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Access and Availability

Procedure Name:   Access and Availability Standards Policy/Procedure Number: OP5000  
Policy Manual Section:   Provider Network Management Related Policies/Procedures:
 
Issuing Department:   Medicare Operations/Provider Network Management
Approving Authority:   Vice President, Provider Network Development and Business Intelligence
Original Procedure Date:   January 1, 2013
Revision Date(s):  
 
Review Date(s):
(No Revisions)  
 
Replaces Procedure Number: 5000pr and PNM05pr


I. Procedure Purpose/Statement of Intent/Background

  • "HealthPlus" shall refer to HealthPlus of Michigan, Inc. and its affiliated entity, HealthPlus Insurance Company, unless otherwise stated.
  • "MedicarePlus" shall refer to the HealthPlus Medicare Advantage Prescription Drug branded products, individual or employer group, which it operates per annual contracts with the Centers for Medicare and Medicaid Services.
  • The policy shall pertain to the Commercial, Medicaid and Medicare product lines and their respective products e.g., HMO, POS, PPO, and Medicare Part D.
  • To assure that the organization complies with all applicable state and federal laws and regulations, including, but not limited to, those pertaining to the Medicaid, Medicare and Medicare Part D programs.
  • To provide direction and processes in regard to the implementation of Centers for Medicare and Medicaid Services (CMS) standards for provider access and availability.
  • Chapter 4, Benefit and Beneficiary Protections, of the Medicare Managed Care Manual (Section 110)[1] specifies that a Medicare Advantage Organization (MAO) ensure that beneficiaries have access to providers to receive Medicare-covered services. To do this MAOs maintain and monitor a network of appropriate providers, supported by written arrangements, in a geographic and specialty mix sufficient to secure available and accessible services. Included with the accessible/available service standards are other requirements specified by CMS. The MAO must also arrange for specialty care outside the plan provider network when network providers are unavailable or in adequate to meet the member's medical needs.
II. Definitions
Term   Definition  
Centers for Medicare and Medicaid Services (CMS)   The federal agency that runs the Medicare program and oversees Medicare Advantage and Part D plans. In addition, CMS works with the States to run the Medicaid program. CMS aims to ensure that the beneficiaries in these programs are able to get high quality health care.
NCQA   National Committee for Quality Assurance-accrediting agency for health plans.
Employer group waiver plan (EGWP)   A type of employer group plan where membership is restricted solely to employer or union sponsored group plan members. There are two basic categories of EGWPs: (1) "800 series" EGWPs - plans offered by Prescription Drug Plans (PDP), Medicare Advantage Organizations (MAO), or Part D Cost Plan Sponsors to employer and union group sponsors (these plans are known as "800 series" plans because of the way they are enumerated in CMS systems); and (2) Direct Contract EGWPs - employers or unions that directly contract with CMS to themselves become a PDP or Medicare Advantage (MA) plan for their members.
Medicare Advantage Organization (MAO)   A public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements.
Medicare Advantage (MA) plan   Health benefits coverage offered under a policy or contract by an MA organization that includes a specific set of health benefits offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the service area (or segment of the service area) of the MA plan.
Practitioner   A professional who provides health care services. Practitioners are usually licensed as required by law.
Provider   An institution or organization that provides services for health plan members. A provider is is licensed or certified by the State to engage in that activity in that State if such licensure or certification is required by State law or regulation.
Provider network   The providers with which a MA organization contracts or makes arrangements to furnish covered health care services to Medicare enrollees under an MA coordinated care or private fee for service (PFFS) plan that has a contracted network under §422.114(c)[2].
Primary Care Practitioners (PCP)   A primary care provider or physician (PCP) is a physician/medical doctor who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. A PCP must be licensed by the State and meet MAO credentialing requirements to be part of an MAO's provider network.
High Volume Specialty Practitioners   Physicians in a specialty with an annual HealthPlus referral rate of greater than 45 referrals per thousand, plus Obstetrics / Gynecology physicians.
Behavioral Health Practitioners   Psychiatrists, PhD-level Psychologists and Master-Prepared Therapists

