ACCESS TO CARE STANDARDS. 4.2.1. The Contractor’s PCMP Network shall have a sufficient number of PCMPs so that each Member has a PCMP and each Member has their choice of at least two (2) PCMPs within their zip code or within thirty (30) minutes of driving time from their location, whichever area is larger. For rural and frontier areas, the Department may adjust this requirement based on the number and location of available providers.
ACCESS TO CARE STANDARDS. The Contractor must demonstrate annually that its Provider Network meets the stricter of the following standards:
2.10.2.1. For Medicare medical providers and facilities, time, distance and minimum number standards updated annually on the CMS website (xxxx://xxx.xxx.xxx/Medicare-Medicaid- Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/InformationandGuida nceforPlans.html);
2.10.2.2. For Medicare pharmacy providers, time, distance and minimum number as required in Appendix E, Article II, Section I and 42 C.F.R. § 423.120; or
2.10.2.3. For Medi-Cal providers and facilities, the Contractor contract with a sufficient number of LTSS providers, including but not limited to SNFs (distinct part and free- standing), MSSP, CBAS and County Social Services Agencies located in the Contractor’s Service Area.
2.10.2.3.1. If the LTSS provider within the Service Area cannot meet the Enrollee’s medical needs, the Contractor must contract with the nearest LTSS provider outside of the covered Service Area. Contractor is responsible for all Covered Services, pursuant to WIC section 14186.3(c).
2.10.2.3.2. Contractor shall ensure the provision of acceptable accessibility standards in accordance with 42 CFR 438.206(c) and Title 28 CCR Section 1300.67.2.2 and as specified below.
2.10.2.4. Ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial Enrollees or comparable to Medi-Cal fee-for-service, if the provider serves only Medi-Cal Enrollees.
ACCESS TO CARE STANDARDS. 5.1. The Contractor must provide or purchase age, linguistic, and culturally competent community behavioral health services for Individuals for whom services are medically necessary and clinically appropriate pursuant to:
5.1.1. CFR § 00, XXX § 000, XXX’x Xxxxxxx 0000 (x) Mental Health and Substance Use Disorder Waiver, and Medicaid (Title XIX) State Plan.
5.1.2. Other provisions of Title XIX of the Social Security Act. 5.1.3. RCW 70.96A, 70.96B, 70.02, 71.05, 71.24, and 71.34. 5.1.4. WAC 388-865, 388-877, 388-877A, and 388-877B.
5.2. The Contractor must ensure services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished. Policies for guidelines must support services detailed in the most current version of the HCA-published Service Encounter Reporting Instructions, available at xxxxx://xxx.xxx.xx.xxx/billers-providers-partners/behavioral-health- recovery/service-encounter-reporting-instructions-seri.
5.3. Services must be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under fee-for-service Medicaid, as set forth in CFR § 440.230.
5.3.1. Great Rivers may place appropriate limits on a service for the purpose of utilization control, provided the services furnished can reasonably be expected to be sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. CFR § 438.210(3)(iii)(B).
5.4. The Contractor must not deny or reduce the amount, duration, or scope of a required service solely because of an Individual’s diagnosis, type of illness, or condition.
5.5. The Contractor must not discriminate against difficult-to-serve Individuals. Examples include
5.5.1. A refusal to treat an Individual because the Individual is deemed too dangerous.
5.5.2. Housing is not available in the community.
5.5.3. A particular type of residential placement is not currently available.
5.6. The Contractor may refuse to provide, reimburse for, or provide coverage of certain services based on moral or religious grounds.
5.6.1. If the Contractor chooses to refuse any services or coverages on moral or religious grounds it must provide a list of those services to all Individuals at intake.
5.6.2. If the Contractor establishes any new policy regarding a moral or religious objection to any service or coverage it must notify Great Rivers thirty (30) d...
ACCESS TO CARE STANDARDS. The Contractor must demonstrate annually that its Provider Network meets the stricter of the following standards:
2.10.2.1. For Medicare medical providers and facilities, time, distance and minimum number standards updated annually on the CMS website (xxxx://xxx.xxx.xxx/Medicare/Medicare- Advantage/MedicareAdvantageApps/ index.html);
2.10.2.2. For Medicare pharmacy providers, time, distance and minimum number as required in Appendix E, Article II, Section I and 42 C.F.R. § 423.120; or
2.10.2.3. For Medi-Cal providers and facilities, the Contractor contract with a sufficient number of LTSS providers, including but not limited to SNFs (distinct part and free- standing), MSSP, CBAS and County Social Services Agencies located in the Contractor’s Service Area.
