Common use of Access to Care Clause in Contracts

Access to Care. Contractor shall provide culturally and linguistically appropriate services and supports, in locations as geographically close as possible, to where Members reside or seek services and choice of Providers (including physical health, behavioral health, including mental health and Substance Use Disorders, and oral health) within the delivery system network that are, if available, offered in non-traditional settings that are accessible to Families, diverse communities, and underserved populations. a. Contractor shall meet, and require Providers to meet, OHP standards for timely access to care and services, taking into account the urgency of need for services. Contractor shall comply with OAR 410-141-3220 and 410-141-3160. Contractor shall make Covered Services available 24 hours a day, 7 days a week, when medically appropriate. b. As specified in OAR 410-123-1000 through 410-123-1640, for routine dental care the Member shall be seen within an average of eight weeks and within 12 weeks or the dental office’s community standard, whichever is less, unless there is a documented special clinical reason which would require longer access time. c. Contractor shall ensure that Providers do not discriminate between Members and non-OHP persons as it relates to benefits and services to which they are both entitled and shall ensure that Providers offer hours of operation to Members that are no less than those offered to non- Members as provided in OAR 410-141-3220. d. Contractor shall provide each Member with an opportunity to select an appropriate Mental Health Practitioner and service site. e. Contractor may not deny Covered Services to, or request Disenrollment of, a Member based on disruptive or abusive behavior resulting from symptoms of a mental or Substance Use Disorders or from another disability. Contractor shall develop an appropriate Treatment Plan with the Member and the Family or advocate of the Member to manage such behavior. f. Contractor shall implement mechanisms to assess each Member with Special Health Care needs in order to identify any ongoing special conditions that require a course of physical health, Substance Use Disorders, or mental health treatment or care management. The assessment mechanisms must use appropriate health care professionals. (1) For Members with Special Health Care Needs determined to need a course of treatment or regular care monitoring, the Individual Service and Support Plan must be developed by Members PCP with Member participation and in consultation with any specialists caring for the Member; approved by Contractor in a timely manner, if approval is required; and developed in accordance with any applicable OHA quality assessment and performance improvement and Utilization Review standards. (2) Based on the Assessment, Contractor shall assist Members with Special Health Care Needs in gaining direct access to Medically Appropriate care from physical health, Substance Use Disorders or mental health specialists for treatment of the Member’s condition and identified needs including the assistance available through intensive care coordinators if appropriate. (3) Contractor shall implement procedures to share with Member’s Primary Care Provider the results of its identification and Assessment of any Member with Special Health Care Needs so that those activities need not be duplicated. Contractor’s procedures shall also require that the Member’s assessment information be shared with other prepaid managed care health services organizations serving the Member. Such coordination and sharing of information must be conducted within federal and State laws, rules, and regulations governing confidentiality. g. Contractor shall comply with the requirements of Title II of the Americans with Disabilities Act and Title VI of the Civil Rights Act by assuring communication and delivery of Covered Services to Members who have difficulty communicating due to a disability, or limited English proficiency or diverse cultural and ethnic backgrounds, and shall maintain written policies, procedures and plans in accordance with the requirements of OAR 410-141-3220. h. Contractor shall comply with the requirement of Title II of the Americans with Disabilities Act by providing services to Members with disabilities in the most integrated setting appropriate to the needs of those Members. i. Contractor shall ensure that its employees, Subcontractors and facilities are prepared to meet the special needs of Members who require accommodations because of a disability or limited English proficiency. Contractor shall include in its Grievance and Appeal procedures, described in Exhibit I, a process for Grievances and Appeals concerning communication or access to Covered Services or facilities. j. In addition to access and Continuity of Care standards specified in the rules cited in Subsection a, of this section, Contractor shall establish standards for access to Covered Services and Continuity of Care which are consistent with the Accessibility requirements in OAR 410-141- 3220. k. Contractor shall ensure that each Member has an ongoing source of primary care appropriate to the Member's needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished as described in OAR 410-141-3120 and required by 42 CFR 438.208 (b)(1) and (2). l. Contractor shall allow each AI/AN enrolled with Contractor to choose an Indian Health Care Provider as the Member’s PCP if: (1) An Indian Health Care Provider is participating as a PCP within the Provider Network; and (2) The AI/AN Member is otherwise eligible to receive services from such Indian Health Care Provider; and (3) The Indian Health Care Provider has the capacity to provide primary health care services to such Members. m. Contractor shall provide female Members with direct access to women’s health specialists within the Provider Network for Covered Services necessary to provide women’s routine and preventive health care services. This is in addition to the Member’s designated PCP if the designated PCP is not a women’s health specialist. n. Contractor shall provide for a second opinion from a qualified Participating Provider, which may include a qualified mental health Participating Provider if appropriate, to determine Medically Appropriate services. If a qualified Participating Provider cannot be arranged then Contractor shall arrange for the Member to obtain the second opinion from a Non-Participating Provider, at no cost to the Member. o. To effectively integrate and coordinate health care and care management for Fully Dual Eligible Members, Contractor shall demonstrate its ability to provide Medicare benefits to Fully Dual Eligible Members. This may be accomplished through a Medicare Advantage plan that is owned by, affiliated with, or contracted by the Contractor.

