Primary Care Network List (PCNL) Guidelines: REQUIREMENTS FOR PCNLs. Instructions for Managed Care Organizations

Transcription

1 Primary Care Network List (PCNL) Guidelines: REQUIREMENTS FOR PCNLs Instructions for Managed Care Organizations Managed care contracts require MCOs to provide a standardized Primary Care Network List (PCNL) for distribution to PMAP, MinnesotaCare, MSC+, MSHO, and SNBC potential enrollees during the managed care enrollment process. This information details the process, format and requirements for the PCNL, per the Families and Children, MSHO, MSC+ and SNBC model contracts. These requirements can also be accessed through the Managed Care website at: Model PCNL MCOs are required to use the most recent version of the standardized Model PCNL. See Attachment 3. The legend for the Model PCNL is: o Text show as <text> is always printed. This text represents variable data. o Text shown as [text] is optionally printed, depending on the italicized notes. o Language in blue italics is instructions to the MCO. It is to be deleted in the MCO s version. Permissible alterations include modifications as allowed in model instructions and as approved by DHS. The document can be formatted as desired (font style, margins), as long as contractual requirements are met. MCOs should alphabetize the items in the Services Section of the PCNL, as appropriate for the terms they use. Contract Specifications Physical specifications for PCNLs are: o Font of 10 point or greater. o A Flesch scale analysis readability score at 7th grade level. o Paper size: 8½ x 11 or 17 x 11. The 17 x 11 document must fold to an 8½ x 11 size. o Paper weight: Paper Weight Range Minimum Maximum Text Weight 19# Bond 20# Bond Cover Weight 19# Bond 20# bond, or Uncoated offset paper, or Glossy paper MCO PCNL Submission Process To allow sufficient time for the PCNL submission and approval process, follow the timeline listed in Attachment 1. Review and edit the draft PCNL prior to submission to DHS. This includes correcting grammar, spelling, and other typographical errors, and ensuring accuracy of data. Errors may cause delays in the approval process. Submit the following to the DHS Contract Manager: o The revised PCNL (in a format ready for printing). 1

2 o o o o A letter or spreadsheet detailing the revisions. Alternatively, the MCO can submit a version of the MCO s last PCNL that highlights the changes. Specify provider network additions, deletions and changes in restrictions to enrollees access to services (e.g., clinic is no longer accepting new patients, etc.). The name and contact information of the person at the MCO to whom questions can be directed. A Flesch Scale Analysis Readability Score at 7th grade level along with the first PCNL of the Contract Year, and as needed thereafter for narrative changes. A signed attestation that the clinic and narrative information contained in the PCNL is accurate as of the date of submission and that the final printed PCNL will meet the specified physical specifications listed on page 1 of the PCNL Guidelines. Notification in writing to the DHS Contract Manger if there are no changes for a required submission. o Submit revised PCNL drafts as necessary until final approval from DHS is obtained. Send a PDF copy of the final approved version of the PCNL to the DHS Contract Manager. Process for Distribution of Final Approved PCNL Determine the number of PCNLs to be printed and print accordingly. Follow the PCNL distribution timelines in Attachment 1. Deliver copies of each final printed program PCNL (PMAP, MinnesotaCare, MSC+, MSHO & SNBC) as indicated in Attachment 2. The MCO may provide the PCNL in an alternative format to the State and to local agencies within its service area according to contractual requirements. (Refer to contract.) Send one electronic copy of any non English PCNL to the Contract Manager and a signed attestation that the Non English version contains the same information as the English version. If the MCO translates the PCNL into other languages, the entire PCNL must be translated, except for the provider listing (data) area. Attachment 1: PCNL Timelines Attachment 2: PCNL Distribution Attachment 3: Model PCNL 2

3 ATTACHMENT 1 PCNL TIMELINES* Semi Annual PCNLs 2nd PCNL 2012 (Oct March 2013) 1st PCNL 2013 (April Sept. 2013) 2nd PCNL 2013 (Oct March 2014) 1st PCNL 2014 (April Sept. 2014) DRAFT PCNL DUE TO CONTRACT MANAGER PCNL APPROVAL TO THE MCO PCNL SUPPLY DELIVERY DATE ** ** ** ** ** ** *Specific PCNL timelines will be indicated in the Request for Proposals (RFP) for new service areas. ** This PCNL is for Open Enrollment. 3