2.10.2.3.1. If the LTSS provider within the Service Area cannot meet the Enrollee’s medical needs, the Contractor must contract with the nearest LTSS provider outside of the covered Service Area. Contractor is responsible for all Covered Services, pursuant to WIC section 14186.3(c).
2.10.2.3.2. Contractor shall ensure the provision of acceptable accessibility standards in accordance with Title 28 CCR Section 1300.67.2.2 and as specified below.
2.10.2.3.3. Ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial Enrollees or comparable to Medi-Cal fee-for-service, if the provider serves only Medi-Cal Enrollees.
ACCESS TO CARE STANDARDS. 4.2.1. The Contractor’s PCMP Network shall have a sufficient number of PCMPs so that each Member has a PCMP and each Member has their choice of at least two (2) PCMPs within their zip code or within thirty (30) minutes of driving time from their location, whichever area is larger. For rural and frontier areas, the Department may adjust this requirement based on the number and location of available providers.
4.2.1.1. In the event that there are less than two (2) medical providers qualified to be a PCMP within the area defined in the prior paragraph for a specific Member, then the requirements of that paragraph shall not apply to that Member.
4.2.2. The Contractor’s PCMP Network shall provide for extended hours on evenings and weekends and alternatives for emergency room visits for after-hours urgent care. The Contractor will determine the appropriate requirements for the number of extended hours and weekend availability based on the needs of the Contractor’s Region, and submit these requirements to the Department for approval. The Contractor shall assess the needs of the Contractor’s Region on a regular basis, no less often than quarterly, and submit a request to the Department to adjust its requirements accordingly.
4.2.2.1. At a minimum, the Contractor’s PCMP Network shall provide for twenty-four (24) hour a day availability of information, referral and treatment of emergency medical conditions.
4.2.3. The Contractor shall have a system to track Member access at the PCMP provider level, including requests for same-day care, requests for routine care and how long a Member must wait before an appointment is available. The Contractor shall provide this information in a mutually agreed reporting format and on a mutually agreed schedule.
4.2.4. The Contractor’s PCMP Network shall be sufficient to ensure that appointments will be available to all Members:
4.2.4.1. Within forty-eight (48) hours of a Member’s request for urgent care.
4.2.4.2. Within ten (10) calendar days of a Member’s request for non-urgent, symptomatic care.
4.2.4.3. Within forty-five (45) calendar days of a Member’s request for non-symptomatic care, unless an appointment is required sooner to ensure the provision of screenings in accordance with the Department’s accepted Early Periodic Screening, Diagnosis and Treatment (EPSDT) schedules.
4.2.5. The Contractor shall reasonably ensure that Members in the Contractor’s Region have access to specialists and other Medicaid providers promptly and w...
ACCESS TO CARE STANDARDS. The Contractor must demonstrate annually that its Provider Network meets the stricter of the following standards:
2.10.2.1. For Medicare medical providers and facilities, time, distance and minimum number standards updated annually on the CMS website (xxxxx://xxx.xxx.xxx/Medicare-Medicaid- Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/MMPInformationandG uidance/MMPApplicationandAnnualRequirements.html);
2.10.2.2. For Medicare pharmacy providers, time, distance and minimum number as required in Appendix E, Article II, Section I and 42 C.F.R. § 423.120; or
2.10.2.3. For Medi-Cal providers and facilities, the Contractor contract with a sufficient number of LTSS providers, including but not limited to SNFs (distinct part and free- standing), MSSP, CBAS and County Social Services Agencies located in the Contractor’s Service Area.
2.10.2.3.1. If the LTSS provider within the Service Area cannot meet the Enrollee’s medical needs, the Contractor must contract with the nearest LTSS provider outside of the covered Service Area. Contractor is responsible for all Covered Services, pursuant to WIC section 14186.3(c).
2.10.2.3.2. Contractor shall ensure the provision of acceptable accessibility standards in accordance with 42 C.F.R. §§ 438.206(c) and 438.68 and Title 28 CCR Section 1300.67.2.2 and as specified below.
2.10.2.4. Ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial Enrollees or comparable to Medi-Cal fee-for-service, if the provider serves only Medi-Cal Enrollees.
ACCESS TO CARE STANDARDS. The Contractor must demonstrate annually that its Provider Network meets the stricter of the following standards:
2.10.2.1. For Medicare medical providers and facilities, time, distance and minimum number standards updated annually on the CMS website (MMP Reference File);
2.10.2.2. For Medicare pharmacy providers, time, distance and minimum number as required in Appendix E, Article II, Section I and 42 C.F.R. § 423.120; or
2.10.2.3. For Medi-Cal providers and facilities, the Contractor contracts with a sufficient number of LTSS providers, including but not limited to SNFs (distinct part and free-standing), CBAS and County Social Services Agencies located in the Contractor’s Service Area.