III. Policy Statement
  • HealthPlus shall follow rules, regulations, and, if applicable, the HealthPlus Bylaws pertaining to this policy.
  • This policy is written to assure compliance with CMS and NCQA requirements related to provider access and availability.
  • HealthPlus staff shall establish procedures for the administration of this policy.
IV. Procedure Statement
  • The Issuing Department(s) and all applicable staff involved in the implementation of this procedure shall follow the rules and regulations directed by CMS and NCQA and directions set forth in the supporting policy.[3]
  • This procedure explains how HealthPlus determines provider access and availability through following CMS and NCQA access standards, and to assure consistency and compliance with CMS rules and regulations.
  • HealthPlus staff shall follow the steps outlined in this procedure for the administration of provider access and availability as directed by CMS in Chapter 4 of the Medicare Managed Care Manual1, as well as in 42 CFR 422.1122.
  • HealthPlus follows CMS rules and regulations regarding ensuring that HealthPlus members have access to and availability for providers within its identified network.
  • This procedure explains how HealthPlus complies with CMS access standards, and applies to individual and employer group waiver plans. Access standards do not necessarily apply for EGWP/800 Series plans, as CMS consider this a matter between MA plan and employer sponsor. However, CMS reserves the right to review EGWP provider networks at its discretion.
  • HealthPlus defines which practitioners and providers a Medicare Advantage member should seek for covered services and when services can be obtained from more than one type of provider/practitioner.[4]
  • HealthPlus maintains a network of practitioners and providers for members that includes but is not limited to, primary care, high volume specialty and behavioral health practitioners, and hospitals, behavioral health providers, skilled nursing facilities, home health agencies, ambulatory clinics, radiology centers, and rehabilitation centers.
V. Procedure
  • Primary Care Appointment Accessibility Standards
    Type of Visit   Accessibility Standard   Performance Goal  
    Preventive health office visit (e.g. well child visit, complete physical, preventive care) Within 30 calendar days 90% of PCPs meet standard
    Non-symptomatic office visit (e.g. follow-up appointment, blood pressure check, suture removal) Within 30 calendar days 90% of PCPs meet standard
    Routine symptomatic, non-urgent visit (e.g. sore throat, cold, headache, low back pain) Within 4 calendar days 90% of PCPs meet standard
    Urgent care visit (e.g. high fever, uncontrolled diarrhea, uncontrolled vomiting) Same day 90% of PCPs meet standard
    After-hours services (e.g. when the practitioner office is closed) Practitioner (or designee) accessible by phone 24 hours / day, 365 days / year 100% of PCPs meet standard
    HealthPlus recognizes that, while practitioners strive to comply with the standard, it may not always be possible. For some appointment categories, HealthPlus has established a performance goal that 90% of practitioners meet the standard; failure to meet the 90% threshold results in the need to pursue an overall improvement effort.  

    HealthPlus strives to achieve less than 15 minutes of waiting time between the scheduled time of the appointment and the time the member is taken to the exam room.  
  • Behavioral Health Care Appointment Accessibility Standards
    Type of Visit   Accessibility Standard   Performance Goal  
    Non-urgent, routine office visit (e.g. depression) Within 10 working days 90% of behavioral health practitioners meet standard
    Urgent care visit (e.g. individuals "too sick to work") Within 48 hours 90% of behavioral health practitioners meet standard
    Non-life threatening emergency Within 6 hours 100% of behavioral health practitioners meet standard
    HealthPlus recognizes that, while practitioners strive to comply with the standard, it may not always be possible. For some appointment categories, HealthPlus has established a performance goal that 90% of practitioners meet the standard; failure to meet the 90% threshold results in the need to pursue an overall improvement effort.  
  • Primary Care Geographic Availability Standards HealthPlus strives to provide members with a choice of primary care physicians within a reasonable distance from home. Because it is not always possible to offer choice, HealthPlus has established a 90% goal for availability of two primary care physicians (Internal Medicine, Pediatrics or Family Practice) and a 100% goal for the availability of one primary care physician (Internal Medicine, Pediatrics or Family Practice).
    • 100% of members have access to 1 primary care physician (Internal Medicine, Pediatrics or Family Practice) within a 30-minute radius from home.
     