Access to Care. Contractor shall provide culturally Culturally and linguistically appropriate services Linguistically Appropriate Services and supports, supports in locations as geographically close as possible, possible to where Members reside or seek services and services. Contractor shall also provide a choice of Providers (including physical health, behavioral healthBehavioral Health, including mental health and Providers treating Substance Use Disorders, and oral healthOral Health) who are able to provide Culturally and Linguistically Appropriate Services within the delivery system network Delivery System Network that are, if available, offered in non-traditional settings that are accessible to Families, diverse communitiesCommunities, and underserved populations. a. Contractor shall meet, and require all Providers to meet, OHP standards for timely access to care and services, taking into account the urgency of need for services. Contractor shall comply with OAR 410-141-3220 and 410-141-31603515. Contractor shall make Covered Services available 24 twenty-four (24) hours a day, 7 seven (7) days a week, when medically appropriate. b. As specified Medically Appropriate as set forth in OAR 410-123141-1000 through 4103515 (1) For Members requiring Medication Assisted Treatment (MAT), Contractor shall: (a) Assist such Members in navigating the health care system and utilize Community resources such as Hospitals, Peer Support Specialists, and the like, as needed until assessment and induction can occur; (b) Ensure Providers provide interim services daily until assessment and induction can occur and barriers to medication are removed. Such daily services may include utilizing the Community resources identified in Sub. Para. (4)(a) above of this Para. a, Sec. 2, Ex. B, Part 4 or other types of Provider settings. In no event shall Contractor or its Provider require Members to follow a detox protocol as a condition of providing such Members with assessment and induction; (c) Provide such Members with an assessment that includes a full physical as well as a bio-123psycho-1640, for routine dental care social spiritual assessment and prescribe and deliver any necessary medication taking into consideration the results of such assessment and also the potential risks and harm to the Member in light of the presentation and circumstances; and (d) Provide no less than two (2) follow up appointments to such Members within one (1) week after the assessment and induction. (2) For Members with Special Health Care Needs or receiving Long Term Services and Supports determined through an assessment to need a course of treatment or regular care Monitoring (regardless of whether Contractor is paying for the Member to receive such services under this Contract) Contractor shall have a mechanism in place to allow Members to directly access a Specialist (for example, through a standing Referral or an approved number of visits), as appropriate for the Member's condition and identified needs. Contractor shall ensure the services supporting Members with ongoing or chronic conditions, or who require Long-Term care and Long Term Services and Supports, are authorized in a manner that reflects each such Member's ongoing need for such services and supports and does not create a burden to Members who need medications or services to appropriately care for chronic conditions; and (3) Regardless of whether Contractor is paying for the Member to receive such services under this Contract, Contractor shall have policies and mechanisms for producing, in consultation with the appropriate Providers, including Medicare Providers, an integrated treatment or care plan, or transition of care plan for Members: (a) With Special Health Care Needs, (b) Receiving Long Term Services and Supports, (c) Who are transitioning from a Hospital or Skilled Nursing Facility care, (d) Who are transitioning from institutional or in-patient Behavioral Health care facilities, (e) Who are receiving Home and Community Based Services for Behavioral Health conditions, and (f) FBDE Members enrolled in Contractor’s Affiliated MA or Dual Special Needs Plans in order to meet CMS goals for reducing duplication of assessment and care planning activities for improved coordination and Member outcomes. b. Report the barriers to access to care for such Members and draft a strategic plan for removing such barriers. Such Report and strategic plan must be provided to OHA upon request. Contractor may request technical support from OHA to assist with the efforts required hereunder. c. For routine Oral Health care Members shall be seen within an average of eight weeks and within 12 weeks or the dental office’s community standard, whichever is less(8) weeks, unless there is a documented documented, special clinical reason which would require longer access time. Pregnant individuals shall be provided Oral Health care according to the timelines outlined in OAR 410-123-1510. c. d. Contractor shall ensure that Providers do not discriminate between Members and non-OHP persons as it relates with respect to benefits and services to which they are both entitled and shall ensure that Providers offer hours of operation to Members that are no less than those offered to non- non-Members as provided in OAR 410-141-32203515. d. e. Contractor shall provide each Member with an opportunity to select an appropriate Mental Behavioral Health Practitioner and service site. e. f. Contractor may does not have the right to, and