Common use of Network Capacity Clause in Contracts

Network Capacity. The Contractor shall maintain and monitor an appropriate and adequate provider network, supported by written agreements, sufficient to provide all Contracted Services under this Contract. The Contractor may provide Contracted Services through Non-Participating Providers, at a cost to the individual that is no greater than if the Contracted Services were provided by Participating Providers, if its network of Participating Providers is insufficient to meet the Behavioral Health needs of Individuals in a manner consistent with this Contract. This provision shall not be construed to require the Contractor to cover such services without authorization. To the extent necessary to provide non-crisis Behavioral Health services covered under this Contract, the Contractor may offer contracts to providers in other RSAs in the state of Washington and to providers in bordering states. The Contractor may not contract for Crisis Services (SUD or Mental Health) or ITA-related services out of Washington State. For non-crisis behavioral health services funded by GFS: The Contractor shall provide non-crisis Behavioral Health services funded by GFS, within Available Resources, to Individuals who meet financial eligibility standards in this Contract and meet one of the following criteria: Have insurance, but are unable to pay the co-pay or deductible for services; Are using excessive Crisis Services due to inability to access non-crisis behavioral health services; and Have more than five (5) visits over six (6) months to the emergency department, withdrawal management facility, or a sobering center due to a SUD. The Contractor must submit a network of contracted service providers adequate to serve the population in the Contractor’s RSA annually by November 1. If the Contractor fails to provide evidence of or HCA is unable to validate contracts with a sufficient number of providers, HCA may terminate this Contract. The network must have sufficient capacity to serve the RSA and include, at a minimum: 24/7/365 Telephone Crisis Intervention; Designated Crisis Responder (DCR); Evaluation and treatment (E&T) and Secure Withdrawal Management and Stabilization capacity to serve the RSA’s non-Medicaid population; Psychiatric inpatient beds to serve the RSA’s non-Medicaid population, including direct contracts with community hospitals at a rate no greater than that outlined in the HCA Fee-for-Service schedule; The Contractor shall notify HCA ninety (90) calendar days prior to terminating any of its Subcontracts or entering into new Subcontracts with entities that provide direct services, including Crisis Services providers. This notification shall occur prior to any public announcement of this change, and should include: The reason for termination The Contractor’s plan for notification of necessary stakeholders of the change in network. How the Contractor will ensure network adequacy with the loss of the subcontractor. If a Subcontract is terminated or a site closure occurs in less than the ninety (90) calendar days, the Contractor shall notify HCA as soon as possible. When a Subcontract is terminated or a site closes unexpectedly, the Contractor shall submit additional information to HCA in writing within seven (7) calendar days that includes: Notification to Ombuds services and Individuals; A provision for uninterrupted services; and Any information released to the media. HCA reserves the right to impose sanctions, in accordance with the Sanctions subsection of this Contract, if the Contractor was notified by the terminating provider in a timely manner and does not comply with the notification requirements of this section. If the Contractor does not receive timely notification from the terminating provider, the Contractor shall provide documentation of the date of notification along with the notice of loss of a terminating provider. Provider network information will be reviewed by HCA for: Completeness and accuracy; Removal of providers who no longer contract with the Contractor; and The effect the change(s) in the provider network will have on the Contractor’s compliance with the network requirements of this section. The Contractor shall meet the following requirements when developing its network: Only licensed or certified Behavioral Health Providers shall provide behavioral health services. Licensed or certified Behavioral Health Providers include, but are not limited to: Health Care Professionals, licensed agencies or clinics, or professionals operating under an agency affiliated license. Within Available Resources, establish and maintain contracts with office-based opioid treatment providers that have obtained a waiver under the Drug Addiction Treatment Act of 2000 to practice medication-assisted opioid addiction therapy. Assist the State in expanding community-based alternatives for crisis stabilization, such as mobile crisis outreach or crisis residential and respite beds. Assist the State in expanding community-based, Recovery-oriented services, use of Certified Peer Counselors and Research- and Evidence-Based Practices. If the Contractor, in HCA’s sole opinion, fails to maintain an adequate network for Crisis Services, HCA reserves the right to immediately terminate this Contract. In establishing, maintaining, monitoring and reporting of its network, the Contractor must consider the following: The expected utilization of services, the characteristics and health care needs of the population, the number and types of providers (training, experience and specialization) able to furnish services, and the geographic location of providers and Individuals (including distance, travel time, means of transportation ordinarily used by Individuals, and whether the location is ADA accessible) for all Contractor funded behavioral health programs and services based on Available Resources. The anticipated needs of priority populations identified in this Contract. The Contractor and its Subcontractors shall: Ensure that all services and activities provided under this Contract shall be designed and delivered in a manner sensitive to the needs of the diverse population; Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract as identified in their needs assessment. The Contractor shall require that providers offer hours of operation for Individuals that are no less than the hours of operation offered to any other patient.

