Common use of Adequacy of Providers Clause in Contracts

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by the Department, of organizational components, including, but not limited to PCPs, Specialty Providers, hospitals and other Health Care Providers necessary for the provision of the services under this Contract. The Contractor shall establish and maintain Provider networks and in-area referral Providers in sufficient numbers, as determined by the Department, to ensure that all Covered Services are available and accessible in a timely manner within the Contractor's Service Area in accordance with § 4 and as approved by the Department. The Contractor shall make available and accessible, as determined by the Department, hospitals, facilities, and professional personnel sufficient to provide the required Core Benefits. The locations of facilities, PCPs, and network Providers must be sufficient in terms of geographic convenience to low-income and rural areas as determined by the Department. The Department’s detailed standards, criteria and requirements for county network submissions and ongoing review are located in the MCO Policy and Procedure Guide. Services to a Medicaid MCO Member shall be provided in the same manner as those services that are provided to the Medicaid Fee-For-Service members or by the other MCOs in the same county or location. The services shall be as accessible to Medicaid MCO Members as they are for non-Medicaid members residing in the same geographic service area. The Contractor shall notify the Department immediately of any changes to the composition of its Provider network and/or subcontractors that adversely affects its ability to make available all Core Benefits in a manner as outlined in § 4 of this Contract and the MCO Policy and Procedure Guide. The Contractor shall have procedures to address changes in its Provider network that negatively affect the ability of Medicaid MCO Members to access all services available within the county or geographic location as determined by the Department. Changes in Provider network composition that are not prior approved by the Department and/or that impair the Medicaid MCO Member's access to services will be considered as grounds for Contract termination or removal from the county or geographical area as determined by the Department. The Contractor understands and agrees that notwithstanding the execution of this Contract, neither the Contractor nor its Subcontractor/network Provider shall provide any services to a Medicaid MCO Member until the Contractor has an adequate Provider network verified and approved by the Department. If during the annual review of the Provider Network Listing Spreadsheet, or during any review conducted at the discretion of the Department, it is determined the Contractor no longer meets the network adequacy standards for a county or counties, the Department shall reserve the right to implement MCO Provider Network Termination and/or Transition Plan, as described in the MCO Policy and Procedure Guide, whether or not a material change in the Contractor’s network has occurred. The Contractor is responsible for all financial costs or charges associated with termination or transition of its Provider network(s), including, but not limited to, costs or charges associated with changes to the enrollment broker’s website, computer system any mailings by the enrollment broker and/or Department costs or charges associated with the process of termination or transitioning a Contractor in a county or counties. The Department may also, in its sole discretion, suspend new enrollments into the Contractor’s health plan, including auto- enrollments and choice, in the affected county or counties including the surrounding counties during the MCO Provider Network Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain an adequate network in the county and surrounding counties. As a part of the MCO Provider Network Termination/Transition Plan, the Contractor must terminate all of its Provider contracts within the terminated counties. The Department may at its discretion impose a daily charge as outlined in Section 13.3

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by the DepartmentSCDHHS, of organizational components, including, but not limited to PCPsprimary care providers, Specialty Providers, hospitals specialty providers and other Health Care Providers providers necessary for the provision of the services under this Contract. The Contractor shall establish and maintain Provider provider networks and in-area referral Providers providers in sufficient numbers, as determined by the DepartmentSCDHHS, to ensure that all Covered Services contracted services are available and accessible in a timely manner within the Contractor's Service Area service area in accordance with § 4 and as approved by the DepartmentSCDHHS. The Contractor shall make available and accessible, as determined by the DepartmentSCDHHS, hospitals, facilities, and professional personnel sufficient to provide the required Core Benefitscore benefits. The locations of facilities, PCPsprimary care providers, and network Providers providers must be sufficient in terms of geographic convenience to low-income and rural areas as determined by the Departmentareas. The Department’s SCDHHS detailed standards, criteria and requirements for county network submissions and ongoing review are located in the MCO Policy and Procedure Guide. Services to a Medicaid MCO Member program member shall be provided in the same manner as those services that are provided to commercial members of the Medicaid Fee-For-Service members or by the other MCOs in the same county or locationContractor. The services shall be as accessible to Medicaid MCO Members program members as they are for non-Medicaid members residing in the same geographic service area. The Contractor shall notify the Department SCDHHS immediately of any changes to the composition of its Provider provider network and/or subcontractors that materially and adversely affects its ability to make available all Core Benefits core benefits in a timely manner as outlined in accordance with § 4 of this Contract and the MCO Policy and Procedure GuideContract. The Contractor shall also have procedures to address changes in its Provider provider network that negatively affect the ability of Medicaid MCO Members program members to access all services available within the county or geographic location as determined by the Departmentservices. Changes Material changes in Provider provider network composition that are not prior approved by the Department SCDHHS and/or that may impair the Medicaid MCO Memberprogram member's access to services will be considered as grounds for Contract termination or removal from the county or geographical