4 ATTACHMENT 2 PCNL DISTRIBUTION Boxes must clearly identify the program, revision date, and region (if appropriate). ALL PCNLs Send two final printed copies of each program PCNL to the respective DHS Contract Manager. Via mail: Contract Manager Name Minnesota Department of Human Services P.O. Box St. Paul, MN PMAP and MSHO PCNLs MCOs send these directly to the counties. In addition, send 25 PMAP PCNLs to: Teressa Saybe 0838 DHS MCRE Operations 444 Lafayette Road St. Paul, MN MinnesotaCare PCNLs IOC ATTN: Phyllis Hahn (Contact your Contract Manager for the unpublished IOC address.) SNBC PCNLs It is strongly suggested that MCOs give courtesy copies to each of the counties in their SNBC service area. (10 copies per county for the following divisions: Social Services, Public Health and Managed Care/Financial Worker contacts). 4

5 ATTACHMENT 3 (cover) (MODEL) Primary Care Network Listing <Insert MCO Name> <Insert the names of the programs that are covered in this PCNL> <Insert contracted service area by county. Identify program specific (PMAP, MinnesotaCare, MSC+, MSHO and SNBC) counties.> <Insert name of MCO, address, Member/Customer Services phone numbers, website (if applicable) and hours of service. This information must be located in a prominent place on the front cover, inside front cover, or first page of the PCNL.> <If this PCNL includes MSHO and integrated SNBC, insert the most current federal contracting statement.> [Insert Material ID and/or approval date of the PCNL. This information can be included on the front and/or back cover of the PCNL.] <Insert the effective date of the PCNL. The date must be prominent but can be placed anywhere on the front cover. The format of the effective date should, at minimum, be Month and Year.> 1

6 (inside front cover) <Insert current language block, ADA statement, and American Indian Health Services statement. Note: MCOs may, in addition to placement inside the front cover, place the American Indian Health Services statement elsewhere in the PCNL.> <MCO Name> will enroll all eligible people who select or are assigned to <MCO Name> without regard to physical or mental condition, health status, need for health services, claims experience, medical history, genetic information, disability, marital status, age, sex, sexual orientation, national origin, race, color, religion, or political beliefs. <MCO Name> will not use any policy or practice that has the effect of such discrimination. Enrolling in this health plan does not guarantee you can see a particular provider on this list. If you want to make sure, you should call that provider to ask whether he or she is still part of this health plan. You should also ask if he or she is accepting new patients. This health plan may not cover all your health care costs. Read your contract or Evidence of Coverage carefully to find out what is covered. 2

7 <Insert Table of Contents> 3

8 Program Description[s] <Insert the applicable descriptions for this PCNL. MCO s may include additional applicable MCO specific information>: Prepaid Medical Assistance Program (PMAP): PMAP is a managed care program that covers health care for the following people who have Medical Assistance: Children under the age of 21 Parents and caretakers of a dependent child Pregnant women Certain low income adults without a dependent child [Our PMAP program is called <Insert name of MCO s PMAP product>.] MinnesotaCare: MinnesotaCare is a managed care program that covers health care for people who do not have access to affordable health care coverage. Some members may be required to pay a premium. [Our MinnesotaCare program is called <Insert name of MCO s MinnesotaCare product>. Minnesota Senior Care Plus (MSC+): MSC+ is a managed care program that covers health care and Elderly Waiver services for people who: are ages 65 and over and have Medical Assistance. [Our MSC+ program is called <Insert name of MCO s MSC+ product>.] If you are enrolled in MSC+, you may have another option available. Check with your county financial worker to see if you can enroll in the Minnesota Senior Health Options (MSHO) program. MSHO is a voluntary program. Minnesota Senior Health Options (MSHO): MSHO is a voluntary managed care program that covers health care and Elderly Waiver services for people who: are ages 65 and over, 4

