Common use of Availability and Access Standards Clause in Contracts

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 enrollees, are available and accessible as required in 42 CFR §438.68, §438.206, and §438.207accessible. 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 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 is are included in Appendix K. I. They include adult and pediatric standards for: •  PCPs’, • ;  Specialists; •  OB/GYNs; •  Basic hospital services; •  Tertiary hospital services6services7; •  Pediatric and adult 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 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 DHHR 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, 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 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 enrollees, are available and accessible as required in 42 CFR §438.68, §438.206, and §438.207accessible. 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 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 is are included in Appendix K. I. They include adult and pediatric standards for: • PCPs’, ; • Specialists; • OB/GYNs; • Basic hospital services; • Tertiary hospital services6services7; • Pediatric and adult 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 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 DHHR 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, 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 enrollees, are available and accessible as required in 42 CFR §438.68, §438.206, and §438.207accessible. 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 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 is are included in Appendix K. J. They include adult and pediatric standards for: • PCPs’, PCPs ; • Specialists; • OB/GYNs; • Basic hospital services; • Tertiary hospital services6services7; • Pediatric dental providers; 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 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 DHHR 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, as specified in 42 CFR §438.206(b) and §457.1230(a).