area as determined by the Departmenttermination. The Contractor understands and agrees that notwithstanding the execution of this Contractcontract, neither the Contractor nor its Subcontractorsubcontractor/network Provider provider shall provide any services to a Medicaid MCO Member program member until the Contractor has an adequate Provider provider network verified and approved by SCDHHS. In the Department. If during the annual review event a MCO’s county network(s) is found to be in violation of the Provider Network Listing Spreadsheetrequirements stated in this section, or during any review conducted at the discretion of the Department, it is determined the Contractor no longer meets the network adequacy standards for a county or counties, the Department SCDHHS shall reserve the right to implement the MCO Provider County Network Termination and/or Transition Plan, as described in the MCO Policy and Procedure Guide, whether or not a material change in the Contractor’s network has occurred. The Contractor is will be responsible for all financial costs or charges associated with termination or transition of its Provider county network(s), including, but not limited to, costs or charges associated with changes to the enrollment broker’s website, website and computer system and any mailings by the enrollment broker and/or Department costs or charges associated with SCDHHS to the process of termination or transitioning a Contractor in a county or countiesContractor’s members concerning the termination(s). The Department SCDHHS may also, in its sole discretion, suspend any new enrollments into in the Contractor’s health plan, including auto- enrollments and choiceauto-enrollments, in the affected county or counties including the surrounding counties county(ies) during the MCO Provider Network Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain an adequate network in the county and surrounding counties. As a part of the MCO Provider Network Termination/Transition Plan, the Contractor must terminate all of its Provider contracts within the terminated counties. The Department may at its discretion impose a daily charge as outlined in Section 13.3network(s).

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by the DepartmentSCDHHS, of organizational components, including, but not limited to to, PCPs, Specialty Providers, hospitals specialty providers and other Health Care Providers providers necessary for the provision of the services under this Contract. The Contractor shall establish and maintain Provider provider networks and in-area referral Providers providers in sufficient numbers, as determined by the DepartmentSCDHHS, to ensure that all Covered Services contracted services are available and accessible in a timely manner within the Contractor's Service Area service area in accordance with § §4 and as approved by the DepartmentSCDHHS. The Contractor shall make available and accessible, as determined by the DepartmentSCDHHS, hospitals, facilities, and professional personnel sufficient to provide the required Core Benefitscore benefits. The locations of facilities, PCPs, and network Providers providers must be sufficient in terms of geographic convenience to low-income and rural areas as determined by the Departmentareas. The Department’s SCDHHS’ detailed standards, criteria and requirements for county network submissions and ongoing review are located in the MCO Policy and Procedure Guide. Services to a Medicaid MCO Member Program member shall be provided in the same manner as those services that are provided to commercial members of the Medicaid Fee-For-Service members or by the other MCOs in the same county or location. The services shall be as accessible to Medicaid MCO Members as they are for non-Medicaid members residing in the same geographic service areaContractor. The Contractor shall notify the Department SCDHHS immediately of any changes to the composition of its Provider provider network and/or subcontractors that materially and adversely affects its ability to make available all Core Benefits core benefits in a timely manner as outlined in § accordance with §4 of this Contract and the MCO Policy and Procedure GuideContract. The Contractor shall also have procedures to address changes in its Provider provider network that negatively affect the ability of Medicaid MCO Members members to access all services available within the county or geographic location as determined by the Departmentservices. Changes Material changes in Provider provider network composition that are not prior approved by the Department SCDHHS and/or that may impair the Medicaid MCO Membermember's access to services will be considered as grounds for Contract termination or removal from the county or geographical area as determined by the Departmenttermination. The Contractor understands and agrees that notwithstanding the execution of this Contract, neither the Contractor nor its Subcontractorsubcontractor/network Provider provider shall provide any services to a Medicaid MCO Member until the Contractor has an adequate Provider provider network verified and approved by SCDHHS. In the Department. If during the annual review event any county network(s) is found to be in violation of the Provider Network Listing Spreadsheetrequirements stated in § 4.9.2, or during any review conducted at the discretion Adequacy of the DepartmentProviders, it is determined the Contractor no longer meets the network adequacy standards for a county or counties, the Department SCDHHS shall reserve the right to implement MCO the Provider County Network Termination and/or 90 Day Transition Plan, as described in the MCO Policy and Procedure Guide, whether or not a material change in the Contractor’s network has occurred. The Contractor is responsible for all financial costs or charges associated with termination or transition of its Provider network(s), including, but not limited to, costs or charges associated with changes to the enrollment broker’s website, computer system any mailings by the enrollment broker and/or Department costs or charges associated with the process of termination or transitioning a Contractor in a county or counties. The Department may also, in its sole discretion, suspend new enrollments into the Contractor’s health plan, including auto- enrollments and choice, in the affected county or counties including the surrounding counties during the MCO Provider Network Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain an adequate network in the county and surrounding counties. As a part of the MCO Provider Network Termination/Transition Plan, the Contractor must terminate all of its Provider contracts within the terminated counties. The Department may at its discretion impose a daily charge as outlined in Section 13.3.

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by the DepartmentSCDHHS, of organizational components, including, but not limited to to, PCPs, Specialty Providers, hospitals specialty providers and other Health Care Providers providers necessary for the provision of the services under this Contract. The Contractor shall establish and maintain Provider provider networks and in-area referral Providers providers in sufficient numbers, as determined by the DepartmentSCDHHS, to ensure that all Covered Services contracted services are available and accessible in a timely manner within the Contractor's Service Area service area in accordance with § §4 and as approved by the DepartmentSCDHHS. The Contractor shall make available and accessible, as determined by the DepartmentSCDHHS, hospitals, facilities, and professional personnel sufficient to provide the required Core Benefitscore benefits. The locations of facilities, PCPs, and network Providers providers must be sufficient in terms of geographic convenience to low-income and rural areas as determined by the Departmentareas. The Department’s SCDHHS’ detailed standards, criteria and requirements for county network submissions and ongoing review are located in the MCO Policy and Procedure Guide. Services to a Medicaid MCO Member Program member shall be provided in the same manner as those services that are provided to commercial members of the Medicaid Fee-For-Service members or by the other MCOs in the same county or location. The services shall be as accessible to Medicaid MCO Members as they are for non-Medicaid members residing in the same geographic service areaContractor. The Contractor shall notify the Department SCDHHS immediately of any changes to the composition of its Provider provider network and/or subcontractors that materially and adversely affects its ability to make available all Core Benefits core benefits in a timely manner as outlined in § accordance with §4 of this Contract and the MCO Policy and Procedure GuideContract. The Contractor shall also have procedures to address changes in its Provider provider network that negatively affect the ability of Medicaid MCO Members members to access all services available within the county or geographic location as determined by the Departmentservices. Changes Material changes in Provider provider network composition that are not prior approved by the Department SCDHHS and/or that may impair the Medicaid MCO Membermember's access to services will be considered as grounds for Contract termination or removal from the county or geographical area as determined by the Departmenttermination. The Contractor understands and agrees that notwithstanding the execution of this Contract, neither the Contractor nor its Subcontractorsubcontractor/network Provider provider shall provide any services to a Medicaid MCO Member until the Contractor has an adequate Provider provider network verified and approved by SCDHHS. In the Department. If during the annual review event any county network(s) is found to be in violation of the Provider Network Listing Spreadsheetrequirements stated in §4.9.2, or during any review conducted at the discretion Adequacy of the DepartmentProviders, it is determined the Contractor no longer meets the network adequacy standards for a county or counties, the Department shall reserve SCDHHS reserves the right to implement MCO the Provider Network Termination and/or Transition Plan, as described in the MCO Policy and Procedure Guide, whether or not a material change in the Contractor’s network has occurred. The Contractor is will be responsible for all financial costs or charges associated with termination or transition of its Provider provider network(s), including, but not limited to, costs or charges associated with changes to the enrollment broker’s website, website and computer system and any mailings by the enrollment broker and/or Department costs or charges associated with SCDHHS to the process of Contractor’s members concerning the termination or transitioning a Contractor in a county or countiesand/or transition(s). The Department SCDHHS may also, in its sole discretion, suspend any new enrollments into in the Contractor’s health plan, including auto- enrollments and choiceauto-enrollments, in the affected county or counties including the surrounding counties (ies) during the MCO Provider Network Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain an adequate network in the county and surrounding counties. As a part of the MCO Provider Network Termination/Transition Plan, the Contractor must terminate all of its Provider contracts within the terminated counties. The Department may at its discretion impose a daily charge as outlined in Section 13.3network(s).