Section 29-5606. SERVICE DELIVERY AND QUALITY ASSURANCE REQUIREMENTS

 

5606.1The managed care provider shall provide each enrolled child with high quality health care at locations that ensure reasonable availability and accessibility.

 

5606.2The managed care provider shall provide, either directly or by referral, each service in the Medicaid managed care benefits package, including patient management, referrals and approvals.

 

5606.3The managed care provider shall ensure that urgent and emergency medical care are available to enrolled children on a twenty-four (24) hour, seven (7) day a week basis, either through the provider or through other appropriate facilities.

 

5606.4The managed care provider shall conduct an orientation program to inform enrolled children and their families of available services and facilities.

 

5606.5The managed care provider shall allow each enrolled child, to the maximum extent feasible, the freedom to choose from among its participating providers of primary health care.

 

5606.6The managed care provider shall notify the Department in writing of the primary health care provider to whom the child is assigned by the end of the first month of enrollment, and within thirty (30) days after a reassignment.

 

5606.7The managed care provider shall provide health education programs for enrolled children, in languages understood by the population being served. The education programs shall include, at a minimum, information regarding the following:

 

(a)The importance and availability of preventive care;

 

(b)The importance and availability of childhood immunizations;

 

(c)The importance of, right to, and procedure of scheduling the Early Periodic Screening, Diagnosis and Treatment (EPSDT) screens for children covered by Medicaid;

 

(d)The importance and availability of reproductive health services; and

 

(e)Preventive and treatment measures for drug abuse and alcoholism.

 

5606.8The managed care provider shall have a system for follow-up of patient care for enrolled children, including an appointment follow-up system for children who do not appear for appointments.

 

5606.9The managed care provider shall maintain a current, unified service delivery record on each enrolled child.

 

5606.10The managed care provider shall establish and maintain a quality assurance program to review the quality, appropriateness and timeliness of the services provided. The quality assurance program shall be approved by the Department in accordance with the requirements of §5606.11.

 

5606.11The managed care provider’s quality assurance program shall:

 

(a)Be consistent with federal Medicaid utilization review and control regulations;

 

(b)Provide for review, by appropriate health care professionals, of the process followed in providing health services; and

 

(c)Provide for systematic data collection on performance utilization and treatment outcomes.

 

5606.12The managed care provider, to the maximum extent possible, shall adhere to the following access standards for enrolled children:

 

(a)Enrolled children shall have access to primary care sites and hospitals within thirty (30) minutes or thirty (30) miles of their residence. Children shall have access to specialty care detailed in HSCSN’s evidence of coverage within thirty (30) minutes or thirty (30) miles of their residence. The Department may make exceptions for an enrolled child who requests to receive services from a specialty provider with whom the child has an established relationship but where the travel time/distance is greater than thirty (30) minutes or thirty (30) miles;

 

(b)Appointments must be available for enrolled children in accordance with the normal practice standards and hours of operation. Maximum expected waiting times for appointments shall be as follows:

 

(1)Emergency care must be provided as the situation dictates. In general, emergency care must be provided in accordance to the timeframe dictated by the nature of the emergency, at the nearest available facility, twenty-four (24) hours a day, seven (7) days a week;

 

(2)Triage and appropriate treatment for urgent care shall be provided the same or next day; and

 

(3)Appointments for non-urgent care and routine primary care shall be provided within three (3) weeks of client request;

 

(c)Enrollees with appointments shall not routinely be made to wait in the office longer than one (1) hour; and

 

(d)Referral appointments to specialists shall not exceed thirty (30) days for routine care or forty-eight (48) hours for urgent care. All emergency care must be provided on an immediate basis, at the nearest facility available, regardless of contracting arrangements.

 

5606.13The managed care provider shall obtain accreditation through an external review by an independent quality accreditation organization such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the National Committee for Quality Assurance (NCQA).

 

5606.14This accreditation process shall begin within twelve (12) months of execution of a Medicaid managed care provider agreement. Provisional accreditation must be received by the end of the third year of participation in the program.

 

source

Final Rulemaking published at 43 DCR 4833, 4842 (September 6, 1996).