Section 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.

See https://law.lis.virginia.gov/admincode/title12/agency5/chapter408/section260/

Section 5-408-270. 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.

See https://law.lis.virginia.gov/admincode/title12/agency5/chapter408/section270/