA, NJ, NM).
  42. This illustrative language would enable an interested Purchaser to track the use of MCO services for which Purchaser has contracted by individuals who are homeless as well as by other hard-to-reach beneficiary populations. See CHSRP, Optional Purchasing Specifications: Medicaid Managed Care for Individuals Who are Homeless (June 2000),../Home/index.html.
  43. One option would be to define an assessment as an encounter between an enrollee and a primary care provider participating in Contractor's provider network at which the provider administers an encounter form that: Top
    • (A) in the case of an enrollee who is a child under age 21, is set forth in Bright Futures: Encounter Forms for Health Professionals appropriate to the age of the child (copies of these forms are available in English and Spanish), www.brightfutures.org;
    • (B) in the case of an enrollee who is an adult age 25 through 64, is consistent with "Table 3" of the U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd Ed. (1996), www.dphp.osophs.dhhs.gov/pubs/GUIDECPS/;
    • (C) in the case of an enrollee who is an adult age 65 and older, is consistent with "Table 4" of the U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd Ed. (1996), www.dphp.osophs.dhhs.gov/pubs/GUIDECPS/; and
    • (D) in the case of an enrollee who is a woman of childbearing age, assists the provider in determining whether the enrollee is pregnant and is consistent with "Table 5" of the U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd Ed. (1996), www.dphp.osophs.dhhs.gov/pubs/GUIDECPS/.
    • Another alternative option would be to include an assessment as to whether in the case of an enrollee under the age of 5 or in the case of an enrolled adolescent who is pregnant, postpartum or breastfeeding, an initial assessment shall include an assessment as to whether the child is at nutritional risk for purposes of establishing eligibility for WIC (The Special Supplemental Nutrition Program for Woman, Infants, and Children under 17 of the Child Nutrition Act of 1966, 42 U.S.C. §1786(b)(8)). (The guidelines for determination of nutritional risk are set forth at 7 C.F.R. §246.7(e)(1)). Top
  44. For an illustrative definition of a child with special health care needs, see CHSRP, Optional Specifications: Purchasing Medicaid Managed Care for Children with Special Health Care Needs (forthcoming, 1999), §108(b).
  45. For illustrative language relating to prior authorization requirements and exclusions, see §103A of Part 1A of CHSRP, Optional Purchasing Specifications: Medicaid Managed Care for Pediatric Services. For language in state Medicaid MCO contracts relating to prior authorization, see Table 3.5, Negotiating the New Health System, 3rd Ed., Vol. 2, Part 3, www.gwu.edu/~chsrp/contracts.html.
  46. Commentary: Sections A2-5(a)(2) and A3-3(c) would require Contractor to maintain separate toll-free lines for emergency and urgent care services and for general information requests, respectively.
  47. An alternative option would be to narrow the scope of the services excluded from prior authorization to a subset of the preventive services described in §A1-2. Under federal law, States and MCOs may not impose prior authorization requirements on emergency services, §1932(b)(2)(A) of the Social Security Act, 42 U.S.C. §1396u-2(b)(2)(A).
  48. For language in state Medicaid MCO contracts relating to data collection and reporting, see Table 5.2, Negotiating the New Health System, 3rd Ed., Vol. 2, Part 4, www.gwu.edu/~chsrp.
  49. Commentary: Such requirements could include cooperation with the data requests of an External Quality Review Organization (EQRO) under §1932(c)(2) of the Social Security Act, 42 U.S.C. §1396u-2(c)(2). They could also include making available for audit records relating to grievances and appeals (see Compliance Measures in Part A1). For illustrative language on collection and report of access and quality data relating to children, see CHSRP, Optional Purchasing Specifications: Medicaid Managed Care for Pediatric Services, §§904 - 905 of Part 9.
  50. Commentary: The CAHPS version 2.0 questionnaires, including Spanish versions, and reporting tools, may be downloaded at www.ahcpr.gov/qual/cahps. HCFA uses CAHPS to measure and report on its Medicare managed care plans. In addition, the National Committee for Quality Assurance (NCQA) uses CAHPS version 2.0H for HEDIS 1999 and NCQA accreditation purposes. The CAHPS version 2.0H survey is designed to "produce standardized results and to achieve response rates of approximately § 50 percent for the population covered by Medicaid." NCQA, HEDIS 2000 Narrative: What's In It and Why It Matters (1999), p. 51. HCFA does not require MCOs participating in Medicaid to use CAHPS or HEDIS beneficiary satisfaction survey protocols.
  51. Commentary: The illustrative language in this section sets forth examples of the types of focus studies that Purchasers and MCO contractors could agree to conduct to determine the degree to which covered services are accessible to enrollees. Purchasers could specify one, several, or all six of the examples, or could substitute their own focus study topics. An alternative option would be to require Contractor to comply with the focus study provisions of HCFA's Quality Improvement System for Managed Care (QISMC) for organizations contracting with Medicare and Medicaid. See Interim QISMC Standards, September 28, 1998, www.hcfa.gov/quality/docs/qismc-in.htm. QISMC Interim Standards and Guidelines are optional for Medicaid MCOs and, effective January 1, 1999, mandatory for Medicare+Choice Organizations. See HCFA Operational Policy Letter #72, September 30, 1998, www.hcfa.gov/medicare/op1072/htm.
  52. Commentary: These focus study topics in subsections (a) through (d) correspond to HEDIS 2000 Access/Availability of Care Measures, National Committee on Quality Assurance, HEDIS 2000 Narrative: What's In It and Why It Matters (1999). Although MCOs participating in Medicaid are not required by HCFA to report HEDIS measures, a number of state Medicaid MCO contracts specify the reporting of HEDIS measures. See Table 5.2, Negotiating the New Health System, 3rd Ed., Vol. 2, Part 4, http://www.gwu.edu/~chsrp/contracts.html.

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