Common use of Network Adequacy Clause in Contracts

Network Adequacy. Medi-Cal standards shall be utilized for long term services and supports, as described below, or for other services for which Medi-Cal is exclusive, and Medicare standards shall be utilized for pharmacy benefits and for other services for which Medicare is primary, unless applicable Medi-Cal standards are more stringent. Home health and durable medical equipment requirements, as well as any other services for which Medicaid and Medicare may overlap, shall be subject to the more stringent of the applicable Medicare and Medi-Cal standards. California has developed transition requirements that specify continuation of existing providers (see section V). Both the State and CMS will monitor access to services through survey, utilization, and complaints data to assess needs to Participating Plan network corrective actions. Participating Plans are responsible for access to services for beneficiaries. In addition to these protections, minimum LTSS standards for Participating Plans are below. CMS and the State will monitor access to care and the prevalence of needs indicated through enrollee assessments, and, based on those findings, may require that Participating Plans initiate further network expansion over the course of the Demonstration. i. Specifically, CMS and the state will require that Participating Plans: - Meet enrollees’ needs by contracting with a sufficient number of health facilities and providers that comply with applicable state and Federal laws, including, but not limited to, physical accessibility and the provision of health plan information in alternative formats. - Maintain an updated, accurate, and accessible listing of a provider's ability to accept new patients, which shall be made available to beneficiaries, at a minimum, by phone, written material, and Internet web site, upon request. - Maintain an appropriate provider network that includes an adequate number of specialists, primary care physicians, hospitals, long-term care providers and accessible facilities within each service area, per applicable Federal and state rules. - Contract with safety net and traditional providers, as defined state regulations, to ensure access to care and services. - Employ care managers directly or contract with care management organizations in sufficient numbers to provide coordinated care services for long-term services and supports as needed for all members.

Network Adequacy. Medi-Cal State Medicaid standards shall be utilized for long long-term services supports and supportsservices, as described below, or for other services for which Medi-Cal Medicaid is exclusive, and Medicare standards shall be utilized for pharmacy benefits and for other services for which Medicare is primary, unless applicable Medi-Cal Medicaid standards for such services are more stringent. Home health and durable medical equipment requirements, as well as any other services for which Medicaid and Medicare may overlap, shall be subject to the more stringent of the applicable Medicare and Medi-Cal Medicaid standards. California MDCH has developed transition requirements that specify continuation of existing providers for LTSS (see section VTable 7-C, “ICO Transition Requirements at Enrollment” below). MDCH and CMS also require that ICOs provide and arrange for timely access to all medically-necessary services covered by Medicare and Medicaid. Both the State MDCH and CMS will monitor access to services through survey, utilization, and complaints data to assess needs to Participating Plan for ICO network corrective actions. Participating Plans are responsible for access to services for beneficiaries. In addition to these protections, minimum LTSS standards for Participating Plans ICOs are below. Michigan will finalize the standards, based on administrative data and based on stakeholder input. CMS and the State MDCH will monitor access to care and the prevalence of needs indicated through enrollee assessments, and, based on those findings, may require that Participating Plans ICOs initiate further network expansion over the course of the Demonstration. i. Specifically.  The ICO is required to assure provider network adequacy and choice of providers. ICOs must have at least two available providers with sufficient capacity to accept enrollees, CMS and allowing enrollee choice of providers, including those providing supports coordination. When an ICO cannot assure choice within 30 miles for each enrollee, it may request a rural exception from MDCH.  The ICO will directly employ or contract with independent care providers of the enrollee’s choice, if the individual meets MDCH qualification requirements, to provide Medicaid Personal Care services. People who currently receive personal care services from an independent care provider may elect to continue to use that provider or select a new provider so long as that provider meets the state will require that Participating Plans: - Meet enrollees’ needs by contracting with qualifications. The ICO must meet the Medicare requirements for any covered services for which Medicare requires a sufficient more rigorous network adequacy standard than Medicaid (including time, distance, and/or minimum number of health facilities and providers that comply with applicable state and Federal lawsor facilities). Medicare network standards account for the type of service area (rural, includingurban, but not limited tosuburban, physical accessibility and the provision of health plan information in alternative formats. - Maintain an updatedetc.), accuratetravel time, and accessible listing of a provider's ability to accept new patients, which shall be made available to beneficiaries, at a minimum, by phone, written material, and Internet web site, upon request. - Maintain an appropriate provider network that includes an adequate minimum number of specialists, primary care physicians, hospitals, long-term care providers and accessible facilities within each service area, per applicable Federal and state rules. - Contract with safety net and traditional the type of providers, as defined state regulationswell as distance in certain circumstances. MDCH and CMS may grant exceptions to these general rules to account for patterns of care for Medicare-Medicaid beneficiaries, to ensure but will not do so in a manner that will dilute access to care for Medicare-Medicaid beneficiaries. Networks will be subject to confirmation through readiness reviews and services. - Employ care managers directly or contract with care management organizations in sufficient numbers to provide coordinated care services for long-term services and supports as needed for all memberson an ongoing basis.

