Part IV. Coordination and Continuity of Care
12VAC5-408-250. Continuity of care.
A. The MCHIP licensee shall provide, arrange, pay for, or reimburse the basic health care services it provides in such a way that:
1. Covered persons' individual needs are assessed on an ongoing basis through their physician or staff and matched with the appropriate level of medical, psychological, or medical social services care. The MCHIP licensee shall monitor the continuity and coordination of care a covered person receives with other facets of care;
2. Covered persons' transition through the system of care are facilitated by the MCHIP licensee and its components;
3. The MCHIP licensee does not impede covered persons' involvement in determining care and treatment;
4. Information necessary to support the provision of care from one plan component to another is provided in a timely manner to covered persons and providers to support the continuity of the covered person's care; and
5. The MCHIP licensee advises its physicians of their responsibility to share specific information with covered persons concerning their illness, condition or treatment, in order for the covered person to follow his plan of care and receive follow-up care when needed.
B. The MCHIP licensee shall assist with denial of care issues by providing adequate information for covered person and provider decisions regarding ongoing care, or if appropriate, discharge.
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.
12VAC5-408-260. Network adequacy.
A. The MCHIP licensee shall provide a sufficient number and mix of services, specialists, and practice sites to meet covered persons' health care needs, including providers serving high risk populations or those specializing in the treatment of costly conditions, and its contractual obligations with reasonable promptness.
B. The MCHIP licensee shall ensure covered persons telephone access 24 hours a day, 7 days a week, to responsible and knowledgeable health care practitioners capable of assessing the covered persons' conditions and, as necessary, providing for appropriate services.
C. The MCHIP licensee shall incorporate strategies into its access procedures to facilitate utilization of the licensee's health care services by covered persons with physical, mental, language or cultural barriers.
D. If the MCHIP licensee does not have a health care provider within its network capable of providing care to covered persons, the licensee shall cover such care out of network. The covered person shall not be responsible for any additional costs incurred by the MCHIP as a result of this referral, consistent with the evidence of coverage, other than any applicable copayment, coinsurance or deductible.
E. The MCHIP licensee shall make provisions for affected covered persons to be notified about the termination of a provider as soon as it becomes aware of the termination. The MCHIP shall inform the affected covered persons of other participating providers available to assume their care and facilitate the covered persons' transition from a terminating provider to another provider so that the covered person's continuity of care is not interrupted. Covered persons undergoing an active course of treatment shall have continued access to care during the transition period.
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.
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.
12VAC5-408-280. Urgent care and emergency services.
A. The MCHIP licensee shall require that participating providers allow its covered persons, on a 24-hour basis, (i) access to medical care or (ii) access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a covered person for prompt medical care in cases where there is a need for urgent care or emergency services.
B. The MCHIP licensee shall provide clear and understandable explanation to covered persons and providers of:
1. What constitutes emergency and urgent care;
2. The process for accessing emergency and urgent care;
3. The responsibility of the covered person for payment for nonemergency services rendered in a hospital emergency facility; and
4. Coverage for out-of-network emergency medical care when a covered person cannot reasonably access network services.
C. The MCHIP licensee shall require its providers to clearly notify covered persons of provisions for urgent care or emergency services when the physician is not available after hours.
D. The MCHIP licensee shall recognize primary care practitioners' authority to facilitate and authorize emergency services for covered persons.
E. Coverage of costs for emergency services shall be consistent with the evidence of coverage and shall not interfere with covered person access to care.
F. Covered persons shall be allowed immediate access to emergency services and access within no more than 24 hours for urgent care. Urgent care access may be provided sooner with appropriate authorization.
G. The MCHIP licensee shall monitor usage of urgent care and emergency service to determine if the services are understood and appropriately used by covered persons and providers.
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.
12VAC5-408-290. Health promotion.
A. Annually, the MCHIP licensee shall develop and implement at least one health guideline for the prevention and early detection of illness and disease. Each written guideline shall:
1. Be available to covered persons upon request;
2. Describe the prevention or early detection intervention and the recommended frequency and condition under which the intervention is required; and
3. Document the scientific basis or authority upon which the guideline is based.
Guidelines may be specific to a defined population segment.
B. The MCHIP licensee shall distribute any preventive health guideline it develops and any updates to its providers as soon as practicable after development of the guideline.
C. The MCHIP shall regularly communicate with its covered persons to encourage the use of preventive health services.
D. At least annually, the MCHIP licensee shall measure covered person and provider compliance with the current preventive care guidelines. The MCHIP licensee may measure compliance by population segment if the guideline is specific to a population segment.
E. Providers who have appropriate knowledge shall be consulted in the adoption of the preventive health guidelines.
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.