Common use of Network Management Clause in Contracts

Network Management. The MCO must: 1. use the results of its Provider profiling activities to identify areas of improvement for individual PCPs and Providers, and/or groups of Providers; 2. establish Provider-specific quality improvement goals for priority areas in which a Provider or Providers do not meet established MCO standards or improvement goals; 3. develop and implement incentives, which may include financial and non-financial incentives, to motivate Providers to improve performance on profiled measures; and 4. at least annually, measure and report to HHSC on the Provider Network and individual Providers’ progress, or lack of progress, towards such improvement goals. If the MCO implements a physician incentive plan, the plan must comply with the requirements of 42 C.F.R. §438.6(h), §422.208 and §422.210. The MCO cannot make payments under a physician incentive plan if the payments are designed to induce providers to reduce or limit Medically Necessary Covered Services to Members. If the physician incentive plan places a physician or physician group at a substantial financial risk for services not provided by the physician or physician group, the MCO must ensure adequate stop-loss protection and conduct and submit annual Member surveys no later than five (5) Business Days after the MCO finalizes the survey results (refer to 42 C.F.R. §422.208 for information concerning “substantial financial risk” and “stop-loss protection”). The MCO must make information regarding physician incentive plans available to Members upon request, in accordance with the Uniform Managed Care Manual’s requirements. The MCO must provide the following information to the Member: 1. whether the Member’s PCP or other Providers are participating in the MCO’s physician incentive plan; 2. whether the MCO uses a physician incentive plan that affects the use of referral services; 3. the type of incentive arrangement; and 4. whether stop-loss protection is provided. No later than five (5) Business Days prior to implementing or modifying a physician incentive plan, the MCO must provide the following information to HHSC: 1. Whether the physician incentive plan covers services that are not furnished by a physician or physician group. The MCO is only required to report on items 2-4 below if the physician incentive plan covers services that are not furnished by a physician or physician group. 2. The type of incentive arrangement (e.g., withhold, bonus, capitation); 3. The percent of withhold or bonus (if applicable); 4. The panel size, and if patients are pooled, the method used (HHSC approval is required for the method used); and If the physician or physician group is at substantial financial risk, the MCO must report proof that the physician or group has adequate stop-loss coverage, including the amount and type of stop-loss coverage.

Network Management. The MCO must: 1. use the results of its Provider profiling activities to identify areas of improvement for individual PCPs and Providers, and/or groups of Providers; 2. establish Provider-specific quality improvement goals for priority areas in which a Provider or Providers do not meet established MCO standards or improvement goals; 3. develop and implement incentives, which may include financial and non-financial incentives, to motivate Providers to improve performance on profiled measures; and 4. at least annually, measure and report to HHSC on the Provider Network and individual Providers’ progress, or lack of progress, towards such improvement goals. If the MCO implements a physician incentive plan, the plan must comply with the requirements of 42 C.F.R. §438.6(h), §422.208 and §422.210. The MCO cannot make payments under a physician incentive plan if the payments are designed to induce providers to reduce or limit Medically Necessary Covered Services to Members. If the physician incentive plan places a physician or physician group at a substantial financial risk for services not provided by the physician or physician group, the MCO must ensure adequate stop-loss protection and conduct and submit annual Member surveys no later than five (5) Business Days after the MCO finalizes the survey results (refer to 42 C.F.R. §422.208 for information concerning “substantial financial risk” and “stop-loss protection”). The MCO must make information regarding physician incentive plans available to Members upon request, in accordance with the Uniform Managed Care Manual’s requirements. The MCO must provide the following information to the Member: 1. whether the Member’s PCP or other Providers are participating in the MCO’s physician incentive plan; 2. whether the MCO uses a physician incentive plan that affects the use of referral services; 3. the type of incentive arrangement; and 4. whether stop-loss protection is provided. No later than five (5) Business Days prior to implementing or modifying a physician incentive plan, the MCO must provide the following information to HHSC: 1. Whether the physician incentive plan covers services that are not furnished by a physician or physician group. The MCO is only required to report on items 2-4 below if the physician incentive plan covers services that are not furnished by a physician or physician group. 2. The type of incentive arrangement (e.g., withhold, bonus, capitation); 3. The percent of withhold or bonus (if applicable); 4. The panel size, and if patients are pooled, the method used (HHSC approval is required for the method used); and If the physician or physician group is at substantial financial risk, the MCO must report proof that the physician or group has adequate stop-loss coverage, including the amount and type of stop-loss coverage.

Network Management. The MCO HMO must: 1. use Use the results of its Provider profiling activities to identify areas of improvement for individual PCPs and Providers, and/or groups of Providers; 2. establish Establish Provider-specific quality improvement goals for priority areas in which a Provider or Providers do not meet established MCO HMO standards or improvement goals; 3. develop Develop and implement incentives, which may include financial and non-financial incentives, to motivate Providers to improve performance on profiled measures; and 4. at At least annually, measure and report to HHSC on the Provider Network and individual Providers’ progress, or lack of progress, towards such improvement goals. If the MCO HMO implements a physician incentive plan, the plan must comply with the requirements of 42 C.F.R. §438.6(h), §422.208 and §422.210. The MCO HMO cannot make payments under a physician incentive plan if the payments are designed to induce providers to reduce or limit Medically Necessary Covered Services to Members. If the physician incentive plan places a physician or physician group at a substantial financial risk for services not provided by the physician or physician group, the MCO HMO must ensure adequate stop-loss protection and conduct and submit annual Member surveys no later than five (5) Business Days after the MCO HMO finalizes the survey results (refer to 42 C.F.R. §422.208 for information concerning “substantial financial risk” and “stop-loss protection”). The MCO HMO must make information regarding physician incentive plans available to Members upon request, in accordance with the Uniform Managed Care Manual’s requirements. The MCO HMO must provide the following information to the Member: 1. whether the Member’s PCP or other Providers are participating in the MCOHMO’s physician incentive plan; 2. whether the MCO HMO uses a physician incentive plan that affects the use of referral services; 3. the type of incentive arrangement; and 4. whether stop-loss protection is provided. No later than five (5) Business Days prior to implementing or modifying a physician incentive plan, the MCO HMO must provide the following information to HHSC: 1. Whether the physician incentive plan covers services that are not furnished by a physician or physician group. The MCO is only required to report on items 2-4 below if the physician incentive plan covers services that are not furnished by a physician or physician group. 2. The type of incentive arrangement (e.g., withhold, bonus, capitation); 3. The percent of withhold or bonus (if applicable); 4. The panel size, and if patients are pooled, the method used (HHSC approval is required for the method used); and If the physician or physician group is at substantial financial risk, the MCO must report proof that the physician or group has adequate stop-loss coverage, including the amount and type of stop-loss coverage.