Common use of PROVIDER NETWORK AND ACCESS REQUIREMENTS Clause in Contracts

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The HMO must provide medical care to its BadgerCare Plus and/or Medicaid SSI members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMO. A. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers‌ Except in emergency situations, the HMO must use only Medicaid enrolled providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled providers, at the FFS rate for those services, unless the HMO can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled at the time the HMO reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The HMO must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. Protocols/Standards to Ensure Access‌ The HMO must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under BadgerCare Plus and Medicaid SSI programs. The HMO’s protocols must include training and information for providers in their network, in order to promote and develop provider skills in responding to the needs of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment or regular case monitoring is needed, the HMO must have mechanisms in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needs. C. Written Standards for Accessibility of Care‌ 1. The HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the HMO. The standards must include the following: • Waiting times for care at facilities; • Waiting times for appointments; • Statement that providers’ hours of operation do not discriminate against BadgerCare Plus and/or Medicaid SSI members; and • Whether or not provider(s) speak the member’s language. 2. The HMO’s standards for waiting times for appointments must be as follows for the indicated provider types: • To be no longer than 30 days for an appointment with a PCP; • To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. • To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The HMO may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: • The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. • Any information the enrollee needs in order to decide among all relevant treatment options. • The risks, benefits, and consequences of treatment or non- treatment. • The enrollee’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. These minimum requirements shall not release the HMO from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The HMO must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO must develop policies and procedures regarding wait times for appointments and care. The HMO shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO or by the Department, the HMO must take corrective action so that providers meet the HMO’s standards and improve access for members. The Department will investigate complaints received of HMOs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and Covered Services‌ 1. Dental Providers

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The HMO PIHP must provide medical care to its BadgerCare Plus and/or Medicaid SSI FCMH members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMOPIHP. A. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers‌ Except in emergency situations, the HMO PIHP must use only Medicaid Wisconsin ForwardHealth enrolled providers for the provision of covered services. The Department reserves the right to withhold from payment development and reconciliation the capitation payments the monies costs related to services provided by non-enrolled providers, at the FFS rate for those servicesservice, unless the HMO PIHP can demonstrate that it reasonably believed, based on the information provided by the Departmentdepartment, that the provider was Medicaid ForwardHealth enrolled at the time the HMO time PHIP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The HMO PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). The Department requires that Medicaid-enrolled providers undergo periodic revalidation. During revalidation providers update their enrollment information with ForwardHealth, and sign the Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation. Providers who fail to revalidate are terminated from Wisconsin Medicaid. B. Protocols/Standards to Ensure Access‌ The HMO PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under BadgerCare Plus and Medicaid SSI programsthe FCMH program. The HMOPIHP’s protocols must include training methods for identification, outreach to and information for providers in their network, in order to promote and develop provider skills in responding to the needs screening/assessment of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or regular case monitoring is needed, the HMO emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have mechanisms expertise in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needscare of children with chronic conditions. C. Written Standards for Accessibility of Care‌ 1. The HMO PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the HMOPIHP. The standards must include the following: • : a. Waiting times for care at facilities; • ; b. Waiting times for appointments; • ; c. Statement that providers’ hours of operation do not discriminate against BadgerCare Plus and/or Medicaid SSI FCMH members; and • and d. Whether or not provider(s) speak the member’s language. 2. The HMOPIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: • : a. To be no longer than 30 days for an appointment with a PCP; • ; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. • ; c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The HMO PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee member who is his or her patient, for the following: • : a. The enrolleemember’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. • . b. Any information the enrollee member needs in order to decide among all relevant treatment options. • . c. The risks, benefits, and consequences of treatment or non- treatment. • nontreatment. d. The enrollee’s member'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. These minimum requirements shall not release the HMO PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The HMO PIHP must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO PIHP must develop policies and procedures regarding wait times for appointments and care. The HMO PIHP shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO PIHP or by the Department, the HMO PIHP must take corrective action so that providers meet the HMOPIHP’s standards and improve access for members. The Department will investigate complaints received of HMOs PIHPs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus Providers and/or Medicaid SSI Providers and Covered Services‌Services‌ Per 42 CFR § 438.207, PIHPs must provide assurances to the State that demonstrates that the PIHP has the capacity to serve the expected enrollment in its service area per the State standards for access to care provided below. All PIHP network reviews are based on the number of providers accepting new patients. 1. Dental ProvidersPrimary Care Provider Network Adequacy Standards

