HCFA outlines care standards for plans
August 1, 1998 2 minutes read
HCFA outlines care standards for plans
Rules require an array of expanded services
The Health Care Financing Administration standards for Medicare+Choice providers include a number of specific patient rights and services, including:
· Renal dialysis service. This service must be provided when the enrollee is temporarily outside the plan's service area, even if it is not an emergency or urgently needed.
· Post stabilization care. Also called maintenance care, this care refers to medically necessary, nonemergency services needed to ensure the enrollee remains stabilized from the time the treating hospital requests authorization until one of three things happens: (1) the enrollee is discharged; (2) a plan physician arrives and assumes responsibility for the enrollee's care; or (3) the treating physician and the plan agree to another arrangement.
Under the proposed rules, the Medicare+ Choice plan is responsible for the cost of post-stabilization care provided outside the plan if it was preapproved; if the organization did not respond within one hour to a physician's request for preapproval of care; or if for some reason, like a busy telephone line, the plan could not be contacted for preapproval.
· Vaccines and screening mammographies. Like traditional Medicare, co-pays and other cost-sharing patient arrangements are not permitted for flu and pneumococcal vaccines. Also, enrollees may self-refer and directly access screening mammographies and flu vaccines.
· Direct access to women's health services. Plans must provide direct access to women's health specialists within the network for routine and preventive health care services.
· Serious illness. Plans must perform a baseline medical assessment and establish a treatment plan for all participants with complex or serious medical conditions within 90 days of their effective enrollment date. Under the treatment plan, beneficiaries must have direct access to what HCFA considers to be an "adequate" number of specialists for that particular enrollee population.
· Baseline health assessment. Medical assessments also must be performed within 90 days of enrollment for new enrollees who do not appear to have complex or serious medical conditions.
· Emergency medical conditions. Retrospective denial of emergency room services is prohibited when the case turns out not to be serious enough to require emergency room attention if a "prudent layperson" would have thought the situation required an emergency room visit. If a physician or other representative affiliated with the organization (e.g., a demand management company) instructs the enrollee to seek emergency services, the organization is responsible for payment for medically necessary emergency services, regardless of the prudent layperson standard.
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