shall not, deny Covered Services to, or request Disenrollment of, a Member based on disruptive or abusive behavior resulting from symptoms of a mental or Substance Use Disorders or from another any other disability. Contractor shall develop an appropriate Treatment Plan Plans with the Member such Members and the Family their Families or advocate of the Member advocates to manage such behavior. f. g. Contractor shall implement mechanisms to assess Assess each Member with Special Health Care needs Needs and Members receiving Long Term Services and Supports (regardless of whether Contractor is paying for the Member to receive such services under this Contract) in order to identify any ongoing special conditions that require a course of physical health, Substance Use DisordersBehavioral Health services, or mental health treatment or care management, or all or any combination thereof. The assessment Assessment mechanisms must use appropriate health care professionals. (1) . For those Members with Special Health Care Needs needs and Members receiving Long Term Services and Supports who are determined to need a course of treatment or regular care monitoringMonitoring (regardless of whether Contractor is paying for the Member to receive such services under this Contract), the Individual Service Contractor shall: (1) Develop and Support implement a written Care Plan. Each Member’s Care Plan must be be: (i) developed by Members PCP the entity designated as primarily responsible for coordinating such services, with Member participation and in consultation with any specialists caring for the Member; approved by Contractor in a timely manner, if approval is required; Providers and developed in accordance with any applicable OHA quality assessment and performance improvement and Utilization Review standards.Specialists caring (2) Based on the Assessment, Contractor shall assist Assist such Members with Special Health Care Needs in gaining direct access to Medically Appropriate care from physical healthhealth or Behavioral Health Specialists, Substance Use Disorders or mental health specialists both, for treatment of the Member’s condition and identified needs including the assistance available through intensive care coordinators the entity designated as primarily responsible for coordinating such Member’s services, if appropriate.; and (3) Contractor shall implement procedures to share with such Member’s Primary Care Provider the results of its identification and Assessment of any Member with Special Health Care Needs so that those activities need are not be duplicated. Contractor’s procedures shall also require that the Member’s assessment information Members’ Assessments be shared with other prepaid managed care health services organizations CCOs serving the MemberMembers. Such coordination and sharing of information must be conducted within federal and State laws, rules, and regulations in accordance with Applicable Laws governing confidentiality. g. h. Contractor shall comply with the requirements of Title II III of the Americans with Disabilities Act and Title VI of the Civil Rights Act Act, and Section 1557 of the ACA by assuring communication and delivery of Covered Services to Members with diverse cultural and ethnic backgrounds. Contractor shall, in order to ensure the communication about, and delivery of, Covered Services in compliance with such Acts, provide, without limitation: (1) Certified or Qualified Health Care Interpreter services for those Members who have difficulty communicating due to a medical condition, a disability, or have limited English proficiency proficiency; or (2) Auxiliary aids and services when no adult is available to communicate in English or diverse cultural and ethnic backgrounds, and Certified or Qualified Health Care Interpreters cannot be made available by telephone. i. Contractor shall maintain written policies, procedures procedures, and plans relating to the communication about, and delivery of Covered Services in compliance with Para. h above of this Section in accordance with the requirements of OAR 410-141-32203515. h. j. Contractor shall comply with the requirement of Title II III of the Americans with Disabilities Act by providing ensuring that services provided to Members with disabilities are provided in the most integrated setting appropriate to the needs of those Members. i. k. Contractor shall ensure that its employees, Subcontractors Subcontractors, and facilities are prepared to meet the special needs of Members who require accommodations because of a disability or limited English proficiency. Contractor shall include in its Grievance and Appeal procedures, described in Exhibit Ex. I, a process for Grievances and Appeals concerning communication or access to Covered Services or facilities. j. l. Contractor shall develop and implement civil rights policies and procedures that comply with 45 CFR §92.8. Contractor shall provide its relevant employees and Subcontractors with training on its civil rights policies and procedures required by 45 CFR § 92.8 as is necessary for the employees and Subcontractors to carry out their job responsibilities and functions. The foregoing training must be in compliance with 45 CFR §92.9 and this Sec. 2 and any other applicable provisions of this Contract. m. In addition to access and Continuity of Care standards specified in the rules cited in Subsection Para. a, of this sectionSec. 