Common use of Access to Care Standards Clause in Contracts

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 § ▇▇, ▇▇▇ § ▇▇▇, ▇▇▇’▇ ▇▇▇▇▇▇▇ ▇▇▇▇ (▇) 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 ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇.▇▇▇/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) days prior to enacting the policy and all of its Individuals within ninety (90) days of adopting of enacting the policy. Any policy not expressly conveyed to Great Rivers prior to the start date of this contract must be classified as “new.”

Access to Care Standards. 5.1. The Contractor must provide or purchase age, linguistic, and culturally competent community behavioral health services for Individuals Enrollees for whom services are medically necessary and clinically appropriate pursuant to: 5.1.1. CFR § ▇▇, ▇▇▇ § ▇▇▇, ▇▇▇▇’▇ ▇▇▇▇▇▇▇ ▇▇▇▇ (▇) 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 HCADBHR-published Service Encounter Reporting Instructions, available at at: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/billers/bha/division-providers-partners/behavioral-health- health-and- recovery/serviceseri-encountercpt-reporting-instructions-seriinformation. 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 IndividualEnrollee’s diagnosis, type of illness, or condition. 5.5. The Contractor must not discriminate against difficult-to-serve IndividualsEnrollees. Examples include 5.5.1. A refusal to treat an Individual Enrollee because the Individual 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 Individuals 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 Individuals Enrollees within ninety (90) days of adopting of enacting the policy. Any policy not expressly conveyed to Great Rivers prior to the start date of this contract must be classified as “new.”