Common use of Availability and Access Standards Clause in Contracts

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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) hours; • Routine cases other than clinical preventive services, must be seen within twenty-one

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 offices, pharmacies and the offices of frequently used specialists, must be located within thirty (30) 30 minutes travel time; • Basic hospital services must be located within forty-five (45) 45 minutes travel time; and • Tertiary services must be located within sixty (60) 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) 60 minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) 60 minutes travel time (not within forty-five (45) 45 minutes travel time). MCOs will be required to comply with updated network standards within ninety (90) 90 days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) 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 Necessarymedically 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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) 48 hours; • Routine cases (as defined in Article II of this contract) other than clinical preventive servicesservices (as defined in Article II of this contract), must be seen within twenty-one21 days (exceptions are permitted at specific times when PCP capacity is temporarily limited); • EPSDT services must be scheduled in accordance to EPSDT guidelines and the EPSDT Periodicity Schedule; • An initial prenatal care visit must be scheduled within 14 days of the date on which the woman is found to be pregnant; and • XXXx should encourage SSI members to schedule an appointment with a PCP or specialist who manages the member’s care within 45 days of initial enrollment. If requested by the member or provider, the MCO should schedule or facilitate an appointment with the member’s PCP. 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.

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 offices, pharmacies and the offices of frequently used specialists, must be located within thirty (30) 30 minutes travel time; •  Basic hospital services must be located within forty-five (45) 45 minutes travel time; and •  Tertiary services must be located within sixty (60) 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) 60 minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) 60 minutes travel time (not within forty-five (45) 45 minutes travel time). MCOs will be required to comply with updated network standards within ninety (90) 90 days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) 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 Necessarymedically 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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: •  Emergency cases must be seen immediately or referred to an emergency facility; •  Urgent cases must be seen within forty-eight (48) 48 hours; •  Routine cases (as defined in Article II of this contract) other than clinical preventive servicesservices (as defined in Article II of this contract), must be seen within twenty-one21 days (exceptions are permitted at specific times when PCP capacity is temporarily limited);  EPSDT services must be scheduled in accordance to EPSDT guidelines and the EPSDT Periodicity Schedule;  An initial prenatal care visit must be scheduled within 14 days of the date on which the woman is found to be pregnant; and  MCOs should encourage SSI members to schedule an appointment with a PCP or specialist who manages the member’s care within 45 days of initial enrollment. If requested by the member or provider, the MCO should schedule or facilitate an appointment with the member’s PCP. 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.

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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: •  Emergency cases must be seen immediately or referred to an emergency facility; •  Urgent cases must be seen within forty-eight (48) hours; •  Routine cases other than clinical preventive services, must be seen within twenty-one

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) 30 minutes travel time; • Basic hospital services must be located within forty-five (45) 45 minutes travel time; and • Tertiary services must be located within sixty (60) 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) 60 minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) 60 minutes travel time (not within forty-five (45) 45 minutes travel time). MCOs will be required to comply with updated network standards within ninety (90) 90 days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) 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 Necessarymedically 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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness timeliness8 state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) 48 hours; 8 These standards may be modified by BMS, in which case the contract and program requirements will supersede this document. • Routine cases (as defined in Article II of this contract) other than clinical preventive servicesservices (as defined in Article II of this contract), must be seen within twenty-one21 days (exceptions are permitted at specific times when PCP capacity is temporarily limited); • EPSDT services must be scheduled in accordance to EPSDT guidelines and the EPSDT Periodicity Schedule; • An initial prenatal care visit must be scheduled within 14 days of the date on which the woman is found to be pregnant; and 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.

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 offices, pharmacies and the offices of frequently used specialists, must be located within thirty (30) 30 minutes travel time; • Basic hospital services must be located within forty-five (45) 45 minutes travel time; and • Tertiary services must be located within sixty (60) 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) 60 minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) 60 minutes travel time (not within forty-five (45) 45 minutes travel time). MCOs will be required to comply with updated network standards within ninety (90) 90 days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) 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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) 48 hours; • Routine cases (as defined in Article II of this contract) other than clinical preventive servicesservices (as defined in Article II of this contract), must be seen within twenty-one21 days (exceptions are permitted at specific times when PCP capacity is temporarily limited); • EPSDT services must be scheduled in accordance to EPSDT guidelines and the EPSDT Periodicity Schedule; • An initial prenatal care visit must be scheduled within 14 days of the date on which the woman is found to be pregnant; and • XXXx should encourage SSI members to schedule an appointment with a PCP or specialist who manages the member’s care within 45 days of initial enrollment. If requested by the member or provider, the MCO should schedule or facilitate an appointment with the member’s PCP. 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.

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 offices, pharmacies and the offices of frequently used specialists, must be located within thirty (30) 30 minutes travel time; •  Basic hospital services must be located within forty-five (45) 45 minutes travel time; and •  Tertiary services must be located within sixty (60) 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) 60 minutes travel time, then the MCO’s basic hospital service must be located within sixty (60) 60 minutes travel time (not within forty-five (45) 45 minutes travel time). MCOs will be required to comply with updated network standards within ninety (90) 90 days of issuance, unless otherwise agreed to in writing by BMS within sixty (60) 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 are provided in a culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. The MCO must also ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities. The MCO must have standards for timeliness of access to care and member services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: •  Emergency cases must be seen immediately or referred to an emergency facility; •  Urgent cases must be seen within forty-eight (48) 48 hours; •  Routine cases (as defined in Article II of this contract) other than clinical preventive servicesservices (as defined in Article II of this contract), must be seen within twenty-one21 days (exceptions are permitted at specific times when PCP capacity is temporarily limited);  EPSDT services must be scheduled in accordance to EPSDT guidelines and the EPSDT Periodicity Schedule;  An initial prenatal care visit must be scheduled within 14 days of the date on which the woman is found to be pregnant; and  MCOs should encourage SSI members to schedule an appointment with a PCP or specialist who manages the member’s care within 45 days of initial enrollment. If requested by the member or provider, the MCO should schedule or facilitate an appointment with the member’s PCP. 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.