3 In the UMCC section 8.1.3.2 for OT/PT/ST the time/distance designation for micro is more stringent than the one for a rural county. Can we confirm what the time/distance requirement is for OT/PT and ST in a metro, micro and rural county? According to the UMCC micro is 60 miles and 80 minutes, while rural is 60 miles and 75 minutes. This is correct. As determined through the stakeholder feedback process, HHSC relied on the Medicare advantage standards as a basis for state network adequacy standards. The five Medicare Advantage geographic categories (Large Metro, Metro, Micro, Rural, and CEAC) were consolidated into the three geographic categories outlined in the UMCC (Metro, Micro, and Rural). The standards noted in your question are consistent with 2017 Medicare Advantage . 4 Cigna HealthSpring recommends blank exceptions should be good for one year if there is a county with no providers. HHSC will consider this recommendation as we develop the exception process. As a reminder, HHSC will coordinate with MCOs to develop the exception process after the full baseline reports are completed in October 2017. 5 Will ‘other physician specialties’ be measured for adequacy? ‘Other Physician Specialties’ is currently listed on the technical specifications, but not on the specialty crosswalk. At this time, “other physician specialties” are not included in the standardized analysis process. However, MCOs must ensure these provider types meet network adequacy standards as outlined in relevant managed care contracts.
14 Continuing with FQHCs & RHCs. In some instances, like BH, FQHC and RHCs have a provider type code, but no map to Spec Code. If FQHCs and RHCs crosswalk to PCPs, OB/GYN using both PT and Spec Code how can it be mapped to BH if it doesn't map to a specialty code? FQHCs and RHCs will not have Specialty Codes. Please see the response to #13. 15 For BH, Provider Type 31 - Psychologist isn't mapped to a Spec code. Should it be mapped to 62 - Psychologist? No, Provider Type 31 has a single specialty code, so there is no need to map to a specialty code. 16 We noted that there are several crosswalk maps where an MD maps to a DO and vice versa - a DO to an MD. These have rejected in our P92/94s. Should these be updated and MDs map to MD and DOs to DOs only? HHSC is revising the crosswalks to match Medicaid provider enrollment (provider types and specialties). HHSC will be working with Maximus to update the EB CHIP Joint Interface Plan to ensure consistency.
46 Draft Tech Specs states HHSC will quarterly monitor provider fluctuation within counties by comparing counts for the current quarter to the previous quarter and baseline. Request HHSC specify how ‘fluctuation’ will be defined in the context of this report/provider counts, and what percentage of change will prompt HHSC to conduct travel time and distance analysis when data indicates a “fluctuation” change. As noted during the webinar on May 9, 2017, HHSC awaits MCO network adequacy experience data to determine reasonable thresholds that would prompt additional analysis during the year. HHSC will coordinate with MCOs as these variables are determined. 47 Use of the provider reconciliation file from the first week/month of the reporting quarter will not represent network changes throughout the reporting quarter, resulting in an incomplete review by HHSC of the MCO’s “current” network status for this report. Resulting corrective action requests (and/or LDs) may be required/imposed that are the result of this incomplete analysis of the current quarter. Recommend reconsidering the file used for quarterly access monitoring to reflect network status at the end of the quarter, which would be more representative of the quarterly reporting/analysis. Network adequacy analysis is a point in time analysis that includes a cross-sectional “snapshot” of the MCO network at the time of the data collection. To more clearly describe the measurement process, HHSC has revised the technical specifications. 48 Please specify the threshold for network adequacy performance results that will prompt remedies imposed by HHSC (corrective action and/or LDs), as described on page 9 of the Tech Specs document. Will adequacy results include decimal figures, and will HHSC impose remedies on any performance less than the 75% or 90% standards? Network adequacy results will include two decimal places and will not be rounded. Following the exception process, remedies may be assessed when performance standards are not met. Yes, with the exception of Other Physician Specialties (which has been removed from the Technical Specifications). Yes, performance will be measured for each MCO by county by program.