Medicaid Contract Purchasing Specifications

Part 6 Access Standards

Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under §1932(c)(1)(A)(i) of the Social Security Act, 42 U.S.C. §1396u-2(c)(1)(A)(i) relating to access standards for MCOs participating in Medicaid.

CHSRP is also developing purchasing specifications related to access standards applicable to the general Medicaid population. The general access purchasing specifications will address: accessibility to different types of services; elements of an accessible MCO; and services that promote access to the items and services covered under the contract. In addition, CHSRP is developing sample purchasing specifications relating to a number of public health issues. Among these are sample specifications for the purchase of services relating to immunizations, tuberculosis, sexually transmitted diseases (STDs), HIV infection and HIV-related conditions, childhood lead poisoning dental and oral health, and diabetes. Upon completion of these sample public health purchasing specifications, the relevant sections of the public health specifications will be incorporated into this Part.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on access standards is for your consideration. Purchasers may also find it useful to review Negotiating the New Health System (3^rd Ed.) which provides other options relating to access standards used by state agency purchasers in contracting with Medicaid MCOs at Table 3.7, Vol. 3, Part 2, pages 3-358 through 3-441 (www.gwu.edu/~chsrp).

Table of Contents

§601. In General
§602. Travel Time
§603. Service Waiting Times
§604. Access by Enrolled Adolescents
§605. Access to Dental Services
§606. Access to Immunizations
§607. Access to STD Services
§608. Access to HIV Services
§609. Access to TB Services
§610. Access to Childhood Lead Poisoning Services
§611. Access to Diabetes Services

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language is for your consideration.

^K§601. In General

(a) Access — Contractor shall ensure that all items and services covered under Part 1 are accessible to each enrolled child in accordance with this Part.

(b) Initial Assessment

(1) In General — Contractor shall ensure that each enrolled child receives an initial assessment within [ ] days of the effective date of enrollment.

(2) Enrolled Children with Special Health Care Needs — Contractor shall ensure that each enrolled child known or identified to Contractor to be a child with special health care needs (as defined in §1401(f)) receives an initial assessment within [ ] days of the effective date of enrollment.

(3) Initial Assessment Defined [RESERVED]¹

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on travel time is for your consideration.

^K§602. Travel Time

Commentary: The following illustrative language addresses three issues of importance to the delivery of health care services to an enrolled child. Purchaser may use this language to specify, at its option, (1) the number of providers to which an enrolled child may have access, (2) the types of providers available to enrolled children in an urban service area, and (3) a specified travel time to each type of provider within the urban area.

(a) Travel Time in Urban Areas²— In the case of an enrolled child living in [drafter insert name of urban area within Contractor's service area], Contractor shall ensure that at least one³ provider from each of the following categories participating in Contractor's provider network is located within [ ] minutes travel time (using ground transportation) of each enrolled child:

(1) primary care providers;

(2) dentists; and

(3) pharmacists.⁴

(b) Travel Time in Rural Areas

(1) Emergency Services — In the case of an enrolled child living in [drafter insert name of rural area within Contractor's service area], Contractor shall ensure that at least oneprovider participating in Contractor's provider network that furnishes emergency services (as defined in §1401(l)) is located within:

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

(B) [ ] travel time of the child using air transportation.

(2) Non-Emergency Physician Services⁵— In the case of an enrolled child living in [drafter insert name of rural area 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] of the child using ground transportation; or

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

^KCompliance measure: Contractor shall make available upon request to the Purchaser a map showing:

(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 enrolled children reside.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on service waiting times is for your consideration.

§603. Service Waiting Times

^L(a) Emergency Medical Condition⁶— Contractor shall ensure that an enrolled child (including an adolescent) who presents with an emergency medical condition (as defined in §1401(k)) to a provider participating in Contractor's provider network receives emergency services (as defined in §1401(l)) immediately.

^K(b) Urgent Medical Condition — Contractor shall ensure that an enrolled child (including an adolescent) who presents with an urgent medical condition (as defined in §1401(aa)) to a provider participating in Contractor's provider network receives items and services covered under Part 1 within [ ] hours of the time that the child presents or that the child's family or caregiver requests (directly or by telephone) treatment on the child's behalf.

^K(c) Other Care

(1) Appointments —Contractor shall ensure that an enrolled child (including an adolescent) receives an appointment with a provider participating in Contractor's provider network for any reason other than an emergency or urgent medical condition described in subsections (a) and (b) consistent with the following:

(A) in the case of visits for a suspected physical or mental illness or condition (including an interperiodic EPSDT screening exam), within [ ] days of request to be seen;

(B) in the case of the first request to be seen made by or on behalf of a newly enrolled child, within [ ] weeks of the request, unless an earlier appointment is necessary in order to comply with the EPSDT periodicity schedule as required in §102 of Part 1;

(C) in the case of periodic EPSDT screening exams (hearing, dental and vision), at the time that such screening exam is scheduled to occur in order to comply with the EPSDT periodicity schedule as required in §102 of Part 1;

(D) in the case an enrolled child who is in a migratory family (as defined in §1401(r)) or in a seasonal agricultural worker family (as defined in §1401(y)), within [ ] hours of the request to be seen;

(E) in the case an enrolled child who is in a homeless family (as defined in §1401(n)), within [ ] hours of the request to be seen;

(F) in the case of an enrolled child (including an adolescent) who presents for treatment for sexual or physical abuse, within [ ] hours of the request to be seen;

(G) in the case an enrolled child who is in foster care or out-of-home placement, within [ ] hours of the request for an appointment made by the child welfare agency; and

(H) in the case of [drafter insert other types of appointments], within [ ] days of the request to be seen.

