Common use of FEDERAL ACCESS STANDARDS Clause in Contracts

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services in a timely manner, and ensure compliance with federally defined provider panel access standards as required by 42 CFR 438.206. a. In establishing and maintaining its provider panel, the MCP shall consider the following: i. The anticipated Medicaid membership. ii. The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment for Medicaid members with physical or mental disabilities. v. The MCP shall adequately and timely cover services provided by an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreement. The MCP shall cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall coordinate with the out- of-network provider with respect to payment and ensure the provider agrees with the applicable requirements. b. Contracting providers shall offer hours of operation no less than the hours of operation offered to commercial members or comparable to Medicaid FFS, if the provider serves only Medicaid members. The MCP shall ensure services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall establish mechanisms to ensure panel providers comply with timely access requirements and shall take corrective action if there is failure to comply. c. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall submit documentation to the Ohio Department of Medicaid (ODM), in a format specified by ODM, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall be submitted to ODM no less frequently than at the time the MCP enters into a contract with ODM; at any time there is a significant change (as defined by ODM) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : - The anticipated Medicaid membership. ii. - The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. - The number and types (in terms of training, experience, and specialization) of panel providers required to deliver furnish the contracted Medicaid services. iv. - The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . - MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under this Agreementthe MCP's provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting panel providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with these timely access requirements requirements. MCPs are required to regularly monitor their provider panels to determine compliance and shall if necessary take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 437.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. MCPs are to follow the procedures specified in the current MCP PVS Instructional Manual in order to comply with these federal access requirements.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : - The anticipated Medicaid membership. ii. - The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. - The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. - The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . - MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under this Agreementthe MCP's provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. MCPs are to follow the procedures specified in the current MCP PVS Instructional Manual, posted on the ODJFS website, in order to comply with these federal access requirements. NORTH EAST REGION - HOSPITALS MINIMUM PROVIDER PANEL REQUIREMENTS (2) 1 1(2) 1 1 1 1 1 1 HOSPITAL SYSTEM 1 1 (1) These hospitals must provide obstetrical services if such a hospital is available in the county/region. (2) The Cuyahoga hospital requirement may be met by either contracting with (1) that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds OR (2) a single general hospital that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds and a hospital system. NORTH EAST CENTRAL REGION - HOSPITALS MINIMUM PROVIDER PANEL REQUIREMENTS

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. Appendix H MCPs are to follow the procedures specified in the current MCP PVS Instructional Manual, posted on the ODJFS website, in order to comply with these federal access requirements. Hospital System 1 1 1 Preferred Providers are the additional provider contracts that must be secured in order for the MCP to receive bonus points. 2 These hospitals cannot be included under any subcontract used to meet the minimum required provider panel requirements. 3 These hospitals must provide obstetrical services if such a hospital is available in the county/region. 4 The Cuyahoga hospital requirement may be met by either contracting with (1) a single hospital system that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds OR (2) a single general hospital that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds and a hospital system. General Hospital3 3 1 1 4 1 1 Preferred Providers are the additional provider contracts that must be secured in order for the MCP to receive bonus points. 2 These hospitals cannot be included under any subcontract used to meet the minimum required provider panel requirements. 3 These hospitals must provide obstetrical services if such a hospital is available in the county/region, except where a hospital must meet the criteria specified in footnote #4 below.

FEDERAL ACCESS STANDARDS. The MCP shall MCPs must provide or arrange for the delivery of all medically necessary, Medicaid-covered health services services, as well as assure that they are in a timely manner, and ensure compliance with the following federally defined provider Provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. :  The anticipated Medicaid membership. ii.  The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii.  The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv.  The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall .  MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFS, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM), in a format specified by ODM, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM no less frequently than at the time the MCP enters into a contract with ODM; at any time there is a significant change (as defined by ODM) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. 1 These hospitals must provide obstetrical services if such a hospital is available in the county/region.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall . MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver furnish the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if Appendix H the MCP’s 's contracted provider panel is unable to provide the services covered under this Agreementthe MCP's provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with w ith the applicable requirements. b. . Contracting panel providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, . when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with w'ith these timely access requirements requirements. MCPs are required to regularly monitor their provider panels to determine compliance and shall if necessary take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODM, OD.IFS. that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, . and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. Total Required Hospitals Ashtabula Cuyahoga Erie Geauga Huron Lake Xxxxxx Xxxxxx Additional Required Hospitals: Out-of-Region Preferred Hospitals: In-Region2 Preferred Hospitals: Out-of Region 1 Preferred Providers are the additional provider contracts that must be secured in order for the MCP to receive bonus points. 2 These hospitals cannot be included under any subcontract used to meet the minimum required provider panel requirements. 3 These hospitals must provide obstetrical services if such a hospital is available in the county/region. 4 The Cuyahoga hospital requirement may be met by either contracting with (1) a single hospital that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds OR (2) a single general hospital that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds and a hospital system.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver furnish the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting panel providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with these timely access requirements requirements. MCPs are required to regularly monitor their provider panels to determine compliance and shall if necessary take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 437.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP.. MCPs are to follow the procedures specified in the current MCP PVS Instructional Manual in order to comply with these federal access requirements. Appendix H