Network Capacity. The Contractor shall maintain and monitor an appropriate and adequate provider network, supported by written agreements, sufficient to provide all Contracted Services GFS services under this Contract. The Contractor may provide Contracted Services through Non-Participating Providers, at a cost Contract to the individual that is no greater than if the Contracted Services were provided by Participating Providers, if its network of Participating Providers is insufficient to meet the Behavioral Health needs of Individuals in a manner consistent with this Contract. This provision shall not be construed to require the Contractor to cover such services without authorization. To the extent necessary to provide non-crisis Behavioral Health services covered under this Contract, the Contractor may offer contracts to providers in other RSAs in the state of Washington and to providers in bordering states. The Contractor may not contract for Crisis Services (SUD or Mental Health) or ITA-related services out of Washington State. For non-crisis behavioral health services funded by GFS: The Contractor shall provide non-crisis Behavioral Health services funded by GFS, within Available Resources, to Individuals who meet financial eligibility standards in this Contract and meet one of the following criteria: Have insurance, but are unable to pay the co-pay or deductible for services; Are using excessive Crisis Services due to inability to access non-crisis behavioral health services; and Have more than five (5) visits over six (6) months to the emergency department, withdrawal management facility, or a sobering center due to a SUD. The Contractor must submit a network of contracted service providers adequate to serve the population in the Contractor’s RSA annually by November 1. If the Contractor fails to provide evidence of or HCA is unable to validate contracts with a sufficient number of providers, HCA may terminate this Contract. The network must have sufficient capacity to serve the RSA and include, at a minimum: 24/7/365 Telephone Crisis Intervention; Designated Crisis Responder (DCR); Evaluation and treatment (E&T) and Secure Withdrawal Management and Stabilization capacity to serve the RSA’s non-Medicaid population; Psychiatric inpatient beds to serve the RSA’s non-Medicaid population, including direct contracts with community hospitals at a rate no greater than that outlined in the HCA Fee-for-Service schedule; The Contractor shall notify HCA ninety (90) calendar days prior to terminating any of its Subcontracts or entering into new Subcontracts with entities that provide direct services, including Crisis Services providers. This notification shall occur prior to any public announcement of this change, and should include: The reason for termination The Contractor’s plan for notification of necessary stakeholders of the change in network. How the Contractor will ensure network adequacy with the loss of the subcontractor. If a Subcontract is terminated or a site closure occurs in less than the ninety (90) calendar days, the Contractor shall notify HCA as soon as possible. When a Subcontract is terminated or a site closes unexpectedly, the Contractor shall submit additional information to HCA in writing within seven (7) calendar days that includes: Notification to Ombuds services and Individuals; A provision for uninterrupted services; and Any information released to the media. HCA reserves the right to impose sanctions, in accordance with the Sanctions subsection of this Contract, if the Contractor was notified by the terminating provider in a timely manner and does not comply with the notification requirements of this section. If the Contractor does not receive timely notification from the terminating provider, the Contractor shall provide documentation of the date of notification along with the notice of loss of a terminating provider. Provider network information will be reviewed by HCA for: Completeness and accuracy; Removal of providers who no longer contract with the Contractor; and The effect the change(s) in the provider network will have on the Contractor’s compliance with the network requirements of this sectionEnrollees. The Contractor shall meet incorporate the following requirements when developing its network: Only licensed or certified Behavioral Health Providers shall provide behavioral