9 have Medical Assistance, and have both Medicare Parts A and B. [Our MSHO program is called <Insert name of MCO s MSHO product>.] If you choose to leave MSHO, you will be enrolled in an MSC+ plan for your Medical Assistance services, if you are eligible to enroll. Special Needs BasicCare (SNBC): SNBC is a voluntary managed care program that covers health care for people with disabilities who: are ages 18 through 64, have Medical Assistance, and have either both Medicare Parts A and B or Medical Assistance only. [Our SNBC program is called <Insert name of MCO s SNBC product>.] <Insert the following if MCO also has an integrated SNBC product.> <Insert name of MCO s SNBC product> also integrates Medical Assistance and Medicare Parts A, B and D for people who choose this option.> > Important Information Clinics The clinic information printed in this listing was correct as of the <Insert actual date of printing or data extract (mm/yyyy or mm/dd/yyyy)>. You need to choose a primary clinic [and dental clinic] when you enroll. Your primary care clinic can provide most of the care services you need, and will help coordinate your care. Please confirm with <Member/Customer Services> that your clinic is still a provider with our health plan before signing up. <Explain the process for selecting a clinic/dental provider.> Cost Sharing You may be required to pay an amount toward some health care services. This is called cost sharing. Some examples of cost sharing are copays or deductibles for certain services. You are responsible to pay your cost sharing amount to your provider. Members will receive an Evidence of Coverage with more information about cost sharing. 5

10 Member Identification (ID) Cards and <[Member Packet, or Welcome Packet insert appropriate name of packet with new member materials that member will receive.]> Members will get a health plan Member Identification (ID) Card. This card must be shown whenever you get health care. <Explain how the member will receive their ID card and member packet.> Service Accessibility If you need special access to get services from a provider, you may ask for information about accessibility by <Insert applicable information.> Service Authorization Our approval is needed for some services to be covered. The approval must be obtained before you get certain services or before we pay for them. <MCO may add additional information about Service Authorization process.> Members will receive an Evidence of Coverage with more information about which services require authorization. Services <Insert care coordination information (below) for MSC+, MSHO, and SNBC. > <<Care Coordination> Add (for members of <MSC+, MSHO, or SNBC>>) if the PCNL includes programs for PMAP and MinnesotaCare members)> <Include a description of the MCO s care systems, care coordination or case management and any other distinguishing information that will assist the enrollee. If enrollees are limited to certain providers within a care system, the MCO must identify the providers available within that care system. You can get more information on <care coordination> services by <Insert applicable information>>. Chemical Dependency <Explain how to access CD services. For example: If you need chemical dependency services, call ABC Care, Inc. at ). > Chiropractic Care 6

11 [MCO may include specific information about how to access chiropractic services.] You can get [more] information on [how to access] chiropractic services by <Insert applicable information.> Dental <Explain how to access dental services. For example: You must select a dental clinic from the list inside or Please call ABC Dental at to find a dentist > Durable Medical Equipment (DME) [MCO may include specific information about how to access DME] You can get [more] information on [how to access] Durable Medical Equipment by <Insert applicable information>. <Insert Elderly Waiver information (below) for PCNLs that include MSC+ and MSHO> Elderly Waiver Home and Community Based Services <Insert for <MSC+ and MSHO members > if the PCNL also includes programs other than MSC+ and MSHO. > If you are aged 65 or over and need help to stay in your home, there is a program called Elderly Waiver (EW). EW offers more services than regular Medical Assistance. Services may include visits by a nurse, home care services, homemaker services, chore services, and more. Your <Care Coordinator> can arrange these services for you. If you would like more information, please <Insert applicable information>. Elderly Waiver Obligation <Insert for <MSC+ and MSHO members > if the PCNL also includes programs other than MSC+ and MSHO. > If you get EW services and your income is over the income limit, you may have to pay a monthly amount. This is called the EW waiver obligation. Your county will notify you of any EW waiver obligation when your eligibility is determined. <Insert Eye Care or Vision Care or both> <MCO may include specific information about how to access eye care services.> 7

12 You can get [more] information on [how to access] <insert eye care or vision care or both> services by <Insert applicable information.> [Health Education <MCOs may include plan specific health services not marketing information such as incentives. If the health service is associated with an incentive, MCOs may refer members to back page, if applicable.>] Home and Community Based Waiver Services for People with Disabilities <Add for SNBC members if the PCNL includes programs for members who are not in SNBC.> We do not cover Home and Community Based Services for People with Disabilities, but you may be eligible to get them through your county. Call your county to apply for these and other waiver services under the Community Alternatives for Disabled Individuals (CADI), Brain Injury (BI), Community Alternative Care (CAC) or Developmental Disability (DD) Waiver programs. These waiver programs offer more services than regular Medical Assistance. Services include extended home care, assisted living, supported employment and more. Home Care Home Care services include skilled nursing, rehabilitation therapies (for example speech, physical, respiratory, and occupational), home health aide, medical equipment and supplies, Personal Care Assistant (PCA) and Private Duty Nurse (PDN) services. <Include specific information about how to access home care services.> For SNBC only PCNLs or for PCNLs that include SNBC along with other programs, add this additional sentence: We do not cover PCA or PDN services for SNBC members, but you may be able to get them through your county. Call your county to apply for these services. Hospitals <Include a statement about how the member can access care. For example: Use the hospital associated with your primary care clinic. > You can get more information on hospital services by <insert applicable information.> 8