2, Ex. B, Part 4, Contractor shall establish standards develop a methodology for evaluating access to Covered Services and Continuity of Care which are consistent with the Accessibility requirements in OAR 410-141- 3220.Covered k. n. Contractor shall ensure that each Member has an ongoing source of primary care appropriate to the Member's needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished as described in OAR 410-141-3120 3860, 410-141-3865, and 410-141- 3870 and as required by 42 CFR 438.208 (b)(1) and (2). l. Contractor shall allow each AI/AN enrolled with Contractor to choose an Indian Health Care Provider as the Member’s PCP if: (1) An Indian Health Care Provider is participating as In accordance with Enrolled Oregon Senate Bill 1529 (2022), Contractor must allow a PCP within the Provider Network; and (2) The AI/AN Member is otherwise eligible to receive services from such Indian Health Care Provider; and (3) The Indian Health Care Provider has the capacity to provide primary health care services to such Members. m. Contractor shall provide female Members with direct access to women’s health specialists within the Provider Network for Covered Services necessary to provide women’s routine and preventive health care services. This is in addition to the Member’s designated PCP if the designated PCP is not a women’s health specialist. n. Contractor shall provide for a second opinion from a qualified Participating Provider, which may include a qualified mental health Participating Provider if appropriate, to determine Medically Appropriate services. If a qualified Participating Provider cannot be arranged then Contractor shall arrange for the Member to obtain the second opinion from choose a Non-Participating Provider, new PCP at no cost to the Memberany time. o. To effectively integrate and coordinate health care and care management for Fully Dual Eligible MembersContractor shall, Contractor shall demonstrate its ability to provide Medicare benefits to Fully Dual Eligible Members. This may be accomplished through a Medicare Advantage plan that is owned by, affiliated with, or contracted by the Contractor.in accordance with 42 CFR § 438.14

Access to Care. Contractor shall provide culturally and linguistically appropriate services and supports, in locations as geographically close as possible, to where Members reside or seek services and choice of Providers (including physical health, behavioral health, including mental health and Substance Use Disorders, and oral health) within the delivery system network that are, if available, offered in non-traditional settings that are accessible to Families, diverse communities, and underserved populations. a. Contractor shall meet, and require Providers to meet, OHP standards for timely access to care and services, taking into account the urgency of need for services. Contractor shall comply with OAR 410-141-3220 and 410-141-3160. Contractor shall make Covered Services available 24 hours a day, 7 days a week, when medically appropriate. b. As specified in OAR 410-123-1000 through 410-123-1640, for routine dental care the Member shall be seen within an average of eight weeks and within 12 weeks or the dental office’s community standard, whichever is less, unless there is a documented special clinical reason which would require longer access time. c. Contractor shall ensure that Providers do not discriminate between Members and non-OHP persons as it relates to benefits and services to which they are both entitled and shall ensure that Providers offer hours of operation to Members that are no less than those offered to non- Members as provided in OAR 410-141-3220. d. Contractor shall provide each Member with an opportunity to select an appropriate Mental Health Practitioner and service site. e. Contractor may not deny Covered Services to, or request Disenrollment of, a Member based on disruptive or abusive behavior resulting from symptoms of a mental or Substance Use Disorders or from another disability. Contractor shall develop an appropriate Treatment Plan with the Member and the Family or advocate of the Member to manage such behavior. f. Contractor shall implement mechanisms to assess each Member with Special Health Care needs in order to identify any ongoing special conditions that require a course of physical health, Substance Use Disorders, or mental health treatment or care management. The assessment mechanisms must use appropriate health care professionals. (1) For Members with Special Health Care Needs determined to need a course of treatment or regular care monitoring, the Individual Service and Support Plan must be developed by Members PCP with Member participation and in consultation with any specialists caring for the Member; approved by Contractor in a timely manner, if approval is required; and developed in accordance with any applicable OHA quality assessment and performance improvement and Utilization Review standards.by (2) Based on the Assessment, Contractor shall assist Members with Special Health Care Needs in gaining direct access to Medically Appropriate care from physical health, Substance Use Disorders or mental health specialists for treatment of the Member’s condition and identified needs including the assistance available through intensive care coordinators if appropriate. (3) Contractor shall implement procedures to share with Member’s Primary Care Provider the results of its identification and Assessment of any Member with Special Health Care Needs so that those activities need not be duplicated. Contractor’s