Common use of Network Providers Clause in Contracts

Network Providers. Contractor shall establish, maintain, and monitor a Provider Network, including hospitals, PCPs, WHCPs, specialist Physicians, clinical laboratories, dentists, OB/GYNs, oral surgeons, pharmacies, behavioral‐health Providers, substance‐abuse Providers, CMHCs, and all other provider types. 5.7.1.1 This network shall be sufficient to provide adequate access to all Covered Services under the Contract, taking into consideration: 5.7.1.1.1 the anticipated number of Enrollees; 5.7.1.1.2 the expected utilization of services, in light of the characteristics and healthcare needs of Contractor’s Enrollees; 5.7.1.1.3 the number and types of Providers required to furnish the Covered Services; 5.7.1.1.4 the number of Network Providers who are not accepting new patients; and 5.7.1.1.5 the geographic location of Providers and Enrollees, taking into account distance, travel time, the means of transportation, and whether the location provides physical access for Enrollees with disabilities. 5.7.1.2 During the first year of this Contract for all Contracting Areas, Contractor shall enter into a contract with any willing and qualified Provider in the Contracting Area that renders Nursing Facility and waiver services, as set forth in Attachment I, so long as the Provider agrees to Contractor’s rate and adheres to Contractor’s QA requirements. To be considered a qualified Provider, the Provider must be in good standing with the Department’s FFS Medical Program. Contractor may establish quality standards in addition to those State and federal requirements and, after the first year of this Contract, contract only with Providers that meet such standards. Such standards must be approved by the Department, in writing, and Contractors may only terminate a contract of a Provider based on failure to meet such standards if two (2) criteria are met: 1) such standards have been in effect for at minimum one (1) year, and 2) Providers are informed at the time such standards come into effect. 5.7.1.3 For NFs and SLFs, Contractor must maintain the adequacy of its Provider Network sufficient to provide Enrollees with reasonable choice within each county of the Contracting Area, provided that each Network Provider meets all applicable State and federal requirements for participation in the HFS Medical Program. Contractor may require as a condition for participation in its network that a NF agree to provide access to Contractor’s or Subcontractor’s Care Management team by acting upon the team’s credentialing applications in accordance with generally applicable standards, to permit qualified members of the team to write medication and lab orders, to access Enrollees in order to conduct physical examinations, and to serve as PCP for an Enrollee. 5.7.1.4 For Providers of each of the Covered Services identified in this section 5.7.1.4 under a HCBS Waiver, Contractor must enter into contracts with a sufficient number of such Providers within each county in the Contracting Area to assure that the Network Providers served at least eighty percent (80%) of the number of Participants in each county who were receiving such services on the day immediately preceding the day such services became Covered Services. For counties served by more than one (1) Provider of such Covered Services, Contractor shall enter into contracts with at least two (2) such Providers, so long as such Providers accept Contractor’s rates, even if one (1) Provider served more than eighty percent (80%) of the Participants, unless the Department grants Contractor an exception, in writing. These Covered Services include: 5.7.1.4.1 Adult day care

Network Providers. Contractor shall establish, maintain, and monitor a Provider Network, including hospitals, PCPsprimary care Providers, WHCPs, specialist Physicians, clinical laboratories, dentists, OB/GYNs, oral surgeons, pharmacies, behavioral‐health behavioral-health Providers, substance‐abuse substance-abuse Providers, CMHCs, and all other provider types. 5.7.1.1 This network shall be sufficient to provide adequate access to all Covered Services under the Contract, taking into consideration:consideration:‌ 5.7.1.1.1 the anticipated number of Enrollees; 5.7.1.1.2 the expected utilization of services, in light of the characteristics and healthcare needs of Contractor’s Enrollees; 5.7.1.1.3 the number and types of Providers required to furnish the Covered Services; 5.7.1.1.4 the number of Network Providers who are not accepting new patients; and 5.7.1.1.5 the geographic location of Providers and Enrollees, taking into account distance, travel time, the means of transportation, and whether the location provides physical access for Enrollees with disabilities.disabilities.‌ 5.7.1.2 During the first year of this Contract for all Contracting Areas, Contractor shall enter into a contract with any willing and qualified Provider in the Contracting Area that renders Nursing Facility and waiver services, as set forth in Attachment I, so long as the Provider agrees to Contractor’s rate and adheres to Contractor’s QA requirements. To be considered a qualified Provider, the Provider must be in good standing with the Department’s FFS Medical Program. Contractor may establish quality standards in addition to those State and federal requirements and, after the first year of this Contract, and contract only with Providers that meet such standards. Such standards must be approved by the Department, in writing, and Contractors may only terminate a contract of a Provider based on failure to meet such standards if two (2) criteria are met: 1a) such standards have been in effect for at minimum one (1) year, and 2b) Providers are informed at the time such standards come into effect. 5.7.1.3 For NFs and SLFs, Contractor must maintain the adequacy of its Provider Network sufficient to provide Enrollees with reasonable choice within each county of the Contracting Area, provided that each Network Provider meets all applicable State and federal requirements for participation in the HFS Medical Program. Contractor may require as a condition for participation in its network that a NF agree to provide access to Contractor’s or Subcontractor’s Care Management team by acting upon the team’s credentialing applications in accordance with generally applicable standards, to permit qualified members of the team to write medication and lab orders, to access Enrollees in order to conduct physical examinations, and to serve as PCP for an Enrollee. 5.7.1.4 For Providers of each of the Covered Services identified in this section 5.7.1.4 under a an HCBS Waiver, Contractor must enter into contracts with a sufficient number of such Providers within each county in the Contracting Area to assure that the Network Providers served at least eighty percent (80%) of the number of Participants in each county who were receiving received such services on the day immediately preceding the day such services became Covered Services. For counties served by more than one (1) Provider of such Covered Services, Contractor shall enter into contracts with at least two (2) such Providers, so long as such Providers accept Contractor’s rates, even if one (1) Provider served more than eighty percent (80%) of the Participants, unless the Department grants Contractor an exception, in writing. These Covered Services include: 5.7.1.4.1 Adult include:‌ 5.7.1. 4.1 adult day care;

