Common use of FEDERAL ACCESS STANDARDS Clause in Contracts

FEDERAL ACCESS STANDARDS. The MyCare Ohio Plan (MCOP) 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 MCOP 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 MCOP. 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 MCOP shall adequately and timely cover services from an out-of-network provider if the MCOP’s contracted provider panel is unable to provide the services covered under the MCOP’s provider agreement. The MCOP shall cover the out-of-network services for as long as the MCOP network is unable to provide the services. The MCOP 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 MCOP shall ensure services are available 24 hours a day, 7 days a week, when medically necessary. The MCOP 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 comply with 42 CFR 438.206 and 438.207, and demonstrate adequate provider panel capacity and services, the MCOP shall submit documentation as specified to the Ohio Department of Medicaid (ODM), in a format specified by ODM, demonstrating the MCOP offers an appropriate range of preventive, primary care, specialty, behavioral health, family planning, and waiver 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 be submitted to ODM no less frequently than at the time the MCOP enters into a contract with ODM; at any time there is a significant change (as defined by ODM) in the MCOP’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 MCOP. d. When a waiver enrollee expresses a preference for an independent (non-agency) provider for an eligible service identified on the member’s person-centered service plan, the MCOP shall make available the following: i. A directory of all non-agency providers of the following waiver services: 1. Personal Care; 2. Waiver Nursing; 3. Home Care Attendant; and

FEDERAL ACCESS STANDARDS. The MyCare Ohio Plan (MCOP) 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 MCOP 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 MCOP. 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 MCOP shall adequately and timely cover services from an out-of-network provider if the MCOP’s contracted provider panel is unable to provide the services covered under the MCOP’s provider agreement. The MCOP shall cover the out-of-network services for as long as the MCOP network is unable to provide the services. The MCOP 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 MCOP shall ensure services are available 24 hours a day, 7 days a week, when medically necessary. The MCOP 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 comply with 42 CFR 438.206 and 438.207, and demonstrate adequate provider panel capacity and services, the MCOP shall submit documentation as specified to the Ohio Department of Medicaid (ODM), in a format specified by ODM, demonstrating the MCOP offers an appropriate range of preventive, primary care, specialty, behavioral health, family planning, and waiver 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 be submitted to ODM no less frequently than at the time the MCOP enters into a contract with ODM; at any time there is a significant change (as defined by ODM) in the MCOP’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 MCOP. d. When a waiver enrollee expresses a preference for an independent (non-agency) provider for an eligible service identified on the member’s person-centered service plan, the MCOP shall make available the following: i. A directory of all non-agency providers of the following waiver services: 1. Personal Care; 2. Waiver Nursing; 3. Home Care Attendant; and

FEDERAL ACCESS STANDARDS. The MyCare Ohio Plan (MCOP) 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 MCOP 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 MCOP. 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 MCOP shall adequately and timely cover services from an out-of-network provider if the MCOP’s contracted provider panel is unable to provide the services covered under the MCOP’s provider agreement. The MCOP shall cover the out-of-network services for as long as the MCOP network is unable to provide the services. The MCOP 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 MCOP shall ensure services are available 24 hours a day, 7 days a week, when medically necessary. The MCOP 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 comply with 42 CFR 438.206 and 438.207, and demonstrate adequate provider panel capacity and services, the MCOP shall submit documentation as specified to the Ohio Department of Medicaid (ODM), in a format specified by ODM, demonstrating the MCOP offers an appropriate range of preventive, primary care, specialty, behavioral health, family planning, and waiver 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 be submitted to ODM no less frequently than at the time the MCOP enters into a contract with ODM; at any time there is a significant change (as defined by ODM) in the MCOP’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 MCOP. d. When a waiver enrollee expresses a preference for an independent (non-agency) provider for an eligible service identified on the member’s person-centered service plan, the MCOP shall make seek out an available independent provider. The MCOP shall offer the following: i. A directory of all non-agency providers independent provider a contract for provision of the following waiver services: 1. Personal Care; 2. Waiver Nursing; 3. Home Care Attendant; andservices to the member when the provider is willing, acceptable to the member, and appropriate to the member’s care, and approved by ODM or the Ohio Department of Aging (ODA) with an active Medicaid provider agreement to render services in accordance with OAC Chapters 173-39 and 5160-45 as appropriate.