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP.. 1. As required by federal regulation, 42 CFR 438.240, each managed care plan (MCP) must have an ongoing Quality Assessment and Performance Improvement Program (QAPI) that is annually prior-approved by the Ohio Department of Job and Family Services (ODJFS). The program must include the following elements:

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under this Agreementthe MCP's provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, . 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. Hospital System 1 1 1 Preferred Providers are the additional provider contracts that must be secured in order for the MCP to receive bonus points. 2 These hospitals cannot be included under any subcontract used to meet the minimim required provider panel requirements. 3 These hospitals must provide obstetrical services if such a hospital is available in the county/region. 4 The Cuyahoga hospital requirement may be met by either contracting with (1) a single hospital system that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds OR (2) a single general hospital that includes fifty (50) pediatric beds and five (5) pediatric intensive care unit (PICU) beds and a hospital system.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : Appendix H Page 9 In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. MCPs are to follow the procedures specified in the current MCP PVS Instructional Manual, posted on the ODJFS website, in order to comply with these federal access requirements.

FEDERAL ACCESS STANDARDS. The MCP shall provide or arrange for the delivery of all medically necessary, Medicaid-covered health services MCPs must demonstrate that they are in a timely manner, and ensure compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFSfee-for-service, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM)ODJFS, in a format specified by ODMODJFS, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM ODJFS no less frequently than at the time the MCP enters into a contract with ODMODJFS; at any time there is a significant change (as defined by ODMODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP. 1. SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS a. The National Association of Insurance Commissioners (NAIC) quarterly and annual Health Statements (hereafter referred to as the “Financial Statements”), as outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(B). The Financial Statements must include all required Health Statement filings, schedules and exhibits as stated in the NAIC Annual Health Statement Instructions including, but not limited to, the following sections: Assets, Liabilities, Capital and Surplus Account, Cash Flow, Analysis of Operations by Lines of Business, Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and Utilization. The Financial Statements must be submitted to BMHC even if the Ohio Department of Insurance (ODI) does not require the MCP to submit these statements to ODI. A signed hard copy and an electronic copy of the reports in the NAIC-approved format must both be provided to ODJFS; b. Hard copies of annual financial statements for those entities who have an ownership interest totaling five percent or more in the MCP or an indirect interest of five percent or more, or a combination of direct and indirect interest equal to five percent or more in the MCP; c. Annual audited Financial Statements prepared by a licensed independent external auditor as submitted to the ODI, as outlined in OAC rule 5101:3-26-09(B); d. Medicaid Managed Care Plan Annual Ohio Department of Job and Family Services (ODJFS) Cost Report and the auditor’s certification of the cost report, as outlined in OAC rule 5101:3-26-09(B); e. Medicaid MCP Annual Restated Cost Report for the prior calendar year. The restated cost report shall be audited upon BMHC request; f. Annual physician incentive plan disclosure statements and disclosure of and changes to the MCP’s physician incentive plans, as outlined in OAC rule 5101:3-26-09(B); g. Reinsurance agreements, as outlined in OAC rule 5101:3-26-09(C);

FEDERAL ACCESS STANDARDS. The MCP shall MCPs must provide or arrange for the delivery of all medically necessary, Medicaid-covered health services services, as well as assure that they are in a timely manner, and ensure compliance with the following federally defined provider Provider panel access standards as required by 42 CFR 438.206. a. : In establishing and maintaining its their provider panel, the MCP shall MCPs must consider the following: i. : • The anticipated Medicaid membership. ii. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. iii. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. iv. • The geographic location of panel providers and Medicaid members, considering distance, travel time, the means of transportation ordinarily used by Medicaid members, and whether the location provides physical access, reasonable accommodations, and accessible equipment access for Medicaid members with physical or mental disabilities. v. The MCP shall . • MCPs must adequately and timely cover services provided by to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under this Agreementthe MCP’s provider agreement. The MCP shall must cover the out-of-network services for as long as the MCP network is unable to provide the services. The MCP shall MCPs must coordinate with the out- out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. b. . Contracting providers shall must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid FFS, if the provider serves only Medicaid members. The MCP shall MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. The MCP shall MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements requirements, and shall must take corrective action if there is failure to comply. c. . In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP shall must submit documentation to the Ohio Department of Medicaid (ODM), in a format specified by ODM, that demonstrates it offers an appropriate range of preventive, primary care, behavioral health, family planning, care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area. This documentation of assurance of adequate capacity and services shall must be submitted to ODM no less frequently than at the time the MCP enters into a contract with ODM; at any time there is a significant change (as defined by ODM) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); on an annual basis; and at any time there is enrollment of a new population in the MCP.