health services. Licensed or certified Behavioral Health Providers includeThe Contractor shall, but are not limited to: Health Care Professionalsin partnership with the BH-ASO, licensed agencies or clinics, or professionals operating under an agency affiliated license. Within Available Resources, establish and maintain contracts with office-based opioid treatment providers that have obtained a waiver under assist the Drug Addiction Treatment Act of 2000 state to practice medication-assisted opioid addiction therapy. Assist the State in expanding expand community-based alternatives for crisis stabilization, such as mobile crisis outreach or crisis residential and respite beds. Assist The Contractor shall assist the State in expanding state to expand community-based, Recoveryrecovery-oriented services and research- and evidence-based practices. The Contractor shall implement an adequate plan to provide Evaluation and Treatment services to Enrollees, which may include the development of less restrictive alternative to involuntary treatment or prevention programs reasonably calculated to reduce the demand for Evaluation and Treatment services, use of Certified Peer Counselors . Regional Behavioral Health entities must develop and Research- implement plans for improving access to timely and Evidence-Based Practicesappropriate treatment for Enrollees with Behavioral Health needs and current or prior criminal justice involvement. If the Contractor, in HCA’s sole opinion, fails to maintain an adequate network of GFS Behavioral Health providers in any contracted service area for Crisis Servicestwo (2) consecutive quarters, and after notification following the first quarter, HCA reserves the right to immediately terminate this Contract. In establishing, maintaining, monitoring and reporting of its network, the Contractor must consider the following: The expected utilization of services, the characteristics and health care needs of the population, the number and types of providers (training, experience and specialization) able to furnish services, and the geographic location of providers and Individuals (including distance, travel time, means of transportation ordinarily used by Individuals, and whether the location is ADA accessible) Contractor’s services for all Contractor funded behavioral health programs and services based on Available Resourcesthat service area. The anticipated needs network established under the Contract must complement and support the network of priority populations identified in this Medicaid providers established by the IAHFC Medicaid Contract. The Contractor shall update and its Subcontractors shall: Ensure that maintain the Contractor’s existing provider manual to include all relevant information regarding GFS services and activities provided under this Contract shall be designed and delivered in a manner sensitive to the needs of the diverse population; Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract as identified in their needs assessmentrequirements. The Contractor shall require have, maintain, and provide to HCA upon request an up-to- date database of its provider network. The Contractor shall update its existing database to meet the following requirements: A network inventory, including licensure, to quantify the number of providers offering GFS services, including a list of all GFS providers. Includes the providers’ names, locations, telephone numbers, GFS services offered, clinical specialty and areas of expertise. Includes a description of each provider’s language(s) spoken and if appropriate, a brief description of the provider’s skills or experiences that providers offer hours would support the cultural or linguistic needs of operation its Enrollees when provided by a provider. Indicates whether each provider has capacity to serve new patients and the limits on capacity for Individuals that are each provider. Updates to the provider database shall be made: no less than quarterly or whenever there is a change in the hours of operation offered Contractor’s network that would affect adequate capacity in a service area. Contractor program staff shall be available to any other patientconduct provider searches based on office or facility location, clinical specialty, provider discipline, provider capacity, available languages and allowable fund sources (e.g., Medicaid, GFS).

