Enrollee Access to Services. A. General
Enrollee Access to Services. 2.11.1. The Contractor must provide services to Enrollees as follows:
Enrollee Access to Services. General The Contractor: Must demonstrate its ability to meet the needs of Enrollees competently and promptly; Must offer adequate choice and availability of Providers, and allow each Enrollee to choose his or her Provider to the extent possible and appropriate; Must provide adequate access to Covered Services (listed in Appendix A), including physical and geographic access. Such access must be designed to accommodate the needs of Enrollees who are disabled or non-English speaking, including access to TTY (for the deaf and hard of hearing) and translation services; Must provide all Covered Services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services provided under MassHealth fee for service. Must provide all Covered Services that are medically necessary pursuant to 130 CMR 450.204, including those Covered Services that: Prevent, diagnose, and treat health impairments; Achieve age-appropriate growth and development; Attain, maintain, or regain functional capacity; and Provide an opportunity for an Enrollee receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or choice. Must ensure that all Covered Services are sufficient in an amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; May place appropriate limits on a Covered Service for the purpose of utilization control, provided that: The furnished services can reasonably be expected to achieve their purpose; Services supporting Enrollees with ongoing or chronic conditions or who require LTSS are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports; and Family planning services are provided in a manner that protects and enables the Enrollee’s freedom to choose the method of family planning to be used. May place appropriate limits on a Covered Service on the basis of Medical Necessity. The Contractor’s Medical Necessity guidelines must, at a minimum, be: Developed with input from practicing physicians throughout the Contractor’s Regions; Developed in accordance with standards adopted by national accreditation organizations where applicable and available; Developed in accordance with the definition of Medical Necessity in this Contract and therefore no more restrictive than MassHealth Medical Necessity guidelines; Updated at least annually or as new treatme...
Enrollee Access to Services. A. General The Contractor must:
Enrollee Access to Services
