Network Adequacy Requirements. The County must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the County must consider:
1. The anticipated BadgerCare Plus enrollment with particular attention to children with serious emotional disturbance.
2. The expected utilization of services, considering member characteristics and health care needs.
3. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
Network Adequacy Requirements. The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this contract. In establishing the network, the HMO must consider:
a. The anticipated Medicaid and BadgerCare enrollment.
b. The expected utilization of services, considering enrollee characteristics and health care needs.
c. The number and types of providers (in terms of training experience and specialization) required to furnish the contracted services.
Network Adequacy Requirements. The PIHP must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the PIHP must consider:
1. The anticipated FCMH enrollment;
2. The expected utilization of services, considering member characteristics and health care needs of children in out-of-home placement enrolled in the FCMH;
3. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
4. The number of network providers not accepting new patients.
5. The geographic location of providers and members, distance, travel time, normal means of transportation used by members and whether provider locations are accessible to members with disabilities.
6. The experience of providers in caring for children in out-of-home placement in order to assure access to timely and adequate mental health and substance abuse services performed by qualified persons with experience treating children in out-of-home care;
7. Its ability to provide trauma-informed care in one or more treatment modalities as specified in “Creating Trauma-Informed and Developmentally Appropriate Systems of Care in Child Abuse and Neglect Prevention: Guiding Principles of Practice” prepared by the Wisconsin Children’s Trust Fund;
8. The requirement that it have a written policy for contracting on an ad hoc basis with non-network providers, including a process for assuring that the providers are Medicaid-certified and clear procedures for billing and payment. The PIHP must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification or upon request of the Department. The PIHP must submit its provider network and facility file electronically to the State’s FTP monthly. The file must be submitted in the format designated by the Department in the PIHP Provider Network File Submission Specification Guide. The PIHP must also notify the appropriate FCMH Managed Care Analyst of changes related to network adequacy. Changes that could affect network adequacy have been defined by the Department as changes in the PIHP’s operations that would affect adequate capacity and services, including modifications to PIHP benefits, geographic service areas, provider networks, payments, or enrollment of a new population into the PIHP. (42 CFR 438.207(c)(2)(i-ii)) The PIHP must notify the Department of any geographical service area ...
Network Adequacy Requirements. The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the HMO must consider:
a. The anticipated BadgerCare Plus and/or Medicaid SSI enrollment.
b. The expected utilization of services, considering enrollee characteristics and health care needs.
c. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
d. The number of network providers not accepting new patients.
e. The geographic location of providers and enrollees, distance, travel time, normal means of transportation used by enrollees and whether provider locations are accessible to enrollees with disabilities. The HMO must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre- contract certification or upon request of the Department. In addition, the HMO must update the documentation and assurance to the Department with respect to network adequacy whenever there has been a significant change, as defined by the Department, in the HMO’s operations that would affect adequate capacity and services, including changes in HMO benefits, geographic service areas, provider network, payments, or enrollment of a new population in the HMO. (42 CFR, §. 438.207(c)(2)(i-ii))
Network Adequacy Requirements. The PIHP must ensure that its delivery network is sufficient to provide adequate access to all services covered under this contract. In establishing the network, the PIHP must consider:
a. The anticipated FCMH enrollment;
b. The expected utilization of services, considering characteristics and health care needs of children in out-of-home placement enrolled in the FCMH;
c. The number and types of providers (in terms of training experience and specialization) required to furnish the contracted services;
Network Adequacy Requirements. Add as a new last paragraph: The HMO must notify the Department of any service area reductions 120 days before the intended decertification date. The HMO must submit a member communication/transition plan for all service area reductions.
