PCP Access Sample Clauses
The "PCP Access" clause defines the rights and procedures for accessing a Primary Care Provider (PCP) within a healthcare agreement or insurance policy. Typically, this clause outlines how members can select or change their PCP, the process for scheduling appointments, and any requirements for referrals to specialists. For example, it may specify that members must choose a PCP from an approved network and obtain referrals for non-emergency specialist visits. The core function of this clause is to ensure that members have clear guidance on how to access primary healthcare services, promoting coordinated care and efficient use of healthcare resources.
PCP Access. At a minimum, the HMO must ensure that all Members have access to an age-appropriate PCP in the Provider Network with an Open Panel within 30 miles of the Member’s residence. For the purposes of assessing compliance with this requirement, an internist who provides primary care to adults only is not considered an age-appropriate PCP choice for a Member under age 21, and a pediatrician is not considered an age-appropriate choice for a Member age 21 and over. Note: This provision does not apply to CHIP Perinates, but it does apply to CHIP Perinate Newborns. OB/GYN Access and CHIP Perinatal Program Provider Access: STAR, STAR+PLUS and CHIP Program Network: at a minimum, STAR, STAR+PLUS and CHIP HMOs must ensure that all female Members have access to an OB/GYN in the Provider Network within 75 miles of the Member’s residence. (If the OB/GYN is acting as the Member’s PCP, the HMO must follow the access requirements for the PCP.) The HMO must allow female Members to select an OB/GYN within its Provider Network. A female Member who selects an OB/GYN must be allowed direct access to the OB/GYN’s health care services without a referral from the Member’s PCP or a prior authorization. A pregnant Member with 12 weeks or less remaining before the expected delivery date must be allowed to remain under the Member’s current OB/GYN care though the Member’s post-partum checkup, even if the OB/GYN provider is, or becomes, Out-of-Network. CHIP Perinatal Program Network: At a minimum, CHIP Perinatal HMOs must ensure that CHIP Perinates have access to a Provider of perinate services within 75 miles of the Member’s residence if the Member resides in an urban area and within 125 miles of the Member’s residence if the Member resides in a rural area.
PCP Access. Contractor shall ensure an Enrollee has access to at least two (2) PCPs within a thirty (30)– mile radius of or thirty (30)–minute drive from the Enrollee’s residence. If an Enrollee lives in a Rural Area, the Enrollee shall have access to at least one (1) PCP within a sixty (60)–mile radius of or sixty (60)– minute drive from his or her residence.