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The HMO must provide medical care to its BadgerCare Plus and/or Medicaid SSI members that are as accessible to them, in terms of timeliness, amount, duration, and scope, as those services are to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMO. A. 1. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers‌ Certified Providers Except in emergency situations, the HMO must use only Medicaid enrolled providers who have been certified by the program for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled certified providers, at the FFS rate for those services, unless the HMO can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled certified by the program at the time the HMO reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook105, contains information regarding provider certification requirements. The HMO must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. 2. Protocols/Standards to Ensure Access‌ Access The HMO must have written protocols to ensure that members have access to screening, diagnosis and referral referral, and appropriate treatment for those conditions and services covered under the BadgerCare Plus and Medicaid SSI programs. The HMO’s protocols must include training and information for providers in their network, network in order to promote and develop provider providers’ skills in responding to the needs of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members members, with special health care needs, where it has been determined to need a course of treatment or regular case monitoring is neededmonitoring, the HMO must have mechanisms in place to allow members to directly access a specialist, specialist as appropriate, appropriate for the member’s condition and identified needs. The HMO must have written protocols to ensure that all members in the Core Plan have access to a comprehensive physical exam within the member’s first certification period. C. 3. Written Standards for Accessibility of Care‌ 1. Care The HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the HMO. The standards must include the following: • Waiting times for care at facilities; • Waiting waiting times for appointments; • Statement that providers’ hours of operation do not discriminate against BadgerCare Plus and/or Medicaid SSI members; and • Whether or not provider(s) speak the member’s language. 2. The HMO’s standards for waiting times for appointments must be as follows for the indicated provider types: • To be no longer than 30 days for an appointment with a PCP; • To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. • To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The HMO may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: • The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. • Any information the enrollee needs in order to decide among all relevant treatment options. • The risks, benefits, and consequences of treatment or non- treatment. • The enrollee’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. These minimum requirements shall not release the HMO from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The HMO must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO must develop policies and procedures regarding wait times for appointments and care4. The HMO shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO or by the Department, the HMO must take corrective action so that providers meet the HMO’s standards and improve access for members. The Department will investigate complaints received of HMOs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and/or Covered Services a. Dental Providers The HMO that covers dental services must have a dental provider within a 35-mile distance from any member residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. If there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the dentist accepts new patients, and Covered Services‌whether full or part-time coverage is available. 1b. Mental Health or Substance Abuse Providers The HMO must have a mental health or substance abuse provider within a 35-mile distance from any member residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. Dental ProvidersIf there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the providers accept new patients, and whether full or part-time coverage is available. c. High Risk Prenatal Care Services (BadgerCare Plus Only) The HMO must provide medically necessary high risk prenatal care within two weeks of the member’s request for an appointment, or within three weeks if the request is for a specific HMO provider, who is accepting new patients. d. HMO Referrals to Out-of-Network Providers for Services The HMO must provide adequate and timely coverage of services provided out of network, when the required medical service is not available within the HMO network. The HMO must coordinate with out-of-network providers with respect to payment and ensure that cost to the member is no greater than it would be if the services were furnished within the network (42 CFR. §. 438.206(b) (v) (5)). e. Primary Care Providers The HMO may define other types of providers as primary care providers. If they do so, the HMO must define these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the HMO certification process. The HMO must have a certified primary care provider within a 20- mile distance from any member residing in the HMO service area, unless there is no certified provider within the specified distance. In that case, the travel distance shall be no more than for a non- enrolled member. A service area for the HMO will be specified down to the zip code. Therefore, all portions of each zip code in the HMO service area must be within 20 miles from a certified primary care provider. This access standard does not prevent a member from choosing an HMO when the member resides in a zip code that does not meet the 20-mile distance standard. However, the member will not be automatically assigned to that HMO. If the member has been assigned to the HMO or has chosen the HMO and becomes dissatisfied with the access to medical care, the member may disenroll from the HMO because of distance. f. Second Medical Opinions The HMO must upon member request, provide members the opportunity to have a second opinion from a qualified network provider subject to referral procedures approved by the Department. If an appropriately qualified provider is not available within the network, the HMO must arrange for a second opinion outside the network at no charge to the member.

