Availability of Services. A. Pursuant to 42 CFR 438.206(a) and (b), the Contractor shall consider the numbers and types (in terms of training, experience and specialization) of providers required to ensure the availability and accessibility of medically necessary services. At a minimum, the Contractor shall meet the following requirements: 1) The Contractor shall maintain and monitor a network of appropriate providers that is supported by written agreements for subcontractors and that is sufficient to provide its beneficiaries with adequate access to all services covered under this Intergovernmental Agreement. In establishing and monitoring the network, the Contractor must document the following: a) The anticipated number of Medi-Cal eligible beneficiaries; b) The expected utilization of services, taking into account the characteristics and SUD treatment needs of beneficiaries; c) The expected number and types of providers in terms of training and experience needed to meet expected utilization; d) The numbers of network providers who are not accepting new beneficiaries; e) The geographic location of providers and their accessibility to beneficiaries, considering distance, travel time, means of transportation ordinarily used by Medi-Cal beneficiaries, and physical access for disabled beneficiaries; f) To the extent required by 42 CFR 438.206(b)(4), if the Contractor is unable to provide necessary medical services covered under the Intergovernmental Agreement to a particular beneficiary, the Contractor must adequately and timely cover these services out of network for the beneficiary, for as long as the Contractor is unable to provide them; g) Pursuant to 42 CFR 438.206(b)(5) the Contractor shall require that out-of- network providers coordinate authorization and payment with the Contractor. As is consistent with 42 CFR 438.106, the Contractor must ensure that the cost to the beneficiary for services provided out of network pursuant to an authorization is no greater than it would be if the services were furnished within the Contractor’s network; and h) The Contractor shall demonstrate that its providers are credentialed according to Section 1(G) of this Agreement and pursuant to 42 CFR 438.214.
Appears in 8 contracts
Samples: Standard Agreement, Standard Agreement, Intergovernmental Agreement
Availability of Services. A. Pursuant to 42 CFR 438.206(a) and (b), the Contractor shall consider the numbers and types (in terms of training, experience and specialization) of providers required to ensure the availability and accessibility of medically necessary services. At a minimum, the Contractor shall meet the following requirements:
1) The Contractor shall maintain and monitor a network of appropriate providers that is supported by written agreements for subcontractors and that is sufficient to provide its beneficiaries with adequate access to all services covered under this Intergovernmental Agreement. In establishing and monitoring the network, the Contractor must document the following:
a) The anticipated number of Medi-Cal eligible beneficiaries;
b) The expected utilization of services, taking into account the characteristics and SUD treatment needs of beneficiaries;
c) The expected number and types of providers in terms of training and experience needed to meet expected utilization;
d) The numbers of network providers who are not accepting new beneficiaries;
e) The geographic location of providers and their accessibility to beneficiaries, considering distance, travel time, means of transportation ordinarily used by Medi-Cal beneficiaries, and physical access for disabled beneficiaries;
f) To the extent required by 42 CFR 438.206(b)(4), if the Contractor is unable to provide necessary medical services covered under the Intergovernmental Agreement to a particular beneficiary, the Contractor must adequately and timely cover these services out of network for the beneficiary, for as long as the Contractor is unable to provide them;
g) Pursuant to 42 CFR 438.206(b)(5) the Contractor shall require that out-of- of network providers coordinate authorization and payment with the Contractor. As is consistent with 42 CFR 438.106, the Contractor must ensure that the cost to the beneficiary for services provided out of network pursuant to an authorization is no greater than it would be if the services were furnished within the Contractor’s network; and
h) The Contractor shall demonstrate that its providers are credentialed according to Section 1(G) of this Agreement and pursuant to 42 CFR 438.214.
Appears in 1 contract
Samples: Standard Agreement
