Availability and Access Standards. This network must include a panel of primary care providers from which the enrollee may select a personal primary care provider. Requirements for adequate access state that: • Routinely used delivery sites, including PCPs’ offices and the offices of frequently used specialists, must be located within thirty (30) minutes travel time; • Basic hospital services must be located within forty-five (45) minutes travel time; and • Tertiary services must be located within sixty (60) minutes travel time. The intent of these standards is to provide for access to services at least as good, if not better, than access to care under the traditional Medicaid program. BMS will periodically publish specific network standards that define which provider types are considered “frequently used specialists” in each county or region, based on a comparison to the traditional Medicaid program or other criteria as defined by BMS. Exceptions to these standards will be permitted where the travel time standard is better than what exists in the community at large. For example if the community standard for basic hospital services is sixty (60) minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) minutes travel time (not within forty-five (45) minutes travel time). MCOs will be required to comply with updated network standards within ninety (90) days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) days of issuance. The MCO must ensure that the hours of operation of its providers are convenient, do not discriminate against enrollees, and are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid fee-for-service. MCOs must ensure that waiting times at sites of care are kept to a minimum and ensure that the waiting time standard for Medicaid enrollees is the same standard used for commercial enrollees. Providers cannot discriminate against Medicaid enrollees in the order that patients are seen or in the order that appointments are given (providers are not permitted to schedule Medicaid-only days). When Medically Necessary, the MCO makes services available 24 hours a day, seven days a week. The MCO must establish a mechanism to ensure that providers comply with the access standards set forth in this contract. The MCO should regularly measure the extent to which providers in the network comply with these requirements and take remedial action if necessary. The MCO must ensure that services ...
Availability and Access Standards. The MCO must ensure that all covered services, including additional or supplemental services contracted by or on behalf of Medicaid enrollees, are available and accessible as required in 42 CFR §438.68, §438.206, and §438.207. The MCO must have policies and procedures, including coverage rules, practice guidelines, payment policies and utilization management, that allow for individual medical necessity determinations. The Department has set minimum provider network adequacy standards that the MCO must meet or exceed in all geographic areas in which the MCO operates. The full list of network adequacy standards is included in Appendix K. They include standards for: • PCPs’, • Specialists; • OB/GYNs; • Basic hospital services; • Tertiary hospital services6; • Pediatric dental providers; • Behavioral Health providers and facilities; • Substance Use Disorder (SUD) providers and facilities; and • Additional providers when it promotes the objectives of the Medicaid program as determined by CMS. The intent of these standards is to provide for access to services at least as good, if not better, than access to care under the traditional Medicaid program. DHHR will periodically publish specific network standards that define which provider types are considered adult and pediatric specialists. The MCO will be required to comply with updated network standards within ninety (90) calendar days of issuance, unless otherwise agreed to in writing by DHHR within sixty (60) calendar days of issuance. During any period in which the MCO does not meet minimum network standards, the MCO must ensure that appropriate processes are implemented to adequately cover services in a timely manner out-of-network, including paying claims to out-of-network providers and ensuring that enrollees incur no additional costs, as specified in 42 CFR §438.206(b) and §457.1230(a).
Availability and Access Standards. The MCO must ensure that all covered services, including additional or supplemental services contracted by or on behalf of Medicaid and WVCHIP enrollees, are available and accessible. The MCO must have policies and procedures, including coverage rules, practice guidelines, payment policies and utilization management, that allow for individual medical necessity determinations. Policies and procedures must outline how cases of medical necessity will be handled when medical service limits or prescription limits are met, per BMS’ policies. BMS has set minimum provider network adequacy standards that the MCO must meet or exceed, as set forth in Appendix I. They include adult and pediatric standards for: PCPs; Specialists; OB/GYNs; Basic hospital services; Tertiary hospital services7; Pediatric and adult dental providers, Behavioral Health providers and facilities; Substance Use Disorder (SUD) providers and facilities; Psychiatric Residential Treatment Facilities (PRTF); and Additional providers when it promotes the objectives of the Medicaid and WVCHIP programs as determined by CMS. The intent of these standards is to provide for access to services at least as good, if not better, than access to care under the traditional Medicaid and WVCHIP programs. BMS will periodically publish specific network standards that define which provider types are considered adult and pediatric specialists. The MCO will be required to comply with updated network standards within ninety (90) calendar days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) calendar days of issuance. During any period in which the MCO does not meet minimum network standards, the MCO must ensure that appropriate processes are implemented to adequately cover services in a timely manner out-of-network, including paying claims to out-of-network providers and ensuring that enrollees incur no additional costs.
Availability and Access Standards. This network must include a panel of primary care providers from which the enrollee may select a personal primary care provider. Requirements for adequate access state that: • Routinely used delivery sites, including PCPs’ offices and the offices of frequently used specialists, must be located within thirty (30) minutes travel time, including but not limited to: pediatric primary care, OB/GYN, pediatric mental health providers, pediatric Substance Use Disorder (SUD) providers, pediatric specialists, pediatric dental; • Basic hospital services must be located within forty-five (45) minutes travel time; and • Tertiary services must be located within sixty (60) minutes travel time. The intent of these standards is to provide for access to services at least as good, if not better, than access to care under the traditional Medicaid program. DHHR will periodically publish specific network standards that define which provider types are considered “frequently used specialists” in each county or region, based on a comparison to the traditional Medicaid program or other criteria as defined by DHHR. Exceptions to these standards will be permitted where the travel time standard is better than what exists in the community at large. For example if the community standard for basic hospital services is sixty (60) minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) minutes travel time (not within forty-five
Availability and Access Standards. The MCO must ensure that all covered services, including additional or supplemental services contracted by or on behalf of Medicaid enrollees, are available and accessible. The MCO must have policies and procedures, including coverage rules, practice guidelines, payment policies and utilization management, that allow for individual medical necessity determinations. BMS has set minimum provider network adequacy standards that the MCO must meet or exceed in all geographic areas in which the MCO operates. The full list of network adequacy standards are included in Appendix J. They include adult and pediatric standards for: • PCPs ; • Specialists; • OB/GYNs; • Basic hospital services; • Tertiary hospital services7; • Pediatric dental providers • Behavioral Health providers and facilities; • Substance Use Disorder (SUD) providers and facilities; and • Additional providers when it promotes the objectives of the Medicaid program as determined by CMS.