(2) Office Waiting Times — Contractor shall ensure that, on average, an enrolled child (including an adolescent) who has a scheduled appointment with a provider participating in Contractor's provider network for any reason other than an emergency or urgent medical condition described in subsections (a) and (b) begins an encounter with the provider within [ ] minutes of the time the appointment is scheduled to begin.⁷

^K(d) Monitoring —Contractor shall monitor the furnishing of items and services covered under Part 1 by providers participating in Contractor's provider network in sufficient detail to collect the data specified by Purchaser under §904(c) of Part 9 to enable Purchaser to determine Contractor's compliance with the requirements of subsections (a), (b), and (c).

^KCompliance Measure: Contractor shall make available upon request to Purchaser 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.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on access by enrolled adolescents is for your consideration.

^K§604. Access by Enrolled Adolescents

Commentary: Evidence from numerous studies suggests that adolescents use significantly fewer health services than is necessary in light of their health status and need for health services. Underutilization appears to be a particular problem in the case of preventive services such as health exams and immunizations, family planning services and supplies, and services for the treatment of physical and mental illnesses and conditions. See Brindis, C. et al., Improving Adolescent Health: An Analysis and Synthesis of Health Policy Recommendations, nahic@itsa.ucsf.edu. The language below illustrates how interested purchasers can encourage MCOs to promote adolescents' use of covered health services.

(a) In General — Contractor shall promote access by enrolled adolescents to the items and services covered under Part 1 by carrying out the following requirements:

(1) §303 (relating to information on self-referral policies and procedures, confidentiality protections, and other matters affecting access to services by enrolled adolescents);

(2) §102B (relating to the delivery of preventive services to enrolled adolescents);

(3) §104A (relating to self-referral for family planning and other specified services without prior authorization);

(4) §005(g)(1) (relating to self-referral for certain services through a school-based health center); and

(5) §103A(d) of Part 1A (relating to exclusion from prior authorization of family planning, STD, and HIV services and for an examination to determine physical or sexual abuse).

(b) Measuring Access and Quality — Contractor shall comply with the requirements of:

(1) §904(c) (relating to the collection and reporting of access data concerning enrolled adolescents);

(2) §803(a)(7) (relating to the conduct of a clinical study of the quality of family planning services furnished to enrolled adolescents); and

(3) §803(a)(8) (relating to the conduct of a clinical study of the quality of EPSDT preventive services furnished to enrolled adolescents).

§605. Access to Dental Services

[To be supplied upon completion of access provisions in sample purchasing specifications for dental and oral health]

§606. Access to Immunizations

[To be supplied upon completion of access provisions in sample purchasing specifications for immunizations]

§607. Access to STD Services

[To be supplied upon completion of access provisions in sample purchasing specifications for sexually transmitted disease services]

§608. Access to HIV Services

[To be supplied upon completion of access provisions in sample purchasing specifications for services for HIV and HIV-related conditions]

§609. Access to TB Services

[To be supplied upon completion of access provisions in sample purchasing specifications for tuberculosis services]

§610. Access to Childhood Lead Poisoning Services

[To be supplied upon completion of access provisions in sample purchasing specifications for childhood lead poisoning services]

§611. Access to Diabetes Services

[To be supplied upon completion of access provisions in sample purchasing specifications for diabetes services]

Endnotes

An alternative option would be to define an initial assessment as: an encounter between an enrolled child and a primary care provider participating in Contractor's provider network at which the provider administers an encounter form set forth in Bright Futures: Encounter Forms for Health Professionals appropriate to the age of the child.
Another alternative option would be to include an assessment as to whether an enrolled child is at nutritional risk for purposes of establishing eligibility for WIC (The Special Supplemental Nutriont Prgoram for Women, Infants, and Children under §17 of the Child Nutrition Act of 1966, 42 U.S.C. §1786(b)(8). An enrolled child under the age of 5 or an enrolled adolescent who is pregnant, postpartum or breastfeeding would be eligible for such services. The guidelines for determination of nutritional risk are set forth at 7 C.F.R. §246.7(e)(1).
This illustrative language does not specify the travel time standard with respect to emergency services in urban areas because, under §005(e), Contractor is required to comply with §1932(b)(2)(B) of the Social Security, which entitles enrolled children to access to in- or out-of-network emergency services. Note also the anti-patient dumping prohibitions applicable to all urban or rural hospitals participating in Medicare referenced in §1301(d) of Part 13.
An alternative option would be to increase the minimum number of providers so that an enrolled child would have a choice of two or more providers within a reasonable travel time.
An alternative option would be to add one or more of the following categories of providers: (1) providers of family planning services who are not primary care physicians; (2) providers of obstetrical services who are not primary care physicians; and (3) acute care hospitals.
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.
See HCFA's February 20, 1998 Letter to State Medicaid Directors requiring that "emergency services must be covered without regard to prior authorization or the emergency care provider's contractual relationship with the [MCO]§to enable a Medicaid enrollee to immediately obtain emergency services at the nearest provider when and where the need arises," www.hcfa.gov/medicaid/bba2208c.htm.
An alternative option would be to add a requirement to ensure that, on average, an enrolled child (including an adolescent) who walks in for an unscheduled appointment with a provider participating in Contractor's provider network for any reason other than an emergency or urgent medical condition described in subsections (a) and (b) begins an encounter with the provider within [ ] minutes.