Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees
7/25/2024

12VAC5-408-270. Travel and appointment waiting times.

A. An MCHIP shall set reasonable and adequate standards for the number and geographic distribution of primary care, specialty care, and institutional service sites. Such standards shall address acceptable average travel times or distances to the nearest primary care delivery site, nearest specialty care site, or nearest institutional service site for covered persons in the service area. The standards must be realistic for the community served, the delivery system utilized by the MCHIP, and clinical safety.

Institutional service sites include acute care hospitals, surgical facilities including tertiary care or other specialty hospitals, licensed acute care hospitals and outpatient surgical hospitals, psychiatric inpatient facilities and other sites as determined appropriate by the department.

B. An MCHIP licensee must set reasonable and adequate standards for access to medical care, including quantifiable and measurable standards for preventive care appointments, routine primary care appointments, urgent care, emergency care, and after-hours care. The standards must be realistic for the community served, the delivery system utilized by the MCHIP, and clinical safety.

C. An MCHIP shall, at least annually, collect and analyze data to measure its performance against the standards developed under subsections A and B of this section. The analysis shall be used by the MCHIP to identify opportunities for improvement and undertake interventions to improve performance. An MCHIP shall subsequently measure the effectiveness of such interventions in improving performance against standards.

D. Routine appointments for nonemergency or nonurgent care shall be available within two weeks of the covered person's request. The department may waive this requirement if the MCHIP licensee can successfully demonstrate that the two-week availability requirement is not feasible.

E. Preventive care appointments, including routine physical examinations, shall be available with 60 days of the covered person's request. The department may waive this requirement if the MCHIP licensee can successfully demonstrate that the 60-day availability requirement is not feasible.

F. Consultations for specialty services shall be at least as required in § 38.2-3407.11:1 of the Code of Virginia.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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