Network Capacity. The Contractor shall maintain and monitor an appropriate and adequate provider network, supported by written agreements, sufficient to provide all Contracted Services GFS services under this Contract. The Contractor may provide Contracted Services through Non-Participating ProvidersContract to its Enrollees; provided that, at a cost to the individual that is no greater than if the Contracted Services were provided by Participating Providers, if its network for purposes of Participating Providers is insufficient to meet the Behavioral Health needs of Individuals in a manner consistent with this Contract. This provision shall not be construed to require the Contractor to cover such services without authorization. To the extent necessary to provide non-crisis Behavioral Health services covered under this Contract, Indian Health Care Providers, whether or not they have executed a written agreement with the Contractor may offer contracts to providers in other RSAs in the state of Washington and to providers in bordering states. The Contractor may not contract for Crisis Services (SUD or Mental Health) or ITA-related services out of Washington State. For non-crisis behavioral health services funded by GFS: The Contractor shall provide non-crisis Behavioral Health services funded by GFSContractor, within Available Resources, to Individuals who meet financial eligibility standards in this Contract and meet one of the following criteria: Have insurance, but are unable to pay the co-pay or deductible for services; Are using excessive Crisis Services due to inability to access non-crisis behavioral health services; and Have more than five (5) visits over six (6) months to the emergency department, withdrawal management facility, or a sobering center due to a SUD. The Contractor must submit a network of contracted service providers adequate to serve the population will be treated as in the Contractor’s RSA annually by November 1provider network. If Any other changes that result in the Contractor fails being unable to meet access including a decrease in the number or frequency of a required service, employee strike or other work stoppage related to union activities, or any changes that results in the Contractor being unable to provide evidence of or HCA is unable to validate contracts with a sufficient number of providers, HCA may terminate this Contracttimely services. The network must have sufficient capacity to serve the RSA and include, at a minimum: 24/7/365 Telephone Crisis Intervention; Designated Crisis Responder (DCR); Evaluation and treatment (E&T) and Secure Withdrawal Management and Stabilization capacity to serve the RSA’s non-Medicaid population; Psychiatric inpatient beds to serve the RSA’s non-Medicaid population, including direct contracts with community hospitals at a rate no greater than that outlined in the HCA Fee-for-Service schedule; The Contractor shall notify HCA ninety (90) calendar days prior to terminating any of its Subcontracts with entities that provide direct services or entering into new Subcontracts subcontracts with entities that provide direct services, including Crisis Services providers. This notification shall occur prior to any public announcement of this change, and should include: The reason for termination The Contractor’s plan for notification of necessary stakeholders of the change in network. How the Contractor will ensure network adequacy with the loss of the subcontractor. If a Subcontract is terminated in less than ninety (90) days or a site closure occurs in less than the ninety (90) calendar days, the Contractor shall notify HCA as soon as possiblepossible and prior to a public announcement. When If a Subcontract subcontract is terminated or a site closes unexpectedlycloses, the Contractor shall submit additional information a plan to HCA in writing within seven (7) calendar days that includesincludes at a minimum: Notification to Ombuds services and Individualsservices; A Individual notification plan; Plan for provision for of uninterrupted services; and Any information released to the media. HCA reserves the right to impose sanctions, in accordance with the Sanctions subsection of this Contract, if the Contractor was notified by the terminating provider in a timely manner and does not comply with the notification requirements of this section. If the Contractor does not receive timely notification from the terminating provider, the Contractor shall provide documentation of the date of notification along with the notice of loss of a terminating provider. Provider network information will be reviewed by HCA for: Completeness and accuracy; Removal of providers who no longer contract with the Contractor; and The effect the change(s) in the provider network will have on the Contractor’s compliance with the network requirements of this section. The Contractor shall meet incorporate the following requirements when developing its network: Only licensed or certified Behavioral Health Providers shall provide behavioral health services. Licensed or certified Behavioral Health Providers includeThe Contractor shall, but are not limited to: Health Care Professionalsin partnership with the BH-ASO, licensed agencies or clinics, or professionals operating under an agency affiliated license. Within Available Resources, establish and maintain contracts with office-based opioid treatment providers that have obtained a waiver under assist the Drug Addiction Treatment Act of 2000 state to practice medication-assisted opioid addiction therapy. Assist the State in expanding expand community-based alternatives for crisis stabilization, such as mobile crisis outreach or crisis residential and respite beds. Assist The Contractor shall assist the State in expanding state to expand community-based, Recoveryrecovery‑oriented services and research- and evidence-oriented based practices and Promising Practices. The Contractor shall