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The HMO PIHP must provide medical care to its BadgerCare Plus and/or Medicaid SSI FCMH members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMOPIHP. A. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers‌ Providers Except in emergency situations, the HMO PIHP must use only Medicaid enrolled providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled providers, at the FFS rate for those services, unless the HMO PIHP can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled at the time the HMO PIHP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The HMO PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. Protocols/Standards to Ensure Access‌ Access The HMO PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under BadgerCare Plus and Medicaid SSI programsthe FCMH program. The HMOPIHP’s protocols must include training methods for identification, outreach to and information for providers in their network, in order to promote and develop provider skills in responding to the needs screening/assessment of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or regular case monitoring is needed, the HMO emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have mechanisms expertise in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needscare of children with chronic conditions. C. Written Standards for Accessibility of Care‌Care 1. The HMO PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the HMOPIHP. The standards must include the following: • : a. Waiting times for care at facilities; • ; b. Waiting times for appointments; • ; c. Statement that providers’ hours of operation do not discriminate against BadgerCare Plus and/or Medicaid SSI FCMH members; and • and d. Whether or not provider(s) speak the member’s language. 2. The HMOPIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: • : a. To be no longer than 30 days for an appointment with a PCP; • ; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. • . c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The HMO PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: • : a. The enrollee’s 's health status, medical care, or treatment options, including any alternative treatment that may be self-administered. • . b. Any information the enrollee needs in order to decide among all relevant treatment options. • . c. The risks, benefits, and consequences of treatment or non- treatment. • nontreatment. d. The enrollee’s '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. These minimum requirements shall not release the HMO PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The HMO PIHP must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO must develop policies and procedures regarding wait times for appointments and care. The HMO shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO or by the Department, the HMO must take corrective action so that providers meet the HMO’s standards and improve access for members. The Department will investigate complaints received of HMOs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and Covered Services‌ 1. Dental Providers

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The HMO must provide medical care to its BadgerCare Plus and/or Medicaid SSI members enrollees that are as accessible to them, in terms of timeliness, amount, duration, and scope, as those services are to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMO. A. 1. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers‌ Certified Providers Except in emergency situations, the HMO must use only Medicaid enrolled providers who have been certified by the program for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled certified providers, at the FFS rate for those services, unless the HMO can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled certified by the program at the time the HMO reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth HandbookHFS 105, contains information regarding provider certification requirements. The Every HMO must require every physician providing services to members enrollees to have a Provider Number or National Provider Identifier (NPI). B. 2. Protocols/Standards to Ensure Access‌ Access The HMO must have written protocols to ensure that members enrollees have access to screening, diagnosis and referral referral, and appropriate treatment for those conditions and services covered under the BadgerCare Plus and Medicaid SSI programs. The HMO’s protocols must include training and information for providers in their network, network in order to promote and develop provider providers’ skills in responding to the needs of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members enrollees, with special health care needs, where it has been determined to need a course of treatment or regular case monitoring is neededmonitoring, the HMO must have mechanisms in place to allow members enrollees to directly access a specialist, specialist as appropriate, appropriate for the memberenrollee’s condition and identified needs. C. 3. Written Standards for Accessibility of Care‌ 1. Care The HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the HMO. The standards must include the following: • Waiting times for care at facilities; • Waiting waiting times for appointments; • Statement that providers’ hours of operation do not discriminate against BadgerCare Plus and/or Medicaid SSI members; and • Whether or not provider(s) speak the member’s language. 2. The HMO’s standards for waiting times for appointments must be as follows for the indicated provider types: • To be no longer than 30 days for an appointment with a PCP; • To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. • To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The HMO may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: • The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. • Any information the enrollee needs in order to decide among all relevant treatment options. • The risks, benefits, and consequences of treatment or non- treatment. • The enrollee’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. These minimum requirements shall not release the HMO from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The HMO must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO must develop policies and procedures regarding wait times for appointments and care4. The HMO shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO or by the Department, the HMO must take corrective action so that providers meet the HMO’s standards and improve access for members. The Department will investigate complaints received of HMOs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and/or Covered Services a. Dental Providers The HMO that covers dental services must have a dental provider within a 35-mile distance from any enrollee residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. If there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the dentist accepts new patients, and Covered Services‌whether full or part-time coverage is available. 