procedures shall also require that the Member’s assessment information be shared with other prepaid managed care health services organizations serving the Member. Such coordination and sharing of information must be conducted within federal and State laws, rules, and regulations governing confidentiality. g. Contractor shall comply with the requirements of Title II of the Americans with Disabilities Act and Title VI of the Civil Rights Act by assuring communication and delivery of Covered Services to Members who have difficulty communicating due to a disability, disability or limited English proficiency or diverse cultural and ethnic backgrounds, and shall maintain written policies, procedures and plans in accordance with the requirements of OAR 410-141-3220. h. Contractor shall comply with the requirement of Title II of the Americans with Disabilities Act by providing services to Members with disabilities in the most integrated setting appropriate to the needs of those Members. i. Contractor shall ensure that its employees, Subcontractors and facilities are prepared to meet the special needs of Members who require accommodations because of a disability or limited English proficiency. Contractor shall include in its Grievance and Appeal procedures, described in Exhibit I, a process for Grievances and Appeals concerning communication or access to Covered Services or facilities. j. In addition to access and Continuity of Care standards specified in the rules cited in Subsection a, of this section, Contractor shall establish standards for access to Covered Services and Continuity of Care which are consistent with the Accessibility requirements in OAR 410-141- 3220. k. Contractor shall ensure that each Member has an ongoing source of primary care appropriate to the Member's needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished as described in OAR 410-141-3120 and required by 42 CFR 438.208 (b)(1) and (2). l. Contractor shall allow each AI/AN enrolled with Contractor to choose an Indian Health Care Provider as the Member’s PCP if: (1) An Indian Health Care Provider is participating as a PCP within the Provider Network; and (2) The AI/AN Member is otherwise eligible to receive services from such Indian Health Care Provider; and (3) The Indian Health Care Provider has the capacity to provide primary health care services to such Members. m. Contractor shall provide female Members with direct access to women’s health specialists within the Provider Network for Covered Services necessary to provide women’s routine and preventive health care services. This is in addition to the Member’s designated PCP if the designated PCP is not a women’s health specialist. n. Contractor shall provide for a second opinion from a qualified Participating Provider, which may include a qualified mental health Participating Provider if appropriate, to determine Medically Appropriate services. If a qualified Participating Provider cannot be arranged then Contractor shall arrange for the Member to obtain the second opinion from a Non-Participating Provider, at no cost to the Member. o. To effectively integrate and coordinate health care and care management for Fully Dual Eligible Members, Contractor shall demonstrate its ability to provide Medicare benefits to Fully Dual Eligible Members. This may be accomplished through a Medicare Advantage plan that is owned by, affiliated with, or contracted by the Contractor.

Access to Care. Contractor shall provide culturally Culturally Responsive and linguistically appropriate services and supports, in locations as geographically close as possible, to where Members reside or seek services and choice of Providers (including physical health, behavioral healthBehavioral Health, including mental health and Providers treating Substance Use Disorders, and oral health) within the delivery system network that are, if available, offered in non-traditional settings that are accessible to Families, diverse communities, and underserved populations. a. Contractor shall meet, and require Providers to meet, OHP standards for timely access to care and services, taking into account the urgency of need for services. Contractor shall comply with OAR 410-141-3220 and 410-141-3160. Contractor shall make Covered Services available 24 hours a day, 7 days a week, when medically appropriate. b. As specified in OAR 410-123-1000 through 410-123-1640, for routine dental Routine oral health care the Member shall be seen within an average of eight weeks and within 12 weeks or the dental office’s community standard, whichever is less(8) weeks, unless there is a documented special clinical reason which would require longer access time. Pregnant women shall be provided oral health care according to the timelines outlined in OAR 410-123-1510. c. Contractor shall ensure that Providers do not discriminate between Members and non-OHP persons as it relates to benefits and services to which they are both entitled and shall ensure that Providers offer hours of operation to Members that are no less than those offered to non- Members as provided in OAR 410-141-3220. d. Contractor shall provide each Member with an opportunity to select an appropriate Mental Behavorial Health Practitioner and service site. e. Contractor may not deny Covered Services to, or request Disenrollment of, a Member based on disruptive or abusive behavior resulting from symptoms of a mental or Substance Use Disorders or from another disability. Contractor shall develop