Network Adequacy Requirements. The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the HMO must consider:
1. The anticipated BadgerCare Plus and/or Medicaid SSI enrollment.
2. The expected utilization of services, considering member characteristics and health care needs.
3. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
4. The number of network providers not accepting new patients.
5. The geographic location of providers and members, distance, travel time, normal means of transportation used by members and whether provider locations are accessible to members with disabilities. The HMO must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification or upon request of the Department. The HMO must also submit an updated provider network and facility file electronically to the State’s FTP as part of the certification review process and when there are significant service area changes. The file must be submitted in the format designated by the Department and include, at a minimum, the name, address, BadgerCare Plus and/or Medicaid SSI provider ID number and/or National Provider Identifier, if applicable, and dates of certification for BadgerCare Plus and/or Medicaid SSI. The HMO must also notify the appropriate Managed Care Contract Compliance Analyst of changes related to network adequacy. Changes that could affect network adequacy have been defined by the Department as changes in the HMO’s operations that would affect adequate capacity and services, including modifications to HMO benefits, geographic service areas, provider networks, payments, or enrollment of a new population into the HMO. (42 CFR 438.207(c)(2)(i-ii)) The HMO must notify the Department of any geographical service area reductions 120 days before the intended decertification date unless DHS agrees to a shorter time period based on extraordinary circumstances beyond the control of the HMO. The HMO must submit a member communication/transition plan for all service area reductions.
Network Adequacy Requirements. The County must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the County must consider:
1. The anticipated BadgerCare Plus enrollment with particular attention to children with serious emotional disturbance.
2. The expected utilization of services, considering member characteristics and health care needs.
3. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
4. The number of network providers not accepting new patients.
5. The geographic location of providers and members, distance, travel time, normal means of transportation used by members.
6. Whether network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid members with physical or mental disabilities.
7. Whether network providers have the ability to communicate with limited English proficient members in their preferred language.
8. As part of the certification application process to review network adequacy and access, each County will be required to document any use of telemedicine (beyond what is covered by ForwardHealth), e-visits, and/or other evolving and innovative technological solutions as part of its covered services, administrative infrastructure, and/or care management model. The County must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification, annual provider network recertification, or upon request of the Department. The County must submit its provider network and facility file electronically to the State’s SFTP weekly and when there are significant service area changes. The file must be submitted in the format designated by the Department in the County Provider Network File Submission Specification Guide. The County must also notify the appropriate Analyst of changes related to network adequacy. Changes that could affect network adequacy have been defined by the Department as changes in the County’s operations that would affect adequate capacity and services, including modifications to County benefits, geographic service areas, provider networks, payments, or enrollment of a new population into the County per (42 CFR 438.207(c)(2)(i-ii)). The County must notify the Department of any geographical service area reductions 120 days before the intended decertification date unless DHS a...
Network Adequacy Requirements. The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the HMO must consider:
a. The anticipated BadgerCare Plus and/or Medicaid SSI enrollment.
b. The expected utilization of services, considering member characteristics and health care needs.
c. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
d. The number of network providers not accepting new patients.
e. The geographic location of providers and members, distance, travel time, normal means of transportation used by members and whether provider locations are accessible to members with disabilities. The HMO must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre- contract certification or upon request of the Department. The HMO must also submit an updated provider network and facility file to the State’s FTP server every 6 months, and notify the appropriate Managed Care Contract Compliance Analyst when there has been a significant change with respect to network adequacy, as defined by the Department, in the HMO’s operations that would affect adequate capacity and services, including changes in HMO benefits, geographic service areas, provider network, payments, or enrollment of a new population into the HMO. (42 CFR, §. 438.207(c)(2)(i-ii)) The HMO must notify the Department of any geographical service area reductions 120 days before the intended decertification date unless DHS agrees to a shorter time period based on extraordinary circumstances beyond the control of the HMO. The HMO must submit a member communication/transition plan for all service area reductions.
Network Adequacy Requirements. The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the HMO must consider:
a. The anticipated BadgerCare Plus and/or Medicaid SSI enrollment.
b. The expected utilization of services, considering member characteristics and health care needs.
c. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services.
d. The number of network providers not accepting new patients.
e. The geographic location of providers and members, distance, travel time, normal means of transportation used by members and whether provider locations are accessible to members with disabilities. The HMO must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre- contract certification or upon request of the Department. The HMO must also submit an updated provider network and facility file to the State’s FTP server monthly, and notify the appropriate Managed Care Contract Compliance Analyst when there has been a significant change with respect to network adequacy, as defined by the Department, in the HMO’s operations that would affect adequate capacity and services, including changes in HMO benefits, geographic service areas, provider network, payments, or enrollment of a new population into the HMO. (42 CFR, §.
