Kaiser Family Foundation Survey on State Medicaid Managed Care ...

State Primary Care Obstetric Care Specialty Care Hospital Care Dental CareMN Access within 30 minutes and 30 miles , orstate's accepted community standard,Appointment wait times: Not to exceed fortyfive(45) days from the date of an Enrollee’srequest for routine and preventive care andtwenty-four (24) hours for Urgent Care.See Primary Care. Access within 60 minutes or 60 miles or thestate's generally accepted community standard.Appointments for a specialist are to be made inaccordance with the time frame appropriate forthe needs of the Enrollee, or the GenerallyAccepted Community Standards.Transport time not to exceed 30 minutes orthe state's generally accepted communitystandard.Within 60 minutes or 60 miles or thestate's generally accepted communitystandard. Appointment wait times: Notto exceed sixty (60) days for regularappointments and forty-eight (48) hoursfor Urgent Care. For the purposes of thissection, regular appointments for dentalcare means preventive care and/orinitial appointments for restorativevisits.MOMSAll Categories: Must comply with state DOI travel distance standards in 20 CSR 400-7.095. For providers not addressed under 20 CSR 400-7.095, MCO shall ensure members have access to those providers within 30 milesAll unless categories: the MCO 60 can miles demonstrate or 60 minutes that for there rural is no and licensed 30 miles provider or 30 minutes that for area, urban in which areas. case the MCO shall ensure members have access to those providers within 60 miles. For those providers addressed under 20 CSR 400-NE 2 PCPs within 30 miles of residence. 1 high-volume specialist within 60 miles ofNJ 1 FTE PCP per 2000 enrollees, and 1 FTE PCP Same as Specialty Care. residence. Access to designated specialists within 45 milesper 1000 DDD enrollees, minimum of 2 peror one hour driving time, whichever is less, of 90county.percent of members within each county.1 acute care hospital within 30 miles ofresidence. Minimum of 1 contracted hospital percounty.NA -- Dental carved out.1 FTE primary care dentist per 2000enrollees.NM Minimum one primary care provider per 1500members/max of 1500 members per PCP.Also: (a) 90 percent of urban residents shalltravel no farther than 30 miles; (b) 90 percentof rural residents shall travel no farther than45 miles; and (c) 90 percent of frontierresidents shall travel no farther than 60 miles.And: For routine asymptomatic appointments:w/in 30 days. For routine symptomaticappointments: w/in 14 days. Urgent careappointments: w/in 24 hours.NV At least one full-time equivalent (FTE) PCP,considering all lines of business for thatprovider, per 1,500 enrollees per service area.If PCP practices in conjunction with a healthcare professional, ratio increased to one FTEPCP per 1,800 recipients. Per geographicservice area, at least 50% of all Network PCPsmust contractually agree to accept eligiblerecipients and at least 50% must accepteligible recipients at all times. If the MCOcontracts with an FQHC and/or the Univ. ofNevada Medical School, physicians from thesetwo orgs can be counted to meet the 50%participation and acceptance requirements.PCP Appointments: Same-day, medicallynecessary, PCPs are available; Urgent care PCPappointments available within two calendardays; Routine care PCP appointments arewithin two weeks. Two week standard notapplicable to regularly scheduled visits tomonitor a chronic medical condition ifschedule calls for less frequent visits.State guidelines. For non-urgent behavioral health care, therequest-to-appointment time shall be no morethan 14 days, unless the member requests alater time. Behavioral health care outpatientappointments for urgent conditions shall beavailable within 24 hours. For specialtyoutpatient referral and consultationappointments, excluding behavioral health(addressed above) the request-to-appointmenttime shall generally be consistent with theclinical urgency, but no more than 21 days.Prenatal Care Appointments: Initialprenatal care appointments shall beprovided for enrolled pregnantrecipients as follows: First trimesterwithin seven (7) calendar days of thefirst request; Second trimester withinseven (7) calendar days of the firstrequest; Third trimester within three(3) calendar days of the first request;and High-risk pregnancies within three(3) calendar days of identification ofhigh risk by the Vendor or maternitycare provider, or immediately if anemergency exists.Must provide access to all types of physicianspecialists for PCP referrals, and must employ orcontract with specialists, or arrange for accessto out of network specialty care in sufficientnumbers to ensure specialty services areavailable in a timely manner. Minimum ratio fornon-PCP specialists is one specialist per one1,500 recipients per service area. Ratios may beadjusted by DHCFP for under-served areas.Specialist Appointments. For specialty referralsto physicians, therapists, behavioral healthservices, vision services, and other diagnosticand treatment health care providers, the MCOmust provide: Same day, medically necessaryappointments within 24 hours of referral;Urgent care appointments within three calendardays of referral; and, Routine appointmentswithin 30 calendar days of referral.State guidelines. For routine asymptomatic memberinitiateddental appointments, therequest to appointment time shall beconsistent with community norms fordental appointments. For routine,symptomatic, member-initiated,outpatient appointments for non-urgentdental care, the request-toappointmenttime shall be no more than14 days. Dental outpatientappointments for urgent conditionsshall be available within 24 hours.Must provide DHCFP with a quarterly reporton the adequacy of contracted hospitals tothe assigned recipient caseload. The reportshall document the number and types ofspecialties covered by contracted hospitals.Reports must be submitted within 45business days after close of the quarter towhich they apply.Dental Appointments: Dental care shallbe provided immediately for dentalemergencies, urgent care or referralappointments within three calendardays and routine appointments withdentists and dental specialists shall beprovided within 30 calendar days orsooner if possible.66 00