Network Providers. Contractor shall establish, maintain, and monitor a Provider Network, including hospitals, PCPs, WHCPs, specialist Physicians, clinical laboratories, dentists, OB/GYNs, oral surgeons, pharmacies, behavioral‐health behavioral-health Providers, substance‐abuse substance-abuse Providers, CMHCs, and all other provider types. 5.7.1.1 This network shall be sufficient to provide adequate access to all Covered Services under the Contract, taking into consideration: 5.7.1.1.1 the anticipated number of Enrollees; 5.7.1.1.2 the expected utilization of services, in light of the characteristics and healthcare needs of Contractor’s Enrollees;Enrollees;‌ 5.7.1.1.3 the number and types of Providers required to furnish the Covered Services; 5.7.1.1.4 the number of Network Providers who are not accepting new patients; and 5.7.1.1.5 the geographic location of Providers and Enrollees, taking into account distance, travel time, the means of transportation, and whether the location provides physical access for Enrollees with disabilities. 5.7.1.2 During the first year of this Contract for all Contracting Areas, Contractor shall enter into a contract with any willing and qualified Provider in the Contracting Area that renders Nursing Facility and waiver services, as set forth in Attachment I, so long as the Provider agrees to Contractor’s rate and adheres to Contractor’s QA requirements. To be considered a qualified Provider, the Provider must be in good standing with the Department’s FFS Medical Program. Contractor may establish quality standards in addition to those State and federal requirements and, after the first year of this Contract, contract only with Providers that meet such standards. Such standards must be approved by the Department, in writing, and Contractors may only terminate a contract of a Provider based on failure to meet such standards if two (2) criteria are met: 1) such standards have been in effect for at minimum one (1) year, and 2) Providers are informed at the time such standards come into effect. 5.7.1.3 For NFs and SLFs, Contractor must maintain the adequacy of its Provider Network sufficient to provide Enrollees with reasonable choice within each county of the Contracting Area, provided that each Network Provider meets all applicable State and federal requirements for participation in the HFS Medical Program. Contractor may require as a condition for participation in its network that a NF agree to provide access to Contractor’s or Subcontractor’s Care Management team by acting upon the team’s credentialing applications in accordance with generally applicable standards, to permit qualified members of the team to write medication and lab orders, to access Enrollees in order to conduct physical examinations, and to serve as PCP for an Enrollee. 5.7.1.4 For Providers of each of the Covered Services identified in this section 5.7.1.4 under a HCBS Waiver, Contractor must enter into contracts with a sufficient number of such Providers within each county in the Contracting Area to assure that the Network Providers served at least eighty percent (80%) of the number of Participants in each county who were receiving such services on the day immediately preceding the day such services became Covered Services. For counties served by more than one (1) Provider of such Covered Services, Contractor shall enter into contracts with at least two (2) such Providers, so long as such Providers accept Contractor’s rates, even if one (1) Provider served more than eighty percent (80%) of the Participants, unless the Department grants Contractor an exception, in writing. These Covered Services include: include:‌ 5.7.1.4.1 Adult day carecare 5.7.1.4.2 Homecare/in-home services 5.7.1.4.3 Day Habilitation‌