an appropriate Treatment Plan with the Member and the Family or advocate of the Member to manage such behavior. f. Contractor shall implement mechanisms to assess each Member with Special Health Care needs in order to identify any ongoing special conditions that require a course of physical health, Substance Use DisordersBehavioral Health services, or mental health treatment or care management. . The assessment Assessment mechanisms must use appropriate health care professionals. (1) For Members with Special Health Care Needs determined to need a course of treatment or regular care monitoring, the Individual Service and Support Intensive Care Coordination Plan (ICCP), must be developed by Members PCP Member’s Intensive Care Coordinator with Member participation and in consultation with any specialists caring for the Member; approved by Contractor in a timely mannermanner and revised upon Assessment of function need or at the request of the Member, at least every 3 months for Members receiving ICC services and every 12 months for other Members, if approval is required; and developed in accordance with any applicable OHA quality assessment Assessment and performance improvement and Utilization Review standards. (2) Based on the Assessment, Contractor shall assist Members with Special Health Care Needs in gaining direct access to Medically Appropriate care from physical health, Substance Use Disorders health or mental health Behavioral Health specialists for treatment of the Member’s condition and identified needs including the assistance available through intensive care coordinators Intensive Care Coordinators if appropriate. (3) Contractor shall implement procedures to share with Member’s Primary Care Provider the results of its identification and Assessment of any Member with Special Health Care Needs so that those activities need are not be duplicated. Contractor’s procedures shall also require that the Member’s assessment Assessment information be shared with other prepaid managed care health services organizations Managed Care Organizations serving the Member. Such coordination and sharing of information must be conducted within federal and State laws, rules, and regulations governing confidentiality. g. Contractor shall comply with the requirements of Title II of the Americans with Disabilities Act and Title VI of the Civil Rights Act by assuring communication and delivery of Covered Services to Members who have difficulty communicating due to a disability, disability or limited English proficiency or diverse cultural and ethnic backgrounds, and shall maintain written policies, procedures and plans in accordance with the requirements of OAR 410-141-3220. h. Contractor shall comply with the requirement of Title II of the Americans with Disabilities Act by providing ensuring that services provided to Members with disabilities are provided in the most integrated setting appropriate to the needs of those Members. i. Contractor shall ensure that its employees, Subcontractors and facilities are prepared to meet the special needs of Members who require accommodations because of a disability or limited English proficiency. Contractor shall include in its Grievance and Appeal procedures, described in Exhibit I, a process for Grievances and Appeals concerning communication or access to Covered Services or facilities. j. In addition to access and Continuity of Care standards specified in the rules cited in Subsection a, of this section, Contractor shall establish standards develop a methodology for evaluating access to Covered Services as described in Exhibit G and Continuity of Care which are consistent with the Accessibility requirements in OAR 410-141- 141-3220. k. Contractor shall ensure that each Member has an ongoing source of primary care appropriate to the Member's needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished as described in OAR 410-141-3120 and required by 42 CFR 438.208 (b)(1) and (2). l. Contractor shall allow each AI/AN Member enrolled with Contractor to choose an Indian Health Care Provider as the Member’s PCP if: (1) An Indian Health Care Provider is participating as a PCP within the Provider Network; and (2) The AI/AN Member is otherwise eligible to receive services from such Indian Health Care Provider; and (3) The Indian Health Care Provider has the capacity to provide primary health care services to such Members. m. Contractor shall provide female Members with direct access to women’s health specialists within the Provider Network for Covered Services necessary to provide women’s routine and preventive health care services. This is in addition to the Member’s designated PCP if the designated PCP is not a women’s health specialist. n. Contractor shall provide for a second opinion from a qualified Participating Provider, which may include a qualified mental health Participating Provider if appropriate, to determine Medically Appropriate services. If a qualified Participating Provider cannot be arranged then Contractor shall arrange for the Member to obtain the second opinion from a Non-Participating Provider, at no cost to the Member. o. To effectively integrate and coordinate health care and care management for Fully Dual Eligible Members, Contractor shall demonstrate its ability to provide Medicare benefits to Fully Dual Eligible Members. This may be accomplished Members through a one or more Medicare Advantage plan plans that is owned by, affiliated with, or contracted by the Contractor.