PRACTITIONER APPOINTMENT AND AFTER-HOURS AVAILABILITY STANDARDS. Gateway Health SM Medicaid Appointment and Availability Standards

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1 PRACTITIONER AND AFTER-HOURS AVAILABILITY STANDARDS Gateway Health SM works with SPH Analytics, an NCQA certified survey vendor, to help us conduct annual audits of practitioner appointment and after-hours accessibility. SPH Analytics contacts PCP, high volume, and high impact practices to report next available or third available appointment for specific visit types described below. After-hours calls are also made to confirm care is available 24/7. Please take a few minutes to review the standards with your practice. Thank you in advance for participating in the survey! Gateway Health SM Medicaid Appointment and Availability Standards Your doctors have agreed to care for Gateway members in a timely manner. Please review the timeframes below for each appointment type: Emergency Care A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part. Immediately seen, or instructed to call 911 or go directly to the nearest emergency room. Examples of emergency situations include seizure, diabetic coma, cardiac arrest, obvious fracture. A medical condition that may result in irreversible complications or even death if injury or illness is not treated in a timely manner. Any injury or illness that has the potential to become something more serious, or even Seen within 24 hours

2 Examples of urgent care situations include abdominal pain of unknown cause, unremitting new symptoms of dizziness for unknown cause, suspected fracture. Services provided to diagnose and treat conditions to prevent deterioration to a more severe level, or minimize/reduce risk of development of chronic illness or the need for more complex treatment. Examples include psoriasis, treatment of chronic conditions such as chronic back pain. SPECIALTY TYPE: Dermatology, Dentist, Orthopedic Surgery, Otolaryngology, and all pediatric sub specialties: Seen within 15 business days from the date of referral Specialties not listed above: from the date of referral General Physical, Health Assessment, or First Time Examination A complete health assessment which also includes gathering information about a person's medical history and lifestyle, doing laboratory tests, and screening for disease. PCPs: PCPs: Within 3 weeks of enrollment in the practice. Appointment standards below apply to Specialists and PCPs who provide initial exams for special needs members EPSDT Screen Within 45 days from the effective date of enrollment unless the child is already under the care of a PCP and is current with screens and immunizations. Members known to Within 7 days from effective date of enrollment, unless member is already in active care be HIV positive or with a PCP or specialist. diagnosed with AIDS Members who receive supplemental security income (SSI) Within 45 days of enrollment unless the Member is already in active care with a PCP or specialist. Appointment standards below apply to OB/GYNs and PCPs who provide prenatal care. First trimester visit Within 10 business days of the member being identified as being pregnant Second trimester visit Within 5 business days of the member being identified as being pregnant Third trimester visit Within 4 business days of the member being identified as being pregnant High risk pregnancy Within twenty-four hours of identification of high risk pregnancy

3 Additional Office Standards for PCPs and Specialists No Show policy If a member misses an appointment, the practice is required to document the missed appointment in the medical record. In addition, three attempts must be made to contact the member. At least one attempt must include a telephone call. Wait time in the waiting room for routine care - The average office waiting time should exceed no more than 30 minutes or at any time, no more than up to one hour when the physician encounters an unanticipated urgent medical condition visit or is treating a member with a difficult medical condition need. Wait time to speak with someone on the telephone should be no longer than 1 minute. After Hours Care for PCPs Primary Care Practices are responsible for providing 24 hour/ 7 days per week coverage for urgent or emergent care. Gateway members must be instructed to call 911 or go directly to the emergency room in the case of a true emergency. Answering services or machines must instruct members on how to reach an on call physician. Gateway Health Medicare Assured SM Appointment and Availability Standards Your doctors have agreed to care for Gateway members in a timely manner. Please review the timeframes below for each appointment type: PCPs & Specialists Emergency Care A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part. PCP & SPECIALISTS: Immediately seen, or instructed to call 911 or go directly to the nearest emergency room.

4 Examples of emergency situations include seizure, diabetic coma, cardiac arrest, obvious fracture. A medical condition that may result in irreversible complications or even death if injury or illness is not treated in a timely manner. Any injury or illness that has the potential to become something more serious, or even Seen within 24 hours Non-Urgent Sick Visit Examples of urgent care situations include abdominal pain of unknown cause, unremitting new symptoms of dizziness for unknown cause, suspected fracture. Medical care for an acute onset of symptoms that is not emergent or urgent in nature. Examples of non-urgent sick visits include cold symptoms such as sore throat and nasal congestion. Services provided to diagnose and treat conditions to prevent deterioration to a more severe level, or minimize/reduce risk of development of chronic illness or the need for more complex treatment. Examples include psoriasis, treatment of chronic conditions such as chronic back pain. Seen within 1 week Seen within 30 business days. Behavioral Health Providers Non-lifethreatening Examples of urgent care situation: An acute dystonic Seen within 6 hours Emergency reaction to antipsychotic medication (drug-induced involuntary muscle spasms), antidepressant-induced hypomania, intrusive thoughts (significant, severe, distressing) A medical condition that may result in irreversible complications or even death if injury or illness is not treated in a timely manner. Any injury or illness that has the potential to become something more serious, or even Seen within 48 hours Initial visit for Examples of urgent care situation: Acute major depression and acute panic disorder Routine outpatient behavioral health services include requests for initial assessments, requests for members discharged from an inpatient setting to a community

5 Initial continued placement and requests for members seen in emergency rooms or by a behavioral health crisis provider for a behavioral health condition. Follow-up Routine Care Examples include marital problems, tensions at work and general anxiety disorder. Seen within 3 weeks Additional Office Standards for PCPs and Specialists Wait time in the waiting room for routine care - the average office waiting time should exceed no more than 30 minutes or at any time, no more than up to one hour when the physician encounters an unanticipated urgent medical condition visit or is treating a member with a difficult medical condition need. After Hours Care for PCPs Primary Care Practices are responsible for providing 24 hour/ 7 days per week coverage for urgent or emergent care. Gateway members must be instructed to call 911 or go directly to the emergency room in the case of a true emergency. Answering services or machines must instruct members on how to reach an on call physician.