Access to Care. All Covered Services must be available to Members on a timely basis in accordance with medically appropriate guidelines, and consistent with generally accepted practice parameters, requirements in this Contract. The HMO must comply with the access requirements as established by the Texas Department of Insurance (TDI) for all HMOs doing business in Texas, except as otherwise required by this Contract. Medicaid HMOs must be responsive to the possibility of increased Members due to the phase-out of the PCCM model in Service Areas where adequate HMO coverage exists. The HMO must provide coverage for Emergency Services to Members 24 hours a day and 7 days a week, without regard to prior authorization or the Emergency Service provider’s contractual relationship with the HMO. The HMO’s policy and procedures, Covered Services, claims adjudication methodology, and reimbursement performance for Emergency Services must comply with all applicable state and federal laws and regulations, whether the provider is in-network or Out-of-Network. A HMO is not responsible for payment for unauthorized non-emergency services provided to a Member by Out-of-Network providers. The HMO must also have an emergency and crisis Behavioral Health Services Hotline available 24 hours a day, 7 days a week, toll-free throughout the Service Area. The Behavioral Health Services Hotline must meet the requirements described in Section 8.1.15. For Medicaid Members, a HMO must provide coverage for Emergency Services in compliance with 42 C.F.R. §438.114, and as described in more detail in Section 8.2.2.1. The HMO may arrange Emergency Services and crisis Behavioral Health Services through mobile crisis teams. For CHIP Members, Emergency Services, including emergency Behavioral Health Services, must be provided in accordance with the Texas Insurance Code and TDI regulations. For the CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency services for CHIP Perinates and CHIP Perinate Newborns. For the STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must require, and make best efforts to ensure, that PCPs are accessible to Members 24 hours a day, 7 days a week and that its Network Primary Care Providers (PCPs) have after-hours telephone availability that is consistent with, Section 8.1.4. CHIP Perinatal HMOs are not required to establish PCP Networks for CHIP Perinates. The HMO must provide that if Medically Necessary Covered Services are not available t...
Access to Care. All Covered Services must be available to Members on a timely basis in accordance the Contract's requirements and medically appropriate guidelines, and consistent with generally accepted practice parameters. The MCO must comply with the access requirements as established by the Texas Department of Insurance (TDI) for all MCOs doing business in Texas, except as otherwise required by this Contract. Medicaid MCOs must be responsive to the possibility of increased Members due to the phase-out of the PCCM model in Service Areas where HHSC has determined that adequate MCO coverage exists. The MCO must provide coverage for Emergency Services to Members 24 hours a day and seven (7) days a week, without regard to prior authorization or the Emergency Service provider's contractual relationship with the MCO. The MCO's policy and procedures, Covered Services, claims adjudication methodology, and reimbursement performance for Emergency Services must comply with all applicable state and federal laws and regulations, whether the provider is Network or Out-of-Network. A MCO is not responsible for payment for unauthorized non-emergency services provided to a Member by Out-of-Network providers.
Access to Care. Contractor shall provide culturally and linguistically appropriate services and supports, in locations as geographically close as possible, to where Members reside or seek services and choice of Providers (including physical health, behavioral health, including mental health and Substance Use Disorders, and oral health) within the delivery system network that are, if available, offered in non-traditional settings that are accessible to Families, diverse communities, and underserved populations.
a. Contractor shall meet, and require Providers to meet, OHP standards for timely access to care and services, taking into account the urgency of need for services. Contractor shall comply with OAR 410-141-3220 and 410-141-3160. Contractor shall make Covered Services available 24 hours a day, 7 days a week, when medically appropriate.
b. As specified in OAR 410-123-1000 through 410-123-1640, for routine dental care the Member shall be seen within an average of eight weeks and within 12 weeks or the dental office’s community standard, whichever is less, unless there is a documented special clinical reason which would require longer access time.
c. Contractor shall ensure that Providers do not discriminate between Members and non-OHP persons as it relates to benefits and services to which they are both entitled and shall ensure that Providers offer hours of operation to Members that are no less than those offered to non- Members as provided in OAR 410-141-3220.
d. Contractor shall provide each Member with an opportunity to select an appropriate Mental Health Practitioner and service site.
e. Contractor may not deny Covered Services to, or request Disenrollment of, a Member based on disruptive or abusive behavior resulting from symptoms of a mental or Substance Use Disorders or from another disability. Contractor shall develop an appropriate Treatment Plan with the Member and the Family or advocate of the Member to manage such behavior.
f. Contractor shall implement mechanisms to assess each Member with Special Health Care needs in order to identify any ongoing special conditions that require a course of physical health, Substance Use Disorders, or mental health treatment or care management. The assessment mechanisms must use appropriate health care professionals.
