Provider Discrimination. The Contractor may not discriminate with respect to the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. If the Contractor declines to include an individual or groups of providers in its provider network, it will provide the affected providers with written notice of the reason for its decision.
Provider Discrimination. Neither Health Plan nor Subcontractor shall discriminate with respect to participation, reimbursement, or indemnification of a provider who is acting within the scope of the provider’s license or certification under applicable State law, solely on the basis of such license or certification. This provision shall not be construed as prohibiting Health Plan and Subcontractor from limiting a provider’s participation to the extent necessary to meet the needs of Covered Persons. This provision also is not intended and shall not interfere with measures established by Health Plan that are designed to maintain quality of care practice standards and control costs consistent with Health Plan’s responsibilities under the applicable State Contract.
Provider Discrimination. Neither Health Plan nor Subcontractor shall discriminate with respect to participation, reimbursement, or indemnification of a provider who is acting within the scope of the provider’s license or certification under applicable State law, solely on the basis of such license or certification. This provision shall not be construed as prohibiting Health Plan and Subcontractor from limiting a provider’s participation to the extent necessary to meet the needs of Covered Persons. This provision also is not intended and shall not interfere with measures established by Health Plan that are designed to maintain quality of care practice standards and control costs consistent with Health Plan’s responsibilities under the applicable State Contract. 5.3 Provider / Covered Person Communications. Neither Health Plan nor Subcontractor shall prohibit or otherwise restrict Provider, when acting within the lawful scope of Provider’s licensure and practice, from advising or advocating on behalf of a Covered Person who is Provider’s patient for the following:
(a) The Covered Person’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered;
(b) Any information the Covered Person needs in order to decide among all relevant treatment options;
(c) The risks, benefits, and consequences of treatment or non-treatment;
(d) The Covered Person’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions; or
Provider Discrimination. Neither Contractor, Subcontractor, nor representatives of Contractor shall provide false or misleading information to providers in an attempt to recruit providers for Contractor’s network. The Contractor shall not discriminate against providers with respect to participation, reimbursement, or indemnification for any provider acting within the scope of that provider’s license or certification under applicable State law or regulation solely on the basis of the provider’s license or certification. Contractor shall not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely based on the license or certification. Contractor shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. If Contractor declines to include individual or groups of providers in its network, it must provide the affected providers written notice of the reason for its decision. Denials of provider enrollment due to excess network capacity must receive DOM approval prior to provider notification. Nothing in this provision, however, shall preclude Contractor from using a fee schedule for different specialties or for different practitioners in the same specialty, or preclude Contractor from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to Members. Contractor shall not employ or contract with providers excluded from participation in Federal health care programs under either Section 1128 or Section 1128A of the Act. Contractor is prohibited from employing or contracting a provider that has been excluded by DOM, other state Medicaid agencies, or other state CHIP.
Provider Discrimination. The Contractor may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. Declining providers. If Contractor declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reason for its decision. 42CFR 438.12 (a)of this section may not be construed to: • Require the MAO to contract with providers beyond the number necessary to meet the needs of its enrollee. • Preclude the MAO from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or • Preclude the MAO from establishing measures that are designed to maintain quality of services and control costs and is consistent with its responsibilities to enrollee.
