Guidelines for the Role of Primary Care Graduate Medical Education Programs

Health Plan Qualification Guidelines for Medicaid Managed Care November, 1997 Medical Residents

For an interim period which shall end July 1, 1998, health plans may use residents as providers of care to enrollees according to EITHER of two ways: 

  1. Health plans may use year two and three resident physicians who are enrolled in upweighted primary care training programs (a listing of such programs is included in the Technical Assistance library) as part of their PCP delivery system as PCPs subject to the follow guidelines:
    • Each resident team shall be comprised of no more than three physicians in training and must be supervised by an attending physician (see Section below for additional information on PCP teams). 
    • Residents outside NYC may work 12 hours to qualify for participation. In NYC residents must work 16 hours per week to qualify to participate. 
    • Each team may impanel no more than 1,500 members per FTE. For example, a team comprised of three residents working sixteen (16) hours each per week and one attending physician devoting twenty (20) hours per week could impanel a maximum of 2,550 members (68 total hours=1.7 FTEs; 1.7 x 1,500 = 2,550). 
    • Residents comprising a team must share the caseload in a manner which assures care coordination. 
    • Residents must comply with all health plan requirements for prior authorization, utilization review, and quality assurance and medical management of plan members. 
    • Members must be granted access to the attending physician if they request an appointment with this individual. 
  2. As participants (but not designated as 'primary care providers') in the care of enrollees as long as all of the following conditions are met:
    • Residents are a part of patient care teams headed by fully licensed and HMO/PHSP credentialed attending physicians serving patients in one or more training sites in an "upweighted" or "designated priority" residency program. 
    • Only the attending physicians and nurse practitioners on the training team, NOT RESIDENTS, may be credentialed to the health plan and may be empaneled with enrollees. Enrollees must be assigned an attending physician or nurse practitioner to act as their PCP, though residents on the team may perform all or many of the visits to the enrollee as long as the majority of these visits are under the direct supervision of the enrollee's designated PCP. Enrollees have the right to request care by their PCP in addition or instead of being seen by a resident. 
    • Residents may work with attending physicians and nurse practitioners to provide continuity of care to patients under the supervision of the patient's PCP. Patients must be made aware of the resident/attending relationship and be informed of their rights to be cared for directly by their PCP. 
    • Residents eligible to be involved in a continuity relationship with patients must be available at least 20% of the total training time in the continuity of care setting and no less than 10% of training time in any training year must be in the continuity setting and no fewer than 9 months a year must be spent in the continuity care setting. 
    • Residents meeting these criteria provide increased capacity for enrollment to their team according to the following formula:
      • PGY-1 300 per FTE
      • PGY-2 750 per FTE
      • PGY-3 1125 per FTE
      • PGY-4 1500 per FTE

      Only hours spent routinely scheduled for patient care in the continuity training site may count as providing capacity and are based on 1.0 FTE=40 hours. 

    • In order for a resident to provide continuity of care to an enrollee, both the resident and the attending PCP must have regular hours in the continuity site and must be scheduled to be in the site together the majority of the time.
    • A preceptor/attending is required to be present a minimum of 16 hours of combined precepting and direct patient care in the primary care setting to be counted as a team supervising PCP and accept an increased number of enrollees based upon the residents working on his/her team. Time spent in patient care activities at other clinical sites or in other activities off-site is not counted towards this requirement.
    • A 16-hour per week attending may have no more than 4 residents on their team. Attendings spending 24-hours per week in patient care/supervisory activity at the continuity site could have 6 residents per team. Attendings spending 32-hours per week could have 8 residents on their team. Two or more attendings may join together to form a larger team as long as the ratio of attending to residents does not exceed 1:4 and all attendings comply with the 16-hour minimum. 
    • Specialty consults must be performed or directly supervised by a plan credentialed specialist. The specialist may be assisted by a resident or fellow. 
    • Responsibility for the care of the enrollee remains with the attending physician. All attending/resident teams must provide adequate continuity of care, 24-hour 7-day coverage and appointment and availability access which meets RFP standards. 
    • Residents who do not qualify to act as continuity providers as part of an attending/resident team may still participate in the episodic care of enrollees as long as that care is rendered directly by an attending physician credentialed to a plan. Such residents would not add to the capacity of that attending to empanel enrollees, however. 
    • Nurse practitioners may not act as attending preceptors for resident physicians.

After July 1, 1998, plans may ONLY use residents as continuity providers for enrollees as described under (b), above. PCP Teams 

Health plans with clinic provider sites may designate teams of physicians/nurse practitioners/physician assistants to serve as PCPs for members receiving primary care at those sites. Such teams may include no more than three practitioners (or four medical residents (who meet the requirements stated in Section above) and an attending physician) and, when a member chooses or is assigned to a team, one of the practitioners must be designated as lead provider for that member. In the case of teams comprised of medical residents under the supervision of an attending physician, the attending physician must be designated as the lead physician. Member-to-Provider Ratios

Health plans must adhere to the member-to-PCP ratios shown below. These ratios are for Medicaid members only, are plan-specific, and assume the practitioner is an FTE (practices 40 hours per week for the plan)

Individual providers with office-based practices 1,500 enrollees: 1 PCP
Practicing with a Physician extender 2,400 enrollees: 1 PCP & PE
Individual providers practicing in Article 28 comprehensive community-based primary care centers 3,000 enrollees: 1 PCP
Practicing with a Physician extender 4,000 enrollees: 1 PCP & PE
Individual providers with practices based primarily in outpatient departments of hospitals (OPD) 2,500 enrollees: 1 PCP
Practicing with a Year 2 or 3 Resident (FTE) 4,000 enrollees: 1 PCP & FTE Resident

The ratios should be prorated for providers who represent less than an FTE to a health plan. For example, if a physician devotes one-half of his/her practice to Health Plan, he/she should be considered to represent capacity for no more than 750 of Health Plan Medicaid enrollees.