2.10.2.3.1. If the LTSS provider within the Service Area cannot meet the Enrollee’s medical needs, the Contractor must contract with the nearest LTSS provider outside of the covered Service Area. Contractor is responsible for all Covered Services, pursuant to WIC section 14186.3(c).
2.10.2.3.2. Contractor shall ensure the provision of acceptable accessibility standards in accordance with 42 C.F.R. §§ 438.206(c) and 438.68 and Title 28 CCR Section 1300.67.2.2 and as specified below.
2.10.2.4. Ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial Enrollees or comparable to Medi-Cal fee-for-service, if the provider serves only Medi-Cal Enrollees.
ACCESS TO CARE STANDARDS. 5.1. The Contractor must provide or purchase age, linguistic, and culturally competent community behavioral health services for Enrollees for whom services are medically necessary and clinically appropriate pursuant to:
5.1.1. CFR § 00, XXX § 000, XXXX’x Xxxxxxx 0000 (x) Mental Health and Substance Use Disorder Waiver, and Medicaid (Title XIX) State Plan.
5.1.2. Other provisions of Title XIX of the Social Security Act. 5.1.3. RCW 70.96A, 70.96B, 70.02, 71.05, 71.24, and 71.34. 5.1.4. WAC 246-341 and 182-538D.
5.2. The Contractor must ensure services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished. Policies for guidelines must support services detailed in the most current version of the DBHR-published Service Encounter Reporting Instructions, available at xxxxx://xxx.xxx.xx.xxx/assets/billers-and-providers/SERI_v2019- 1EffectiveJuly1_2019.pdf.
5.3. Services must be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under fee-for-service Medicaid, as set forth in CFR § 440.230.
5.3.1. Great Rivers may place appropriate limits on a service for the purpose of utilization control, provided the services furnished can reasonably be expected to be sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. CFR § 438.210(3)(iii)(B).
5.4. The Contractor must not deny or reduce the amount, duration, or scope of a required service solely because of an Enrollee’s diagnosis, type of illness, or condition.
5.5. The Contractor must not discriminate against difficult-to-serve Enrollees. Examples include
5.5.1. A refusal to treat an Enrollee because the Enrollee is deemed too dangerous.
5.5.2. Housing is not available in the community.
5.5.3. A particular type of residential placement is not currently available.
5.6. The Contractor may refuse to provide, reimburse for, or provide coverage of certain services based on moral or religious grounds.
5.6.1. If the Contractor chooses to refuse any services or coverages on moral or religious grounds it must provide a list of those services to all Enrollees at intake.
5.6.2. If the Contractor establishes any new policy regarding a moral or religious objection to any service or coverage it must notify Great Rivers thirty (30) days prior to enacting the policy and all of its Enrollees within ...
ACCESS TO CARE STANDARDS. 24. Subsection 5.8.1 is amended by deleting and replacing, as follows: 5.8.1 Provider types, including primary care Providers, Behavioral Health Providers, OB/GYNs, dental
ACCESS TO CARE STANDARDS. The Contractor shall assess the adequacy of its provider network at least on a quarterly basis. The Contractor must certify through submission of quarterly reports to the Department the adequacy of its provider network and notify the Department of any major initiatives or changes to program design (e.g., expanded benefits). Refer to the Medallion 4.0 Network Requirements Submission Manual (NRSM) for network reporting format requirements. The Contractor shall report any network deficiencies as soon as identified, and no later than within five (5) business days. The Contractor must also submit a request for an exemption using the Medallion Network Exemption Request Form for any circumstance whereby the Contractor is unable to meet the Department’s network time and distance standards. Such a request may be granted only in circumstances where there exists a shortage of the number of providers in a specialty practicing in the region (i.e., provider shortage area). The Contractor’s request for exemption shall also identify the Contractor’s strategy (for its enrolled members) for ensuring timely access to care for all contract covered services. The Department will review and reserves the right to request changes to the provider network, which must be completed within specified timeframes. The Contractor shall contract with a broad range of providers to meet the complex needs of its members. Services shall be delivered in the most integrated setting possible while offering opportunities for active community living and workforce participation. The Department shall be the sole determiner of the Contractor’s network sufficiency. The Department, as part of the program development cycle, will set network adequacy for new population group expansions. These standards shall be considered as operational guidelines.
