Some of the MCPs have programs to defray these costs. For example, in recent years the Central California Alliance for Health (serving Santa Cruz, Monterey and Merced counties) had a grant program
that offered grant opportunities to increase provider capacity, including for equipment purchases.
– Excerpts of DHCS Contracts
ADDENDUM A: Two-Plan Boilerplate
– Exhibit A, Attachment 9, Section 4, Access Standards, and Section 16, Out-of-Network Providers
A. Appropriate Clinical Timeframes
Contractor shall ensure that Members are offered appointments for covered health care services within a time period appropriate for their condition.
B. Standards for Timely Appointments
Members must be offered appointments within the following timeframes:
- Urgent care appointment for services that do not require prior authorization
– within 48 hours of a request
- Urgent appointment for services that do require prior authorization
– within 96 hours of a request
- Non-urgent primary care appointments
– within ten business days of request
- Appointment with a specialist
– within 15 business days of request
C. Provider Shortage
Contractor shall arrange for a Member to receive timely care as necessary for their health condition if timely appointments within the time and distance standards required in Attachment 6, Provision 8 of this contract are not available. Contractor shall refer Members to, or assist Members in locating, available and accessible contracted providers in neighboring service areas for obtaining health care services in a timely manner appropriate for the Member's needs.
Section 16, Out of Network Providers
A. If Contractor's network is unable to provide necessary services covered under the Contract to a particular Member, Contractor must adequately and timely cover these services out of network for the Member, for as long as the entity is unable to provide them. Out-of-network providers must coordinate with the entity with respect to payment. Contractor must ensure that cost to the Member is not greater than it would be if the services were furnished within the network.
ADDENDUM B: Two Plan Boilerplate – Exhibit A, Attachment 6, Provider Network, Section 8, Time and Distance Standard
Contractor shall maintain a network of Primary Care Physicians which are located within 30 minutes or 10 miles of a Member's residence unless the Contractor has a DHCS-approved alternative time and distance standard.
ADDENDUM C: Two Plan Boilerplate – Exhibit A, Attachment 10, Scope of Services, Section 5, Services for Members Under 21 Years of Age
Contractor shall cover and ensure the provision of screening, preventive and Medically Necessary diagnostic and treatment services for Members under 21 years of age including Early and Periodic Screening, Diagnostic and Treatment (EPSDT) supplemental services.
Contractor shall ensure that appropriate diagnostic and treatment services are initiated as soon as possible but no later than 60 calendar days following either a preventive screening or other visit that identifies a need for follow-up.
A. Provision of IHAs for Members under Age 21
- For Members under the age of 18 months, Contractor shall ensure the provision of an IHA within 120 calendar days following the date of enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages two and younger whichever is less.
- For Members 18 months of age and older upon enrollment, Contractor is responsible to ensure an IHA is performed within 120 calendar days of enrollment.
- Contractor shall ensure that performance of the California Child Health and Disability Prevention (CHDP) program's age appropriate assessment due for each child at the time of enrollment is accomplished at the IHA. The initial assessment must include, or arrange for provision of, all immunizations necessary to ensure that the child is up-to-date for age, and an age appropriate IHEBA. See MMCD Policy Letter PL 13-001 for specific IHEBA requirements.
B. Children's Preventive Services
- Contractor shall provide preventive health visits for all Members under 21 years of age at times specified by the most recent AAP periodicity schedule. This schedule requires more frequent visits than does the periodicity schedule of the CHDP program. Contractor shall provide, as part of the periodic preventive visit, all age specific assessments and services required by the CHDP program and the age specific health education behavioral assessment as necessary.
- Where the AAP periodicity exam schedule is more frequent than the CHDP periodicity examination schedule, Contractor shall ensure that the AAP scheduled assessment includes all assessment components required by the CHDP for the lower age nearest to the current age of the child.
- Where a request is made for children's preventive services by the Member, the Member's parent(s) or guardian or through a referral from the local CHDP program, an appointment shall be made for the Member to be examined within two weeks of the request.
- At each non-emergency primary care encounter with Members under the age of 21 years, the Member (if an emancipated minor) or the parent(s) or guardian of the Member shall be advised of the children's preventive services due and available from Contractor, if the Member has not received children's preventive services in accordance with CHDP preventive standards for children of the Members' age. Documentation shall be entered in the Member's Medical Record which shall indicate the receipt of children's preventive services in accordance with the CHDP standards or proof of voluntary refusal of these services in the form of a signed statement by the Member (if an emancipated minor) or the parent(s) or guardian of the Member. If the responsible party refuses to sign this statement, the refusal shall be noted in the Member's Medical Record.
Contractor shall ensure that all children receive necessary immunizations at the time of any health care visit. Contractor shall cover and ensure the timely provision of vaccines in accordance with the most recent childhood immunization schedule and recommendations published by the Advisory Committee on Immunization Practices (ACIP). Documented attempts that demonstrate Contractor's unsuccessful efforts to provide the immunization shall be considered sufficient in meeting this requirement.
