Primary Care Providers. The MCO's PCP Network may include Providers from any of the following practice areas: General Practice; Family Practice; Internal Medicine; Pediatrics; Obstetrics/Gynecology (OB/GYN); Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs) (when APRNs and PAs are practicing under the supervision of a physician specializing in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a PCP under this contract); Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar community clinics; and specialist physicians who are willing to provide a Medical Home to selected Members with special needs and conditions. Texas Government Code Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require the MCO to use advance practice registered nurses (APRNs) and physician assistants (PAs) practicing under the supervision of a Network physician. The MCO must treat APRNs and PAs in the same manner as other Network PCPs with regard to: (1) selection and assignment as PCPs, (2) inclusion as PCPs in the MCO's Provider Network, and (3) inclusion as a PCP in any Provider Directory maintained by the MCO. An internist or other Provider who provides primary care to adults only is not considered an age-appropriate PCP choice for a Member birth through age 20. An internist or other Provider who provides primary care to adults and children may be a PCP for children if:
1. the Provider assumes all MCO PCP responsibilities for such child Members in a specific age range from birth through age 20,
2. the Provider has a history of practicing as a PCP for the specified age range, as evidenced by the Provider's primary care practice including an established patient population within the specified age range, and
3. the Provider has admitting privileges to a local Hospital that includes admissions to pediatric units. A pediatrician is not considered an age-appropriate choice for a Member age 21 and over. The PCP for a Member with disabilities, Special Health Care Needs, or Chronic or Complex Conditions may be a specialist physician who agrees to provide PCP services to the Member. The specialty physician must agree to perform all PCP duties required in the Contract, and PCP duties must be within the scope of the specialist's license. Any interested person may initiate the request through the MCO for a specialist to serve as a PCP for a Member with disabilities, Special Health Care Needs, or C...
Primary Care Providers. The MCO’s PCP Network may include Providers from any of the following practice areas: General Practice; Family Practice; Internal Medicine; Pediatrics; Obstetrics/Gynecology (OB/GYN); Advanced Practice Nurses (APNs) and Physician Assistants (PAs) (when APNs and PAs are practicing under the supervision of a physician specializing in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a PCP under this contract); Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar community clinics; and specialist physicians who are willing to provide a Medical Home to selected Members with special needs and conditions. Section 533.005(a)(13) of the Texas Government Code requires the MCO to use APNs practicing under the supervision of a physician as PCPs in its Provider Network for STAR and STAR+PLUS. An internist or other Provider who provides primary care to adults only is not considered an age-appropriate PCP choice for a Member birth through age 20. An internist or other Provider who provides primary care to adults and children may be a PCP for children if:
Primary Care Providers. The HMO’s PCP Network may include Providers from any of the following practice areas: General Practice; Family Practice; Internal Medicine; Pediatrics; Obstetrics/Gynecology (OB/GYN); Certified Nurse Midwives (CNM) and Physician Assistants (PAs) practicing under the supervision of a physician; Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar community clinics; and specialist physicians who are willing to provide a Medical Home to selected Members with special needs and conditions. Section 533.005(a)(13), Government Code, requires the HMO to use Advanced Practice Nurses practicing under the supervision of a physician as PCPs in its Provider Network for STAR and STAR+PLUS. CHIP Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates. CHIP Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP Perinatal Newborns. An internist or other Provider who provides primary care to adults only is not considered an age-appropriate PCP choice for a Member under age 21. An internist or other Provider who provides primary care to adults and children may be a PCP for children if:
Primary Care Providers. Section 7.8.1.1 is added and Sections 7.8.8 and 7.8.11.4 are modified with the following language:
Primary Care Providers. 59 7.9 OB/GYN PROVIDERS.................................................. 63 7.10
Primary Care Providers. 1. The Health Plan shall enter into agreements with a sufficient number of PCPs to ensure adequate accessibility for Enrollees of all ages. The Health Plan shall select and approve its PCPs. The Health Plan shall ensure its approved PCPs agree to the following:
(a) The PCP’s agreement to accept the associated Case Management responsibilities.
(b) The PCP’s agreement to provide or arrange for coverage of services, consultation or approval for referrals twenty four (24) hours per day, seven days per week by Medicaid enrolled providers who will accept Medicaid reimbursement. This coverage must consist of an answering service, call forwarding, provider call coverage or other customary means approved by the Agency. The chosen method of twenty four (24) hour coverage must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical decision. The after hours coverage must be accessible using the medical office’s daytime telephone number. The PCP or covering medical professional must return the call within thirty (30) minutes of the initial contact.
(c) The PCP’s agreement to arrange for coverage of primary care services during absences due to vacation, illness or other situations which require the PCP to be unable to provide services. Coverage must be provided by a Medicaid enrolled PCP.