(1) For Members with Special Health Care Needs determined to need a course of treatment or regular care monitoring, the Individual Service and Support Plan must be developed by Members PCP with Member partici...
Access to Care. The Contractor shall:
A. Ensure the availability of twenty-four (24) hour per day, seven (7) days per week, telephone coverage which will immediately page an on-call medical professional. The Contractor shall provide the OHCA evidence of the number. The Contractor shall provide all enrolled members in his/her panel with the information necessary to access the 24-hour coverage. The Contractor is authorized to use the OHCA’s Nurse Advice Line toll-free number as a resource to fulfill the after hours telephone coverage requirement.
B. Comply with Federal and State standards regarding access and quality of care. The Contractor agrees to cooperate with the OHCA’s external quality of care review organization and its Medicaid Director with regard to utilization reviews conducted and other quality assurance efforts.
C. Make a medical evaluation of the member or cause such an evaluation to be made:
1. within twenty-four (24) hours with appropriate treatment and follow up as deemed medically necessary for those members with an urgent medical condition
2. available within three (3) weeks for non-urgent medical problems. This standard does not apply to appointments for routine physical exams, nor for regularly scheduled visits to monitor a chronic medical condition, if that condition calls for visits to occur less frequently than once every three weeks.
D. Offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the Contractor serves only Medicaid members.
Access to Care. Inmates have access to care to meet their serious medical, dental, and mental health needs. Outcome: Inmates have access to care in a timely manner with referral to an appropriate clinician as needed. Measure: Documentation by DC4-698B, DC4-698A, and the Call Out Schedule (OBIS). Standard: Achievement of outcome must meet one hundred percent (100%) of chart reviews. Reference: Procedure 403.006, HSB 15.05.20 and HSB 15.03.22.
Access to Care. PROVIDER shall:
a) Make a medical evaluation or cause such an evaluation to be made:
1. For new or existing members with urgent medical conditions: within twenty-four
Access to Care. Primary Care Physician (PCP)
Access to Care. To what extent are enrollees able to receive timely access to personal, home care and other services such as dental care, optometry and audiology?
Access to Care. In order to obtain benefits, you must designate a network primary care provider for each member. You may select any network primary care provider who is accepting new patients. However, you may not change your selection more frequently than once each month. If you do not select a network primary care provider for each member, one will be assigned. You may obtain a list of network primary care providers at our website or by contacting our Member Services department. Your network primary care provider will be responsible for coordinating all covered health services with other network providers. You do not need a referral from your network primary care provider for mental or behavioral health services, obstetrical or gynecological treatment and may seek care directly from a network obstetrician or gynecologist. You may change your network primary care provider by submitting a written request, online at our website, or by contacting our office at the number shown on your identification card. The change to your network primary care provider of record will be effective no later than 30 days from the date we receive your request. Your network is subject to change upon advance written notice. A network service area may not be available in all areas. If you move to an area where we are not offering access to a network, the network provisions of the contract will no longer apply. In that event, benefits will be calculated based on the eligible service expense, subject to the deductible amount for network providers. You will be notified of any increase in premium.
Access to Care. Access to care in rural Georgia counties continues to be an ongoing issue. The Georgia Board of Health Care Workforce (2017) released a report that included the current number of physicians in Georgia counties. The report also includes the counties that do not have practicing physicians based on specialties. Eight of the 159 counties do not have a practicing physician; all of which are rural counties. This same report found that 75 counties do not have a practicing Obstetrics and Gynecologist (OB-GYN). Many counties overlap with not having a family medicine doctor or an OB-GYN including Xxxxxxxxxx, Gaslcock, Truetlen, Talbot, Webster, Xxxxxxx, Xxxx, Xxxxxxxx, Xxxxxx, Xxxxxx and Xxxxxx. This lack of physicians, in part, is due to the closing of hospitals in these areas. In the past 10 years, Georgia has had 7 hospital closures in rural counties, with 18 more being deemed “vulnerable” for closure (The Chartis Group, 2020). With the closing of hospitals, these rural areas lose physicians, including OB-GYNs.