implement an adequate plan to provide Evaluation and Treatment services, use including Culturally Appropriate Care, to Enrollees, which may include the development of Certified Peer Counselors less restrictive alternative to involuntary treatment or prevention programs reasonably calculated to reduce the demand for Evaluation and Research- and Evidence-Based PracticesTreatment services. If the Contractor, in HCA’s sole opinion, and in conjunction with recommendations provided by the ACH, fails to maintain an adequate network of Behavioral Health providers in any contracted service area for Crisis Servicestwo (2) consecutive quarters, and after notification following the first quarter, HCA reserves the right to immediately terminate this Contract. In establishing, maintaining, monitoring and reporting of its network, the Contractor must consider the following: The expected utilization of services, the characteristics and health care needs of the population, the number and types of providers (training, experience and specialization) able to furnish services, and the geographic location of providers and Individuals (including distance, travel time, means of transportation ordinarily used by Individuals, and whether the location is ADA accessible) Contractor’s services for all Contractor funded behavioral health programs and services based on Available Resourcesthat service area. The anticipated needs network established under the Contract must complement and support the network of priority populations identified in this Medicaid providers established by the AH-IMC Medicaid Contract. The Contractor shall update and its Subcontractors shall: Ensure that maintain the Contractor’s existing provider manual to include all relevant information regarding GFS services and activities provided under this Contract shall be designed and delivered in a manner sensitive to the needs of the diverse population; Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract as identified in their needs assessmentrequirements. The Contractor shall require update its existing database to meet the following requirements: Includes a list of all GFS providers. Includes the providers’ names, locations, telephone numbers, GFS services offered, clinical specialty and areas of expertise. Includes a description of each provider’s language(s) spoken and if appropriate, a brief description of the provider’s skills or experiences that providers offer hours would support the cultural or linguistic needs of operation its Enrollees when provided by a provider. Indicates whether each provider has capacity to serve new patients and the limits on capacity for Individuals that are each provider. Updates to the provider database shall be made: no less than quarterly or whenever there is a change in the hours of operation offered Contractor’s network that would affect adequate capacity in a service area. Contractor program staff shall be available to any other patientconduct provider searches based on office or facility location, clinical specialty, provider discipline, provider capacity, available languages and allowable fund sources (e.g., Medicaid, GFS).

Network Capacity. The Contractor shall maintain and monitor an appropriate and adequate provider network, supported by written agreements, sufficient to provide all Contracted Services GFS services under this Contract. The Contractor may provide Contracted Services through Non-Participating Providers, at a cost Contract to the individual that is no greater than if the Contracted Services were provided by Participating Providers, if its network of Participating Providers is insufficient to meet the Behavioral Health needs of Individuals in a manner consistent with this Contract. This provision shall not be construed to require the Contractor to cover such services without authorization. To the extent necessary to provide non-crisis Behavioral Health services covered under this Contract, the Contractor may offer contracts to providers in other RSAs in the state of Washington and to providers in bordering states. The Contractor may not contract for Crisis Services (SUD or Mental Health) or ITA-related services out of Washington State. For non-crisis behavioral health services funded by GFS: The Contractor shall provide non-crisis Behavioral Health services funded by GFS, within Available Resources, to Individuals who meet financial eligibility standards in this Contract and meet one of the following criteria: Have insurance, but are unable to pay the co-pay or deductible for services; Are using excessive Crisis Services due to inability to access non-crisis behavioral health services; and Have more than five (5) visits over six (6) months to the emergency department, withdrawal management facility, or a sobering center due to a SUD. The Contractor must submit a network of contracted service providers adequate to serve the population in the Contractor’s RSA annually by November 1. If the Contractor fails to provide evidence of or HCA is unable to validate contracts with a sufficient number of providers, HCA may terminate this Contract. The network must have sufficient capacity to serve the RSA and include, at a minimum: 24/7/365 Telephone Crisis Intervention; Designated Crisis Responder (DCR); Evaluation and treatment (E&T) and Secure Withdrawal Management and Stabilization capacity to serve the RSA’s non-Medicaid population; Psychiatric inpatient beds to serve the RSA’s non-Medicaid population, including direct contracts with community hospitals at a rate no greater than that outlined in the HCA Fee-for-Service schedule; The Contractor shall notify HCA ninety (90) calendar days prior to terminating any of its Subcontracts or entering into new Subcontracts with entities that provide direct services, including Crisis Services providers. This notification shall occur prior to any public announcement of this change, and should include: The reason for termination