1b. Mental Health or Substance Abuse Providers The HMO must have a mental health or substance abuse provider within a 35-mile distance from any enrollee residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. Dental ProvidersIf there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the providers accept new patients, and whether full or part-time coverage is available. c. High Risk Prenatal Care Services (BadgerCare Plus Only) The HMO must provide medically necessary high risk prenatal care within two weeks of the enrollee’s request for an appointment, or within three weeks if the request is for a specific HMO provider, who is accepting new patients. d. HMO Referrals to Out-of-Network Providers for Services The HMO must provide adequate and timely coverage of services provided out of network, when the required medical service is not available within the HMO network. The HMO must coordinate with out-of-network providers with respect to payment and ensure that cost to the enrollee is no greater than it would be if the services were furnished within the network (42 CFR. §. 438.206(b) (v) (5)). e. Primary Care Providers The HMO may define other types of providers as primary care providers. If they do so, the HMO must define these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the HMO certification process. The HMO must have a certified primary care provider within a 20- mile distance from any enrollee residing in the HMO service area, unless there is no certified provider within the specified distance. In that case, the travel distance shall be no more than for a non- enrolled member. A service area for the HMO will be specified down to the zip code. Therefore, all portions of each zip code in the HMO service area must be within 20 miles from a certified primary care provider. This access standard does not prevent a member from choosing an HMO when the member resides in a zip code that does not meet the 20-mile distance standard. However, the member will not be automatically assigned to that HMO. If the member has been assigned to the HMO or has chosen the HMO and becomes dissatisfied with the access to medical care, the member may disenroll from the HMO because of distance. f. Second Medical Opinions The HMO must upon enrollee request, provide enrollees the opportunity to have a second opinion from a qualified network provider subject to referral procedures approved by the Department. If an appropriately qualified provider is not available within the network, the HMO must arrange for a second opinion outside the network at no charge to the enrollee.

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The HMO PIHP must provide medical care to its BadgerCare Plus and/or Medicaid SSI members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMOPIHP. A. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers‌ Certified Providers Except in emergency situations, the HMO PIHP must use only Medicaid enrolled certified providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled certified providers, at the FFS rate for those services, unless the HMO PIHP can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled certified at the time the HMO PIHP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The HMO PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. Protocols/Standards to Ensure Access‌ Access The HMO PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under BadgerCare Plus and Medicaid SSI programsthe FCMH program. The HMOPIHP’s protocols must include training methods for identification, outreach to and information for providers in their network, in order to promote and develop provider skills in responding to the needs screening/assessment of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or regular case monitoring is needed, the HMO emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have mechanisms expertise in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needscare of children with chronic conditions. C. Written Standards for Accessibility of Care‌Care 1. The HMO PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the HMOPIHP. The standards must include the following: • : a. Waiting times for care at facilities; • ; b. Waiting times for appointments; • ; c. Statement that providers’ hours of operation do not discriminate against BadgerCare Plus and/or Medicaid SSI FCMH members; and • and d. Whether or not provider(s) speak the member’s language. 2. The HMOPIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: • : a. To be no longer than 30 days for an appointment with a PCP; • ; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. • . c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The HMO may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: • The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. • Any information the enrollee needs in order to decide among all relevant treatment options. • The risks, benefits, and consequences of treatment or non- treatment. • The enrollee’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. These minimum requirements shall not release the HMO PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The HMO PIHP must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO must develop policies and procedures regarding wait times for appointments and care. The HMO shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO or by the Department, the HMO must take corrective action so that providers meet the HMO’s standards and improve access for members. The Department will investigate complaints received of HMOs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and Covered Services‌ 1. Dental Providers