If immunizations cannot be given at the time of the visit, the Member must be instructed as to how to obtain necessary immunizations or a scheduled and documented appointment must be made. Appropriate documentation shall be entered in the Member's Medical Record that, indicates all attempts to provide immunization(s); instructions as to how to obtain necessary immunizations; the receipt of vaccines or proof of prior immunizations; or proof of voluntary refusal of vaccines in the form of a signed statement by the Member (if an emancipated minor) or the Parent(s) or guardian of the Member. If the responsible party refuses to sign this statement, the refusal shall be noted in the Member's Medical Record.
Upon Federal Food and Drug Administration (FDA) approval of any vaccine for childhood immunization purposes, Contractor shall develop policies and procedures for the provision and administration of the vaccine. Such policies and procedures shall be developed within thirty (30) calendar days of the vaccine's approval date. Contractor shall cover and ensure the provision of the vaccine from the date of its approval regardless of whether or not the vaccine has been incorporated into the Vaccines for Children (VFC) Program. Policies and procedures must be in accordance with any Medi-Cal fee-for-service guidelines issued prior to final ACIP recommendations.
Contractor shall provide information to all network providers regarding the VFC Program.
Exhibit A, Attachment 10 Scope of Services, 6 Services for Adults
C. Immunizations. Contractor is responsible for assuring that all adults are fully immunized. Contractor shall cover and ensure the timely provision of vaccines in accordance with the most current California Adult Immunization recommendations.
In addition, Contractor shall cover and ensure the provision of age and risk appropriate immunizations in accordance with the findings of the IHA, other preventive screenings and/or the presence of risk factors identified in the health education behavioral assessment.
Contractor shall document attempts to provide immunizations. If the Member refuses the immunization, proof of voluntary refusal of the immunization in the form of a signed statement by the Member or guardian of the Member shall be documented in the Member's Medical Record. If the responsible party refuses to sign this statement, the refusal shall be noted in the Member's Medical Record. Documented attempts that demonstrate Contractor's unsuccessful efforts to provide the immunization shall be considered evidence in meeting this requirement
ADDENDUM D: Two Plan Boilerplate – Exhibit A, Attachment 8, Provider Compensation Arrangements, Section 12, Immunizations; and Attachment 9, Section 9, Access to Services with Special Arrangements, E. Immunizations
Health plans shall reimburse local health departments for the administration fee for immunizations given to Members. However, the health plan is not required to reimburse the local health department for an immunization provided to a Member who was already up to date. The local health department shall provide immunization records when immunization services are billed to the health plan. The health plan shall not be obligated to reimburse providers other than local health departments unless they enter into an agreement with the Contractor.
Members may access local health department clinics for immunizations. Contractor shall, upon request, provide updated information on the status of Members' immunizations to the local health department clinic. The local health department clinic shall provide immunization records when immunization services are billed to the Contractor.
For requirements of Medi-Cal Managed Care health plans to contract with the local health department, see Addendum G.
ADDENDUM E: Two Plan Boilerplate – Exhibit A, Attachment 11, Case Management and Coordination of Care, Section 19, Immunization Registry Reporting
Contractor shall ensure that recipient-specific immunization information is periodically reported to an immunization registry(ies) established in the Contractor's Service Area(s) as part of the Statewide Immunization Information System. Reports shall be made following the Member initial health assessment and all other health care visits which result in an immunization being provided. Reporting shall be in accordance with all applicable State and Federal laws.
ADDENDUM F: Exhibit A, Attachment 10, Scope of Services, Section 7, Pregnant Women
A. Prenatal Care. Contractor shall cover and ensure the provision of all Medically Necessary services for pregnant women. Contractor shall ensure that the most current standards or guidelines of the American College of Obstetricians and Gynecologists (ACOG) are utilized to provide, at a minimum, quality perinatal services.
ADDENDUM G: Two Plan Boilerplate – Exhibit A, Attachment 12, Local Health Department Coordination
1. Subcontracts. Contractor shall negotiate in good faith and execute a Subcontract for public health services listed in A through D below with the local health department. The Subcontract shall specify: the scope and responsibilities of both parties in the provision of services to Members; billing and reimbursements; reporting responsibilities; and how services are to be coordinated between the local health department and the Contractor, including exchange of medical information as necessary. The Subcontract shall meet the requirements contained in Exhibit A, Attachment 6, provision 12, regarding Subcontracts.
- Family Planning Services: as specified in Exhibit A, Attachment 8, provision 9.
- Sexually Transmitted Disease (STD) services …
- HIV Testing and Counseling as specified in Exhibit A, Attachment 8, provision 11.
- Immunizations: as specified in Exhibit A, Attachment 8, provision 12.