Common use of Primary Care Providers Clause in Contracts

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 Chronic or Complex Conditions. The MCO must handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR and CHIP newborns must either have admitting privileges at a Hospital that is part of the MCO's Provider Network, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. The MCO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) days a week. The MCO is encouraged to enter into Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the office telephone is answered after-hours by an answering service that meets language requirements of the Major Population Groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's 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); Advanced Practice Registered Nurses (APRNsAPNs) and Physician Assistants (PAs) (when APRNs 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. Texas Government Code Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require ), Government Code, requires the MCO HMO to use advance practice registered nurses (APRNs) and physician assistants (PAs) Advanced Practice Nurses 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 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 MCO's Provider Network, same PCP Network for CHIP Members and (3) inclusion as a PCP in any Provider Directory maintained by the MCOCHIP 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 birth through under age 2021. 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 HMO PCP responsibilities for such child Members in a specific age range from birth through group under age 2021, 2. the Provider has a history of practicing as a PCP for the specified age range, group as evidenced by the Provider's ’s primary care practice including an established patient population under age 20 and within the specified age range, and 3. the Provider has admitting privileges to a local Hospital 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, Contract and PCP duties must be within the scope of the specialist's ’s license. Any interested person may initiate the request through the MCO HMO for a specialist to serve as a PCP for a Member with disabilities, Special Health Care Needs, or Chronic or Complex Conditions. The MCO must HMO shall handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR STAR, CHIP, and CHIP newborns Perinatal Newborns must either have admitting privileges at a Hospital that is part of the MCO's HMO’s Provider Network, Network or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, Medicaid Hospital or make referral arrangements with a Provider who has admitting privileges to a Network Medicaid Hospital. The MCO HMO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) 7 days a week. The MCO HMO is encouraged to enter into include in its Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the The office telephone is answered after-hours by an answering service that service, which meets language requirements of the Major Population Groups and that which can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the The office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's ’s telephone. Another recording is not acceptable; and 3. the The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, PCP or another designated medical providerpractitioner, who can return the call within 30 minutes. 1. the The office telephone is only answered during office hours; 2. the The office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the The office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning Returning after-hours calls outside of 30 minutes. The CHIP MCOs HMOs must require PCPs, through contract provisionsprovisions or Provider Manual, to provide children birth through under the age 20 of 21 with preventive services in accordance with the AAP recommendationsrecommendations for CHIP Members and CHIP Perinate Newborns. Medicaid MCOs HMOs must require PCPs, through contract provisionsprovisions or Provider Manual, to provide children birth through under the age 20 of 21 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO HMO must require PCPs, through contract provisionsprovisions or Provider Manual, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO HMO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO HMO must require PCPs, through contract provisionsprovisions or Provider Manual, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' ’ care with specialty care providers after referral. The MCO HMO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's 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); Advanced Practice Registered Nurses Certified Nurse Midwives (APRNsCNM) 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)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. Texas Government Code Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require ), Government Code, requires the MCO HMO to use advance practice registered nurses (APRNs) Pediatric and physician assistants (PAs) Family Advanced Practice Nurses 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 physician as PCPs in the MCO's Provider Network, and (3) inclusion as a PCP in any Provider Directory maintained by the MCOits provider network for STAR. 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 under age 2021. 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 HMO PCP responsibilities for such child Members in a specific age range from birth through group under age 2021, 2. the Provider has a history of practicing as a PCP for the specified age range, group as evidenced by the Provider's ’s primary care practice including an established patient population under age 20 and within the specified age range, and 3. the Provider has admitting privileges to a local Hospital hospital that includes admissions to pediatric units. A pediatrician is not considered an age-appropriate choice for a Member age 21 and over. Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8 Version 1.0 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, Contract and PCP duties must be within the scope of the specialist's ’s license. Any interested person may initiate the request through the MCO HMO for a specialist to serve as a PCP for a Member with disabilities, Special Health Care Needs, or Chronic or Complex Conditions. The MCO must HMO shall handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. X. PCPs who provide Covered Services for STAR and CHIP newborns must either have admitting privileges at a Hospital hospital that is part of the MCO's HMO’s Provider Network, Network or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, or make referral arrangements with a Provider who has admitting privileges to a Network Hospitalhospital. The MCO HMO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) 7 days a week. The MCO HMO is encouraged to enter into include in its Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the The office telephone is answered after-hours by an answering service that service, which meets language requirements of the Major Population Groups and that which can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the The office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's ’s telephone. Another recording is not acceptable; and 3. the The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, PCP or another designated medical providerpractitioner, who can return the call within 30 minutes. 