2. The Health Plan shall provide the following:
a. At least one (1) FTE PCP per county including, but not limited to, the following specialties:
(1) Family Practice;
(2) General Practice;
(3) Obstetrics or Gynecology;
(4) Pediatrics; and
Primary Care Providers. The Health Plan shall enter into agreements with a sufficient number of PCPs with demonstrated experience in the provision and management of medical and psycho-social health care for persons with HIV/AIDS, to ensure accessibility for enrollees of all ages. The Health Plan shall select and approve its PCPs. PCPs shall practice in one of the following areas: general practice, family practice, pediatrics, internal medicine, infectious disease, hematology, obstetrics, or gynecology. The Health Plan may consider and approve physicians in other areas of specialty as a PCP on a case-by-case basis. The Health Plan shall ensure its approved PCPs agree to the following:
a. The PCP’s agreement to accept the associated case/care management responsibilities.
Primary Care Providers. The MCO’s PCP Network may include Providers from any of the following practice areas: General Practice; Family Practice; Internal Medicine; Pediatrics; Obstetrics/Gynecology (OB/GYN); Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs) (when APRNs and PAs are practicing under the supervision of a physician specializing in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a PCP under this contract); Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar community clinics; physicians serving Members residing in Nursing Facilities effective March 1, 2015; and specialist physicians who are willing to provide a Medical Home to selected Members with special needs and conditions. Texas Government Code Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require the MCO to use advance practice registered nurses (APRNs) and physician assistants (PAs) practicing under the supervision of a Network physician. The MCO must treat APRNs and PAs in the same manner as other Network PCPs with regard to: (1) selection and assignment as PCPs, (2) inclusion as PCPs in the MCO’s Provider Network, and (3) inclusion as a PCP in any Provider Directory maintained by the MCO. An internist or other Provider who provides primary care to adults only is not considered an age-appropriate PCP choice for a Member birth through age 20. An internist or other Provider who provides primary care to adults and children may be a PCP for children if:
Primary Care Providers. 7.8.1 HMO must have a system for monitoring Member enrollment into its plan to allow HMO to effectively plan for future needs and recruit network providers as necessary to ensure adequate access to primary care and specialty care. The Member enrollment monitoring system must include the length of time required for Members to access care within the network. The monitoring system must also include monitoring after-hours availability and accessibility of PCPs.
7.8.1.1 HMO must provide supporting documentation, as required by 42 C.F.R. Section 438.207(b), as specified and requested by the State, to verify that their provider network meets the requirements of this contract at the time the HMO enters into a contract and at the time of a significant change as required by 42 C.F.R. Section 438.207(c). A significant change can be, but is not limited to, change in ownership (purchase, merger, acquisition), new start-up, bankruptcy, and/or a major subcontractor change directly affecting a provider network such as (IPA's, BHO, medical groups, etc.).
7.8.2 HMO must maintain a primary care provider network in sufficient numbers and geographic distribution to serve a minimum of forty-five percent (45%) of the mandatory STAR eligibles in each county of the service area. HMO is required to increase the capacity of the network as necessary to accommodate enrollment growth beyond the forty-fifth percentile (45%).
7.8.3 HMO must maintain a provider network that includes pediatricians and physicians with pediatric experience in sufficient numbers and geographic distribution to serve eligible children and adolescents in the service area and provide timely access to the full scope of benefits, especially THSteps checkups and immunizations.
7.8.4 HMO must comply with the access requirements as established by the Texas Department of Insurance for all HMOs doing business in Texas, except as otherwise required by this contract.
7.8.5 HMO must have physicians with board eligibility/certification in pediatrics available for referral for Members under the age of 21.
7.8.5.1 Individual PCPs may serve more than 2,000 Members. However, if HHSC determines that a PCP's Member enrollment exceeds the PCP's ability to provide accessible, quality care, HHSC may prohibit the PCP from receiving further enrollments. HHSC may direct HMOs to assign or reassign Members to another PCP's panel.
7.8.6 HMO must have PCPs available throughout the service area to ensure that no Member must travel more than...
Primary Care Providers a. For the purpose of provider network review, the Department analyzes the following primary care provider speciality codes: 090 – Certificed Pediatric Nurse Practitioners 092 – Certified Family Nurse Practitioners 093 – Other Nurse Practitioners 095 – Nurse Practitioner/Nurse Midwife 100 – Physician Assistants 160 – Registered Nurse 212 – Nurse Midwives 316 – Family Practitioners 318 – General Practitioners 322 – Internal Medicine 328 – OB/Gynecologists 345 – Pediatricians 350 – Licensed Midwives The PIHP may define other types of providers as primary care providers. If the PIHP chooses to do so, they must define these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the PIHP certification process.
b. The PIHP must have an enrolled primary care provider within a 20-mile distance (or within 10-mile distance for the cities of Milwaukee, Kenosha, Racine) from any member residing in the PIHP service area, unless there is no Medicaid-enrolled provider within the specified distance. In that case, the travel distance shall be no more than for a non-enrolled member.
c. The PIHP must have a sufficient number of primary care providers in the network with pediatric board certification or eligibility and experience working with children with special health care needs so that each child is served. In Milwaukee County, there must be a sufficient number of primary care providers in all zip codes in the county.