13 Interpreter Services Hearing and language interpreter services are available to help you get services. Oral interpretation can be given to you in your language. You may be able to get written information in your language. <Specify how enrollees can access interpretation services. For example: Call Customer/Member Services or XYZ Interpreter Agency to get interpreter services. > Mental Health <Explain how to access MH services. For example: If you need mental health services, call ABC Care, Inc. at ). > <Insert nursing home information (below) for MSC+, MSHO, and SNBC. > Nursing Home [and Skilled Nursing Home] Care <Add (for members of MSC+, MSHO, or SNBC) if the PCNL includes programs for PMAP and MinnesotaCare members.)> < If the PCNL includes programs other than MSC+ and MSHO, begin sentence with For MSC+ and MSHO members,> <We> will cover a total of 180 days of nursing home care. If you need nursing home care beyond the 180 days, the Minnesota Department of Human Services (DHS) will pay for your care. This applies unless you were already in the nursing home when you enroll in our plan. < If the PCNL includes programs other than SNBC, begin sentence with For SNBC members, > We will cover 100 days of nursing home care. If you need nursing home care beyond the 100 days, the Minnesota Department of Human Services (DHS) will pay for your care. This applies unless you were already in the nursing home when you enrolled in the plan. You can get more information on nursing home services by <Insert applicable information.> Open Access Services You may choose to receive care from any <[physician/health care provider]>, clinic, hospital, pharmacy, or family planning agency to get some services even if it is not in our network. The services are: family planning, diagnosis of infertility, testing and 9

14 treatment of sexually transmitted diseases, and testing for AIDS or HIV related conditions. You can get more information on open access services by <Insert applicable information.> Pharmacy Members must use our network of pharmacies for drugs covered by our health plan. [MCO s may add additional information about obtaining pharmacy services.] Remember to have your <plan sponsor> identification card and your Minnesota Health Care Programs card available when you call to refill your prescription. Also, remember to show your identification card when picking up your prescriptions. < Insert the following for PMAP, MSC+ and SNBC (Medicaid only): People with Medicare must enroll in a Medicare Prescription Drug Program (Medicare Part D) to get most of their drugs. OR, if this PCNL also includes MSHO, insert If you are enrolled in PMAP, MSC+, or SNBC (Medicaid only) and have Medicare, you must enroll in a Medicare Prescription Drug Program (Medicare Part D) to get most of your drugs. > You can get more information on pharmacy services by <Insert applicable information.> Specialty Care <Include information about whether there are referral or authorization requirements.> You can get additional information on how to access specialty care by <Insert applicable information.> <Insert the following information regarding spenddowns for PCNLs that include SNBC.> Spenddowns SNBC members who have an income over a certain limit may have to pay an amount each month called a institutional or medical spenddown. SNBC members with an institutional spenddown continue to pay their spenddown to the facility in which they 10

15 live. Members who do not pay their spenddowns as required will be disenrolled from SNBC. People with a medical spenddown are not eligible to enroll in SNBC. Transition of Care When you join <MCO Name> we will help you continue to get necessary health care services that were authorized before you enrolled with us. Some examples of these services are: orthodontia, mental health, chemical dependency, at risk pregnancy, or prescriptions. Transportation <If the PCNL includes MinnesotaCare, add (as applicable) for members of MSHO, MSC+, PMAP, SNBC > We are not required to provide transportation to your primary care clinic if it is over 30 miles from your home if a primary care clinic is available within 30 miles. Exceptions to rides more than 30 miles from your home can be made in certain circumstances. If you need a ride and a closer clinic in our network is not available, please call our <Insert applicable information.> [MCOs may include additional information about how the enrollee can access transportation benefits.] Urgent/After Hours/Emergency Care <Explain how to access urgent and after hours care. Do not list the sites. Some examples may include the following: Please call your doctor s office for instructions on how to get urgent care or after hours care. or Call Nurse line at (toll free). > In an emergency that needs treatment right away, either call 911 or go to the nearest emergency room. [Other Things That You Should Know < MCO may insert health plan specific information but must restrict this section to informational only (i.e., necessary for the member to make an informed decision) not marketing.>] 11