1. the The office telephone is only answered during office hours; 2. the The office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the The office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning Returning after-hours calls outside of 30 minutes. The CHIP MCOs HMO must require PCPs, through contract provisionsprovisions or Provider Manual, to provide children birth through under the age 20 of 21 with preventive services in accordance with the AAP recommendationsrecommendations for CHIP Members and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Members. Medicaid MCOs The HMO must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisionsprovisions or Provider Manual, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO HMO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8 Version 1.0 The MCO HMO must require PCPs, through contract provisionsprovisions or Provider Manual, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' ’ care with specialty care providers after referral. The MCO HMO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's ’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 (APRNsAPNs) and Physician Assistants (PAs) (when APRNs 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 Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require requires the MCO to use advance practice registered nurses (APRNs) and physician assistants (PAs) APNs 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 physician as PCPs in the MCO's its Provider Network, Network for STAR and (3) inclusion as a PCP in any Provider Directory maintained by the MCOSTAR+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: 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 ’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 ’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 Chronic or Complex Conditions. The MCO must handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR and CHIP newborns must either have admitting privileges at a Hospital that is part of the MCO's ’s Provider Network, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. The MCO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) days a week. The MCO is encouraged to enter into Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the office telephone is answered after-hours by an answering service that meets language requirements of the Major Population Groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's ’s telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's ’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 (APRNsAPNs) and Physician Assistants (PAs) (when APRNs 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 Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require requires the MCO to use advance practice registered nurses (APRNs) and physician assistants (PAs) APNs 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 physician as PCPs in the MCO's its Provider Network, Network for STAR and (3) inclusion as a PCP in any Provider Directory maintained by the MCOSTAR+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: 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 ’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 ’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 Chronic or Complex Conditions. The MCO must handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR and CHIP newborns must either have admitting privileges at a Hospital that is part of the MCO's ’s Provider Network, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. The MCO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) days a week. The MCO is encouraged to enter into Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the office telephone is answered after-hours by an answering service that meets language requirements of the Major Population Groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's ’s telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' ’ care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's HMO’s PCP Network may include Providers from any of the following practice areas: General Practice; Family Practice; Internal Medicine; Pediatrics; Obstetrics/Gynecology Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8 Version 1.7 (OB/GYN); Advanced Practice Registered Nurses Certified Nurse Midwives (APRNsCNM) 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)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. Texas Government Code Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require ), Government Code, requires the MCO HMO to use advance practice registered nurses (APRNs) Pediatric and physician assistants (PAs) Family Advanced Practice Nurses 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 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 MCO's Provider Network, same PCP Network for CHIP Members and (3) inclusion as a PCP in any Provider Directory maintained by the MCOCHIP 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 birth through under age 2021. 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 HMO PCP responsibilities for such child Members in a specific age range from birth through group under age 2021, 2. the Provider has a history of practicing as a PCP for the specified age range, group as evidenced by the Provider's ’s primary care practice including an established patient population under age 20 and within the specified age range, and 3. the Provider has admitting privileges to a local Hospital 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, Contract and PCP duties must be within the scope of the specialist's ’s license. Any interested person may initiate the request through the MCO HMO for a specialist to serve as a PCP for a Member with disabilities, Special Health Care Needs, or Chronic or Complex Conditions. The MCO must HMO shall handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR STAR, CHIP, and CHIP newborns Perinatal Newborns must either have admitting privileges at a Hospital that is part of the MCO's HMO’s Provider Network, Network or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, Medicaid Hospital or make referral arrangements with a Provider who has admitting privileges to a Network Medicaid Hospital. The MCO HMO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) 7 days a week. The MCO HMO is encouraged to enter into include in its Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the office telephone is answered after-hours by an answering service that meets language requirements Responsible Office: HHSC Office of the Major Population Groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups servedGeneral Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.Section 8 Version 1.7

Primary Care Providers. The MCO's ’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 ’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 Conditions, or in a Nursing Facility may be a specialist physician who agrees to provide PCP services to the Member. The specialty specialist physician must agree to perform all PCP duties required in the Contract, and PCP duties must be within the scope of the specialist's ’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 Chronic or Complex Conditions. The MCO must handle such these requests in accordance with 28 T.A.C. Part 1, Tex. Admin. Code Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR and CHIP newborns must either have admitting privileges at a Hospital that is part of the MCO's Provider Network, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. The MCO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) days a week. The MCO is encouraged to enter into Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the office telephone is answered after-hours by an answering service that meets language requirements of the Major Population Groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's ’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 physicians serving Members residing in Nursing Facilities effective September 1, 2014;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 ’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 Conditions, or in a Nursing Facility may be a specialist physician who agrees to provide PCP services to the Member. The specialty specialist physician must agree to perform all PCP duties required in the Contract, and PCP duties must be within the scope of the specialist's ’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 Chronic or Complex Conditions. The MCO must handle such these requests in accordance with 28 T.A.C. Part 1, Tex. Admin. Code Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR and CHIP newborns must either have admitting privileges at a Hospital that is part of the MCO's Provider Network, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. The MCO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) days a week. The MCO is encouraged to enter into Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the office telephone is answered after-hours by an answering service that meets language requirements of the Major Population Groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.

