Common use of Documentation of Network Adequacy Clause in Contracts

Documentation of Network Adequacy. A. The Contractor shall give assurances to the Department and provide supporting documentation that demonstrates Contractor has the capacity to serve the expected enrollment in its service area in accordance with the network adequacy standards developed by the Department as required by departmental guidance and regulation. (42 C.F.R. § 438.207(a).) B. The Contractor shall submit documentation to the Department, in a format specified by the Department, to demonstrate that it complies with the following requirements: 1) Offers an appropriate range of specialty services that are adequate for the anticipated number of beneficiaries for the service area. 2) Maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of beneficiaries in the service area. (42 C.F.R. § 438.207(b).) C. The Contractor shall submit the documentation as specified by the Department, but no less frequently than the following: 1) At the time it enters into this Contract with the Department; 2) On an annual basis; and 3) At any time there has been a significant change, as defined by the Department, in Contractor’s operations that would affect the adequacy and capacity of services, including the following: a) A decrease of 25 percent or more in services or providers available to beneficiaries; b) Changes in benefits; c) Changes in geographic service area; d) Composition of or payments to Contractor’s provider network; or e) Enrollment of a new population in Contractor’s county. (42 C.F.R. § 438.207(c).) D. The Contractor shall include details regarding the change and Contractor’s plans to ensure beneficiaries continue to have access to adequate services and providers.