  • High Volume Specialty Geographic Availability Standards
    • 90% of members have access to 1 practitioner from each identified high-volume specialty within a 30-minute radius from home.
     
  • Behavioral Health Practitioners Geographic Availability Standards
    • 90% of members have access to 1 psychiatrist within a 30-minute radius from home
    • 90% of members have access to 1 PhD-level psychologist within a 30-minute radius from home
    • 90% of members have access to 1 master-prepared therapist within a 30-minute radius from home
    • 90% of members have access to 1 substance abuse practitioner within a 30-minute radius from home
     
  • Hospital Geographic Availability Standards
    • 90% of members have access to an inpatient care hospital within a 30-minute radius from home
     
  • Behavioral Health Facility (inpatient, residential, ambulatory) Geographic Availability Standard
    • 90% of members have access to a behavioral health facility (inpatient, residential or ambulatory) within a 30-minute radius from home
     
  • Skilled Nursing Facilities Geographic Availability Standard
    • 90% of members have access to a skilled nursing facility within a 30-minute radius from home
     
  • Home Health Agencies Geographic Availability Standard
    • 90% of members have access to a home health agency within a 30-minute radius from home
     
  • Ambulatory Clinics Geographic Availability Standard
    • 90% of members have access to an ambulatory clinic within a 30-minute radius from home
     
  • Radiology Centers Geographic Availability Standard
    • 90% of members have access to a radiology center within a 30-minute radius from home
     
  • Physical Medicine and Rehabilitation Facilities Geographic Availability Standard
    • 90% of members have access to a physical medicine or rehabilitation facility within a 30-minute radius from home
     
  • Primary Care Practitioner Number Standards
    • Family Practice - 1 practitioner: 750 members
    • Internal Medicine - 1 practitioner: 750 members
    • Pediatrics - 1 practitioner: 750 members
     
  • High Volume Specialty Practitioner Number Standards
    • 1 practitioner in each high-volume specialty: 10,000 members
     
  • Behavioral Health Practitioner Number Standards
    • 1 psychiatrist: 10,000 members
    • 1 PhD-level psychologist: 50,000 members
    • 1 master-prepared therapist: 5,000 members
     
  • Monitoring Methodology:

    On an annual basis, HealthPlus :

    • Generates specialist referral reports to determine which types of specialties are receiving >45 referrals per 1,000 members and qualify as "high volume".
    • Utilizes GeoAccess software to map the location of hospitals, primary care, high-volume specialties, behavioral health practitioners, behavioral health facilities, skilled nursing facilities, home health facilities, ambulatory clinics, radiology centers, physical medicine and rehabilitation facilities.
    • Generates reports of practitioner counts and compares to member counts to determine practitioner-to-member ratios for PCPs, each high volume specialty, and behavioral health practitioners.
    • Reviews the alternate means of transportation for MedicarePlus members in the counties in which HealthPlus holds contracts for MedicarePlus participating providers.
    • Reviews the appointment accessibility for a random sample of PCP offices during Provider Network Educator servicing visits to determine that accessibility standards are being met.
    • Reviews the appointment accessibility for a random sample of behavioral health practitioners and facilities through either telephonic means or during on-site visits to determine if accessibility standards are being met.
       
    • Evaluates member complaints about access and availability to identify any significant issues.
    • Completes after-hours telephone surveys to determine 24-hour PCP accessibility.
    • Fields the CAHPS member satisfaction survey to assess member experiences with provider access.
    • Prepares a report of access and availability monitoring activities and activities for improvement for presentation to the Quality Improvement Committee on an annual basis.

     

VI. Implementation
HealthPlus staff is responsible for establishing, publishing, and maintaining procedures and work rules to implement this procedure.

Attachments:  

Attachment Number   Description  
None
 

 

 

 

Source/Regulation  

[3] NCQA 2012 HP Standards and Guidelines. QI 4 & 5;
[4] NCQA 2012 Medicare Advantage Deeming Module, MA 13

Additional Resources: