Common use of Adequacy of Providers Clause in Contracts

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by SCDHHS, of organizational components, including, but not limited to, PCPs, specialty providers and other 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 SCDHHS, to ensure that all contracted services are available and accessible in a timely manner within the Contractor's service area in accordance with §4 and as approved by SCDHHS. The Contractor shall make available and accessible, as determined by SCDHHS, 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. SCDHHS’ detailed standards, criteria and requirements for county network submissions and ongoing review are located in the Policy and Procedure Guide. Services to a Program member shall be provided in the same manner as those services that are provided to commercial members of the Contractor. The Contractor shall notify SCDHHS immediately of any changes to the composition of its provider network and/or subcontractors that materially and adversely affects its ability to make available all core benefits in a timely manner in accordance with §4 of this Contract. The Contractor shall also have procedures to address changes in its provider network that negatively affect the ability of members to access services. Material changes in provider network composition that are not prior approved by SCDHHS and/or that may impair the member's access to services will be considered as grounds for Contract termination. The Contractor understands and agrees that notwithstanding the execution of this Contract, neither the Contractor nor its subcontractor/network provider shall provide any services until the Contractor has an adequate provider network verified and approved by SCDHHS. In the event any county network(s) is found to be in violation of requirements stated in §4.9.2, Adequacy of Providers, SCDHHS reserves the right to implement the Provider Network Termination and/or Transition Plan, as described in the Policy and Procedure Guide. The Contractor will be responsible for all financial costs associated with termination or transition of its provider network(s), including, but not limited to, costs associated with changes to the enrollment broker’s website and computer system and any mailings by the enrollment broker and/or SCDHHS to the Contractor’s members concerning the termination and/or transition(s). SCDHHS may also, in its sole discretion, suspend any new enrollments in the Contractor’s plan, including auto-enrollments, in the affected county (ies) during the Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain the county network(s).

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by SCDHHS, of organizational components, including, but not limited to, PCPs, specialty providers and other 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 SCDHHS, to ensure that all contracted services are available and accessible in a timely manner within the Contractor's service area in accordance with §4 and as approved by SCDHHS. The Contractor shall make available and accessible, as determined by SCDHHS, 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. SCDHHS’ detailed standards, criteria and requirements for county network submissions and ongoing review are located in the Policy and Procedure Guide. Services to a Program member shall be provided in the same manner as those services that are provided to commercial members of the Contractor. The Contractor shall notify SCDHHS immediately of any changes to the composition of its provider network and/or subcontractors that materially and adversely affects its ability to make available all core benefits in a timely manner in accordance with §4 of this Contract. The Contractor shall also have procedures to address changes in its provider network that negatively affect the ability of members to access services. Material changes in provider network composition that are not prior approved by SCDHHS and/or that may impair the member's access to services will be considered as grounds for Contract termination. The Contractor understands and agrees that notwithstanding the execution of this Contract, neither the Contractor nor its subcontractor/network provider shall provide any services until the Contractor has an adequate provider network verified and approved by SCDHHS. In the event any county network(s) is found to be in violation of requirements stated in §§ 4.9.2, Adequacy of Providers, SCDHHS reserves shall reserve the right to implement the Provider County Network Termination and/or 90 Day Transition Plan, as described in the Policy and Procedure Guide. The Contractor will be responsible for all financial costs associated with termination or transition of its provider network(s), including, but not limited to, costs associated with changes to the enrollment broker’s website and computer system and any mailings by the enrollment broker and/or SCDHHS to the Contractor’s members concerning the termination and/or transition(s). SCDHHS may also, in its sole discretion, suspend any new enrollments in the Contractor’s plan, including auto-enrollments, in the affected county (ies) during the Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain the county network(s).

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by SCDHHS, of organizational components, including, but not limited to, PCPsto primary care providers, specialty providers and other 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 SCDHHS, to ensure that all contracted services are available and accessible in a timely manner within the Contractor's service area in accordance with §§ 4 and as approved by SCDHHS. The Contractor shall make available and accessible, as determined by SCDHHS, hospitals, facilities, and professional personnel sufficient to provide the required core benefits. The locations of facilities, PCPsprimary care providers, and network providers must be sufficient in terms of geographic convenience to low-income and rural areas. SCDHHS’ 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 Program Medicaid MCO program member shall be provided in the same manner as those services that are provided to commercial members of the Contractor. The services shall be as accessible to Medicaid MCO program members as they are for non-Medicaid members residing in the same geographic service area. The Contractor shall notify SCDHHS immediately of any changes to the composition of its provider network and/or subcontractors that materially and adversely affects its ability to make available all core benefits in a timely manner in accordance with §§ 4 of this Contract. The Contractor shall also have procedures to address changes in its provider network that negatively affect the ability of Medicaid MCO program members to access services. Material changes in provider network composition that are not prior approved by SCDHHS and/or that may impair the Medicaid MCO program member's access to services will be considered as grounds for Contract termination. The Contractor understands and agrees that notwithstanding the execution of this Contractcontract, neither the Contractor nor its subcontractor/network provider shall provide any services to Medicaid MCO program member until the Contractor has an adequate provider network verified and approved by SCDHHS. In the event any a MCO’s county network(s) is found to be in violation of the requirements stated in §4.9.2, Adequacy of Providersthis section, SCDHHS reserves 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. The Contractor will be responsible for all financial costs associated with termination or transition of its provider county network(s), including, but not limited to, costs associated with changes to the enrollment broker’s website and computer system and any mailings by the enrollment broker and/or SCDHHS to the Contractor’s members concerning the termination and/or transition(stermination(s). SCDHHS may also, in its sole discretion, suspend any new enrollments in the Contractor’s plan, including auto-enrollments, in the affected county (iescounty(ies) during the Termination/Transition Plan period or until the Contractor has demonstrated that it will be able to maintain the county network(s).

Adequacy of Providers. The Contractor shall maintain appropriate levels, as determined by SCDHHSthe Department, of organizational components, including, but not limited to, to PCPs, specialty providers Specialty Providers, hospitals and other providers Health Care 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 SCDHHSthe Department, to ensure that all contracted services Covered 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 SCDHHSthe Department. The Contractor shall make available and accessible, as determined by SCDHHSthe Department, 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 areasareas as determined by the Department. SCDHHS’ 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 Program member Medicaid MCO Member shall be provided in the same manner as those services that are provided to commercial the Medicaid Fee-For-Service members of or by the Contractorother 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 SCDHHS the Department 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 ContractContract and the MCO Policy and Procedure Guide. The Contractor shall also have procedures to address changes in its provider Provider network that negatively affect the ability of members Medicaid MCO Members to access servicesall services available within the county or geographic location as determined by the Department. Material changes Changes in provider Provider network composition that are not prior approved by SCDHHS the Department and/or that may impair the memberMedicaid MCO Member's access to services will be considered as grounds for Contract terminationtermination 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 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 SCDHHSthe Department. In If during the event 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 network(s) is found to be in violation of requirements stated in §4.9.2or counties, Adequacy of Providers, SCDHHS reserves the Department shall reserve the right to implement the 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 will be is 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 and website, computer system and any mailings by the enrollment broker and/or SCDHHS to Department costs or charges associated with the Contractor’s members concerning the process of termination and/or transition(s)or transitioning a Contractor in a county or counties. SCDHHS The Department may also, in its sole discretion, suspend any new enrollments in into the Contractor’s health plan, including auto-enrollmentsauto- enrollments and choice, in the affected county (ies) 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 network(s).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