Network Adequacy. Medi-Cal The following standards will be used for access to all covered services except in the event that Medicaid or Medicare standards are more stringent and would provide for increased access to providers. Each MMP’s provider network must meet the existing applicable Medicare and Medicaid provider network requirements. State Medicaid standards shall be utilized for long term services community-based and supportsfacility-based LTSS, as described below, or for other services for which Medi-Cal Medicaid is exclusive, and Medicare standards shall be utilized for pharmacy benefits and for other services for which Medicare is primary, unless applicable Medi-Cal Medicaid standards for such services are more stringentfavorable to the Enrollee (i.e., offer broader coverage). Home health and durable medical equipment requirements, as well as any other services for which Medicaid and Medicare may overlap, shall be subject to the more stringent favorable to the Enrollee (i.e., offer broader coverage) of the applicable Medicare and Medi-Cal Medicaid standards. California has developed transition requirements MMPs shall ensure they maintain a network of providers that specify continuation is sufficient in number, mix and geographic distribution to meet the complex and diverse needs of existing providers the anticipated number of Enrollees in the service area. Networks will be subject to confirmation through readiness reviews and regular examination on an ongoing basis. Medicare network standards account for the type of service area (see section Vrural, urban, suburban, etc.), travel time, and minimum number of the type of providers, as well as distance in certain circumstances. Both the The State and CMS will monitor access to services through survey, utilization, and complaints data to assess needs to Participating Plan network corrective actions. Participating Plans are responsible for access to services for beneficiaries. In addition may grant exceptions to these protectionsgeneral rules to account for patterns of care for Medicare- Medicaid Enrollees, minimum LTSS standards for Participating Plans are below. CMS and the State but will monitor not do so in a manner that will dilute access to care and for Enrollees. Additionally, the prevalence of needs indicated through enrollee assessments, and, based on those findings, may require that Participating Plans initiate further provider network expansion over the course must meet all of the Demonstration.following requirements: i. SpecificallyTwenty-four Hour Coverage: The MMP will provide coverage, CMS either directly or through its PCPs, to Enrollees on a twenty four (24) hours per day, seven (7) days per week basis. If PCPs are to provide such coverage, the MMP will have a back-up plan for instances where the PCP is not available. The MMP will also have written policies and the state will require that Participating Plans: - Meet enrollees’ needs by contracting with a sufficient number of health facilities procedures describing how Enrollees and providers that comply with applicable state and Federal laws, including, but not limited to, physical accessibility and can contact the provision MMP to receive instructions for treatment of health plan information in alternative formats. - Maintain an updated, accurate, and accessible listing of a provider's ability to accept new patients, which shall be made available to beneficiaries, at a minimum, by phone, written material, and Internet web site, upon request. - Maintain an appropriate provider network that includes an adequate number of specialists, primary care physicians, hospitals, long-term care providers and accessible facilities within each service area, per applicable Federal and state rules. - Contract with safety net and traditional providers, as defined state regulations, to ensure access to care and services. - Employ care managers directly emergent or contract with care management organizations in sufficient numbers to provide coordinated care services for long-term services and supports as needed for all membersurgent medical problem.