Common use of FEDERAL ACCESS STANDARDS Clause in Contracts

FEDERAL ACCESS STANDARDS. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under the MCP’s 's provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, . 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); and at any time there is enrollment of a new population in the MCP. Hospital System1 1 These hospitals 1 1 1 Hospital system includes; physician networks and therefore these physicians could be considered when fulfilling contracts for PCP and non-PCP provider panel requirements Minimum PCP Capacity Requirements - ABD PCPs Total Required Ashtabula Cuyahoga Erie Geauga Huron Lake Lxxxxx Xxxxxx Additional Required: In-Region * Number of Eligibles 25,810 1462 18425 532 213 432 963 2474 451 1 Acceptable PCP specialty types include Family/General Practice or Internal Medicine Gastroenterology 3 2 1 Nephrology 2 1 1 Neurology 3 2 1 Otolaryngologist 3 1 1 1 Physical Med Rehab 3 2 1 Psychiatry 11 5 3 3 Urology 4 2 2 1 All required providers must provide obstetrical services if such a hospital is available be located within the region. 2 Additional required providers may be located anywhere within the region MCPs must comply with all applicable program integrity requirements, including those specified in the county/region.42 CFR 455 and 42 CFR 438 Subpart H.

FEDERAL ACCESS STANDARDS. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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.and

FEDERAL ACCESS STANDARDS. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • - The anticipated Medicaid membership. • - The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • - The number and types (in terms of training, experience, and specialization) of panel providers required to deliver furnish the contracted Medicaid services. • - 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 for Medicaid members with disabilities. • - MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under the MCP’s 's provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting panel providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with these timely access requirements, . MCPs are required to regularly monitor their provider panels to determine compliance and must if necessary take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 437.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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 MCPs are to follow the procedures specified in the county/regioncurrent MCP PVS Instructional Manual in order to comply with these federal access requirements.

FEDERAL ACCESS STANDARDS. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under the MCP’s 's provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Appendix H Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); and at any time there is enrollment of a new population in the MCP. 1 These hospitals 1. As required by federal regulation, 42 CFR 438.240, each managed care plan (MCP) must provide obstetrical services if such a hospital have an ongoing Quality Assessment and Performance Improvement Program (QAPI) that is available in annually prior-approved by the county/region.Ohio Department of Job and Family Services (ODJFS). The program must include the following elements:

FEDERAL ACCESS STANDARDS. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); and at any time there is enrollment of a new population in the MCP. 1. 1 These hospitals 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 provide obstetrical services if such a hospital is available include all required Health Statement filings, schedules and exhibits as stated in the county/region.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. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • The anticipated Medicaid membership. • The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • The number and types (in terms of training, experience, and specialization) of panel providers required to deliver furnish the contracted Medicaid services. • 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 for Medicaid members with disabilities. • MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s contracted provider panel is unable to provide the services covered under the MCP’s provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting panel providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with these timely access requirements, . MCPs are required to regularly monitor their provider panels to determine compliance and must if necessary take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 437.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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 MCPs are to follow the procedures specified in the county/region.current MCP PVS Instructional Manual in order to comply with these federal access requirements. Appendix H

FEDERAL ACCESS STANDARDS. MCPs must demonstrate that they are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: In establishing and maintaining their provider panel, MCPs must consider the following: • - The anticipated Medicaid membership. • - The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the MCP. • - The number and types (in terms of training, experience, and specialization) of panel providers required to deliver the contracted Medicaid services. • - 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 for Medicaid members with disabilities. • - MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s 's contracted provider panel is unable to provide the services covered under the MCP’s 's provider agreement. The MCP must cover the out-of-network services for as long as the MCP network is unable to provide the services. MCPs must coordinate with the out-of-network provider with respect to payment and ensure that the provider agrees with the applicable requirements. Contracting providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary 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 must be submitted to ODJFS no less frequently than at the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s 's operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); 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