West Virginia Health Care Authority

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Primary Care Pilot Program

PREVENTIVE AND PRIMARY CARE
PILOT PROGRAM
Application Instructions

APPLICATION(with Attachment B)    ATTACHMENT A

The West Virginia Health Care Authority is soliciting applications from providers for the establishment of pilot programs providing preventive and primary care services to the uninsured for a prepaid fee. This is the second year for the program which was authorized  by the Legislature in 2006 (West Virginia Code § 16-2J-1 et seq.).

Applicants must submit completed applications to the HCA by email using a pdf format on or before November 30, 2007. The email address is KMyers@hcawv.org.

If you have any questions regarding this matter, please contact Marianne Kapinos, General Counsel, or Kay Myers, Paralegal.

The Preventive and Primary Care Pilot Program is designed to encourage West Virginians to establish and use a medical home and to expand primary care and preventive services for uninsured West Virginians.

Participating Providers:

The program currently has three participating providers. A participating provider may be a private office practice or an ambulatory health care facility. The Health Care Authority (HCA) is seeking a variety of participating providers that reflects diversity in practice types, program design and geographical location. The HCA will select a maximum of five additional provider organizations, each of which may incorporate up to three clinical sites within the program.

Required Services:

Participating providers must offer a minimum set of specified primary and preventive care services to program enrollees. See Attachment A. Specialty or hospital care is not a covered service. All required services except X-ray, the interpretation of diagnostic services, and the administration of immunizations must be performed on site. Participating providers may provide additional services which are not on Attachment A. Those additional services must be clearly delineated in the application.

Patient Subscribers:

Participation is open to persons who are not insured and have not had insurance coverage for the past twelve months, with exception for those who have lost insurance coverage due to emancipation, divorce, or job termination. Subscribers may be enrolled as individuals, families or employee groups.

Data and Program Review/Evaluation:

This is a three year pilot program designed to determine the efficacy of prepaid clinic models and to provide a basis for future development and expansion of such models. Participating providers must submit data and other information as required by the HCA and the Insurance Commissioner to examine such issues as the financial implications for providers and patients, enrollment patterns, utilization patterns, impact on health outcomes, system effects and the need for future health planning.

The data required for evaluation include: 1) data which is customarily gathered in medical practices, such as CPT codes and HCPCS codes, diagnoses, lab work ordered and results, specialty and other referrals, and patient demographics; 2) additional data may be gathered by incorporating new elements to traditional data collected by providers such as routine medical histories and patient surveys; and, 3) program evaluation will also include analysis of financial reports and other data submitted to the Insurance Commissioner pursuant to this pilot program.

Regulatory Authority and Oversight:

Participation by providers in this program is not considered as providing insurance or as offering insurance services. This program exempts the participating providers from existing insurance mandates. See W. Va. Code § 16-2J-5(f). The Insurance Commissioner and the HCA are responsible for the regulatory oversight of this pilot project.

Funding Available:

None

Applicants:

Any ambulatory health care facility or private office professional licensed to practice in West Virginia that can satisfy all of the service requirements outlined in Attachment A is eligible to apply to participate in the pilot program.

Selection Process:

Selection of participating providers will be made by the HCA, in consultation with the Insurance Commissioner.

 

APPLICATION(with Attachment B)    ATTACHMENT A

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