The Contractor’s plan for notification of necessary stakeholders of the change in network. How the Contractor will ensure network adequacy with the loss of the subcontractor. If a Subcontract is terminated or a site closure occurs in less than the ninety (90) calendar days, the Contractor shall notify HCA as soon as possible. When a Subcontract is terminated or a site closes unexpectedly, the Contractor shall submit additional information to HCA in writing within seven (7) calendar days that includes: Notification to Ombuds services and Individuals; A provision for uninterrupted services; and Any information released to the media. HCA reserves the right to impose sanctions, in accordance with the Sanctions subsection of this Contract, if the Contractor was notified by the terminating provider in a timely manner and does not comply with the notification requirements of this section. If the Contractor does not receive timely notification from the terminating provider, the Contractor shall provide documentation of the date of notification along with the notice of loss of a terminating provider. Provider network information will be reviewed by HCA for: Completeness and accuracy; Removal of providers who no longer contract with the Contractor; and The effect the change(s) in the provider network will have on the Contractor’s compliance with the network requirements of this sectionEnrollees. The Contractor shall meet incorporate the following requirements when developing its network: Only licensed or certified Behavioral Health Providers shall provide behavioral health services. Licensed or certified Behavioral Health Providers includeThe Contractor shall, but are not limited to: Health Care Professionalsin partnership with the BH-ASO, licensed agencies or clinics, or professionals operating under an agency affiliated license. Within Available Resources, establish and maintain contracts with office-based opioid treatment providers that have obtained a waiver under assist the Drug Addiction Treatment Act of 2000 state to practice medication-assisted opioid addiction therapy. Assist the State in expanding expand community-based alternatives for crisis stabilization, such as mobile crisis outreach or crisis residential and respite beds. Assist The Contractor shall assist the State in expanding state to expand community-based, Recoveryrecovery-oriented services and research- and evidence-based practices. The Contractor shall implement an adequate plan to provide Evaluation and Treatment services to Enrollees, which may include the development of less restrictive alternative to involuntary treatment or prevention programs reasonably calculated to reduce the demand for Evaluation and Treatment services, use of Certified Peer Counselors . Regional Behavioral Health entities must develop and Research- implement plans for improving access to timely and Evidence-Based Practicesappropriate treatment for Enrollees with Behavioral Health needs and current or prior criminal justice involvement. If the Contractor, in HCA’s sole opinion, fails to maintain an adequate network of GFS Behavioral Health providers in any contracted service area for Crisis Servicestwo (2) consecutive quarters, and after notification following the first quarter, HCA reserves the right to immediately terminate this Contract. In establishing, maintaining, monitoring and reporting of its network, the Contractor must consider the following: The expected utilization of services, the characteristics and health care needs of the population, the number and types of providers (training, experience and specialization) able to furnish services, and the geographic location of providers and Individuals (including distance, travel time, means of transportation ordinarily used by Individuals, and whether the location is ADA accessible) Contractor’s services for all Contractor funded behavioral health programs and services based on Available Resourcesthat service area. The anticipated needs network established under the Contract must complement and support the network of priority populations identified in this Medicaid providers established by the AH-IMC Medicaid Contract. The Contractor shall update and its Subcontractors shall: Ensure that maintain the Contractor’s existing provider manual to include all relevant information regarding GFS services and activities provided under this Contract shall be designed and delivered in a manner sensitive to the needs of the diverse population; Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract as identified in their needs assessmentrequirements. The Contractor shall require have, maintain, and provide to HCA upon request an up- to-date database of its provider network. The Contractor shall update its existing database to meet the following requirements: A network inventory, including licensure, to quantify the number of providers offering GFS services, including a list of all GFS providers. Includes the providers’ names, locations, telephone numbers, GFS services offered, clinical specialty and areas of expertise. Includes a description of each provider’s language(s) spoken and if appropriate, a brief description of the provider’s skills or experiences that providers offer hours would support the cultural or linguistic needs of operation its Enrollees when provided by a provider. Indicates whether each provider has capacity to serve new patients and the limits on capacity for Individuals that are each provider. Updates to the provider database shall be made: no less than quarterly or whenever there is a change in the hours of operation offered Contractor’s network that would affect adequate capacity in a service area. Contractor program staff shall be available to any other patientconduct provider searches based on office or facility location, clinical specialty, provider discipline, provider capacity, available languages and allowable fund sources (e.g., Medicaid, GFS).