Primary Care Providers. The MCO's 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); Advanced Practice Registered Nurses Certified Nurse Midwives (APRNsCNM) 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)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. Texas Government Code Section 533.005(a)(13) and Texas Health and Safety Code Section 62.1551 require ), Government Code, requires the MCO HMO to use advance practice registered nurses (APRNs) Pediatric and physician assistants (PAs) Family Advanced Practice Nurses 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 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 MCO's Provider Network, same PCP Network for CHIP Members and (3) inclusion as a PCP in any Provider Directory maintained by the MCOCHIP 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 birth through under age 2021. An internist or other Provider who provides primary care to adults and children may be a PCP for children if: 1. : 1 the Provider assumes all MCO HMO PCP responsibilities for such child Members in a specific age range from birth through group under age 20, 2. 21, 2 the Provider has a history of practicing as a PCP for the specified age range, group as evidenced by the Provider's ’s primary care practice including an established patient population under age 20 and within the specified age range, and 3. and 3 the Provider has admitting privileges to a local Hospital 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, Contract and PCP duties must be within the scope of the specialist's ’s license. Any interested person may initiate the request through the MCO HMO for a specialist to serve as a PCP for a Member with disabilities, Special Health Care Needs, or Chronic or Complex Conditions. The MCO must HMO shall handle such requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter J. PCPs who provide Covered Services for STAR STAR, CHIP, and CHIP newborns Perinatal Newborns must either have admitting privileges at a Hospital that is part of the MCO's HMO’s Provider Network, Network or make referral arrangements with a Provider who has admitting privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting privileges at a Network Hospital, Medicaid Hospital or make referral arrangements with a Provider who has admitting privileges to a Network Medicaid Hospital. The MCO HMO must require, through contract provisions, that PCPs are accessible to Members 24 hours a day, seven (7) 7 days a week. The MCO HMO is encouraged to enter into include in its Network Provider agreements with sites that offer primary care services during evening and weekend hours. The following are acceptable and unacceptable telephone arrangements for contacting PCPs after their normal business hours. 1. the Acceptable after-hours coverage: 1 The office telephone is answered after-hours by an answering service that service, which meets language requirements of the Major Population Groups and that which can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes; 2. the office telephone is answered after normal business hours by a recording in the language of each of the Major Population Groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider's telephone. Another recording is not acceptable; and 3. the office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes. 1. the office telephone is only answered during office hours; 2. the office telephone is answered after-hours by a recording that tells patients to leave a message; 3. the office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and 4. returning after-hours calls outside of 30 minutes. The CHIP MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the AAP recommendations. Medicaid MCOs must require PCPs, through contract provisions, to provide children birth through age 20 with preventive services in accordance with the Texas Health Steps periodicity schedule. The MCO must require PCPs, through contract provisions, to provide adults with preventive services in accordance with the U.S. Preventive Services Task Force requirements. The MCO must make best efforts to ensure that PCPs follow these periodicity requirements for children and adult Members. Best efforts must include, but not be limited to, Provider education, Provider profiling, monitoring, and feedback activities. The MCO must require PCPs, through contract provisions, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members' care with specialty care providers after referral. The MCO must make best efforts to ensure that PCPs assess Member needs for referrals and make such referrals. Best efforts must include, but not be limited to, Provider education activities and review of Provider referral patterns.