Medicaid Contract Purchasing Specifications

Access to Care Standards

One of the Contractor duties common to many of the purchasing specifications is to ensure that covered benefits and services are accessible to enrolled children. In the context of Medicaid MCOs, care is accessible if an enrolled child is able to obtain, within a period of time that is reasonable in light of the child's condition, needed services that are covered under the contract between the state Medicaid agency and the MCO. The following provisions set forth access standards, including service waiting times and geographic accessibility, appropriate to the subpopulation of children addressed.

[On-line Navigation: To view the entire purchasing specification, click on the name in the left column. To view a specific provision, click on the section number in the right column.]

Purchasing Specification	Related Contract Language
ACCESS	§A1-1 (emergency services) §A1-3(a) (pediatric preventive services §A1-5 (specialty services) §A1-7 (pharmacy services) §A2-5 (24/7 availability) §A2-6 (geographic access) §A2-7 (in-office waiting times)
CD	§101(e) (other contractor duties)
CW	§108 (appointment times for non-emergency care)
CBHN	Chapter I (prime/prime):‡ §206(b) (crisis services) §206(c) (behavioral health providers) §206(d) (residential treatment facility) §206(e) (substance abuse services) Chapter II (prime/subprime):‡ §211(b) (crisis services) §211(c) (behavioral health providers) §211(d) (residential treatment facility) §211(e) (substance abuse services)
CSHCN	§205(b) (primary care) §205(c) (specialty services)
CC	§103 (oral interpreter)
DENTAL	§201 (enrollee access to providers)
IMMUN	§007 (access)
LEAD	§006 (access standards)
MEDIPED	§602 (travel time) §603 (service waiting times) §604 (access by enrolled adolescents)
SCHIP	§602 (travel time) §603 (service waiting times) §604 (access by enrolled adolescents)

‡The "prime/prime" arrangement has two primary contractors—the MCO and the BHO—to which the state purchaser makes capitation payments. Under this arrangement, a child is enrolled in both the MCO and the BHO. The "prime/subprime" arrangement involves one primary contractor and a subcontractor. The state purchaser contracts with and makes capitation payments to an MCO; the MCO, in turn, subcontracts with the BHO for the provision of behavioral health services.

ACCESS = Access to Services (July 2000)
CD = Child Development Services (July 2000)
CW = Child Welfare (December 2001)
CBHN = Children with Behavioral Health Needs (December 2000)
CSHCN = Children with Special Health Care Needs (August 2000)
CC = Cultural Competence (Updated, November 2001)
DENTAL = Dental and Oral Pediatric Health Services (March 2000)
IMMUN = Immunizations (May 1998)
LEAD = Childhood Lead Poisoning Services (November 1998)
MEDIPED = Medicaid Pediatric Services (September 1999)
SBHC = School-Based Health Center Services (January 2002)
SCHIP = SCHIP Pediatric Services (April 2002)