16 <Listings> You can get updated information about listed providers by <Insert applicable information>. You can also get information on specialists that are not listed in this booklet by <Insert applicable information>. < Instructions: Listings should be statewide, rather than grouped by region. List clinics by county of location, or as approved by the DHS Contract Manager. Clinics in bordering counties may be included in the PCNL. Primary Care Clinics must include: o Clinic Name o Addresses o Telephone numbers o Clinic identification numbers (or the care system identification numbers if that is the selection enrollees are to make). Clinic numbers may be up to seven alpha and/or numeric characters long. Do not use hyphens or dashes in identification numbers. o Information about restrictions to an enrollee s access to services must be stated. Examples include the following: 1) patients over 65 years of age, 2) children under 16 years old, or 3) no new patients. o Non English languages spoken by providers o Optional to include: clinic customer service information, such as office hours, pharmacy on site services, and hospital association if there is a separate hospital listing. Hospitals (choose one or both of the following options.) If hospital is also listed separately (i.e., in addition to being listed with each clinic), the address, telephone number, access information and non English language information is not required. That information is only required in one area not both: o If included with each clinic listing must include: Hospital Name Addresses Telephone numbers Any other access information Non English languages for on site interpreter staff only o If listed separately must include: 12

17 A statement informing enrollees how to find out what hospitals are associated with their primary care clinic Hospital Name Addresses Telephone numbers Any other access information Non English languages for on site interpreter staff only Other Listings: o Nursing Homes must be listed in the MSC+, MSHO, and SNBC PCNLs. o The MCO must identify multi specialties or specialty with each clinic. o Any provider category from which the enrollee must make an advance selection must also be listed. o Other providers, such as Indian Health Services, may be included. Examples of listings are included as follows. > 13

18 Health Plan Medical Clinics & Hospitals <Include the name of the State at least at the beginning of the section> Minnesota Benton County City / Town ABC Clinic # Main St. Foley, MN (320) Multispecialty clinic: allergy, dermatology, family practice, geriatric medicine, Internal Medicine, OB GYN, and Pediatrics. No new patients Russian spoken Hospital Affiliation: XYZ Hospital Sherburne County City / Town ABC Pediatric Clinic # Main St. Elk River, MN (612) Multispecialty clinic: allergy, endocrinology, and pediatrics. Only patients age 16 years and younger. French, Spanish and Hmong spoken Hospital Affiliation: XYZ Hospital Stearns County City / Town ABC Seniors Clinic # Main St. St. Cloud, MN (320) Multispecialty clinic: internal medicine, geriatric medicine. Only patients age 65 years and older. German, Vietnamese and Somali spoken Hospital Affiliation: XYZ Hospital 1000 Lake Drive St. Cloud, MN (320)

19 [Health Plan Other Providers (e.g. Dental Clinics)] <Include the name of the State at least at the beginning of the section> Minnesota Benton County City / Town ABC Pediatric Dentistry # Main St. Foley, MN (320) Patients age 16 years and younger Sherburne County City / Town ABC Clinic # Main St. Elk River, MN (612) No new patients Arabic spoken Stearns County City/ Town ABC Clinic # Main St. St. Cloud, MN (320) French spoken 15

20 (last page or back cover) <The last page of the PCNL may be used for marketing information: Marketing materials may not include false or misleading information. Listing benefits covered under the contract as special benefits is considered to be false or misleading. A benefit can be considered to be special if a MCO can specify how a benefit or set of benefits listed in the marketing materials is specially packaged. Inducements may be promoted: If the inducement is offered to all of the MCO s enrollees who meet the criteria for the program. If the inducement is specifically linked to a preventive service or expected health outcome and the link between the two is clearly stated on the marketing materials. If the inducement is included in marketing materials beyond those materials given to potential enrollees. Below is an example of what might be included on the last page or back cover: The Health Plan provides: Welcome calls to all new members Prenatal and infant care classes A monthly newsletter Social services support Fitness Program should describe how the enrollee can get more information. Safety Items should explain how the enrollee can get more information. Health Plan [Health Plan contact information, must include toll free number, TDD/TTY, and plan website]> 16