Enrollee Access to Services. General The Contractor: Must demonstrate its ability to meet the needs of Enrollees competently and promptly; Must offer adequate choice and availability of Providers, and allow each Enrollee to choose his or her Provider to the extent possible and appropriate; Must provide adequate access to Covered Services (listed in Appendix A), including physical and geographic access. Such access must be designed to accommodate the needs of Enrollees who are disabled or non-English speaking, including access to TTY (for the deaf and hard of hearing) and translation services; Must provide all Covered Services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services provided under MassHealth fee for service. Must provide all Covered Services that are medically necessary pursuant to 130 CMR 450.204, including those Covered Services that: Prevent, diagnose, and treat health impairments; Achieve age-appropriate growth and development; Attain, maintain, or regain functional capacity; and Provide an opportunity for an Enrollee receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or choice. Must ensure that all Covered Services are sufficient in an amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; May place appropriate limits on a Covered Service for the purpose of utilization control, provided that: The furnished services can reasonably be expected to achieve their purpose; Services supporting Enrollees with ongoing or chronic conditions or who require LTSS are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports; and Family planning services are provided in a manner that protects and enables the Enrollee’s freedom to choose the method of family planning to be used. May place appropriate limits on a Covered Service on the basis of Medical Necessity. The Contractor’s Medical Necessity guidelines must, at a minimum, be: Developed with input from practicing physicians throughout the Contractor’s Regions; Developed in accordance with standards adopted by national accreditation organizations where applicable and available; Developed in accordance with the definition of Medical Necessity in this Contract and therefore no more restrictive than MassHealth Medical Necessity guidelines; Updated at least annually or as new treatments, applications and technologies are adopted as generally accepted professional medical practice; Evidence-based, if practicable; and Applied in a manner that considers the individual health care needs of the Enrollee. Must submit changes to its Medical Necessity guidelines, program specifications and services components for all Covered Services to EOHHS no less than 60 days prior to any change, or another timeframe specified by EOHHS; Must not arbitrarily deny or reduce the amount, duration, or scope of a required Covered Service solely because of diagnosis, type of illness, or condition of the Enrollee; Must comply with all federal requirements regarding the provision of services, including but not limited to 42 CFR 431.51(b)(2) and 42 CFR 441.202; Must make interpretation services, including oral interpretation, and auxiliary aids and services, such as TTY/TDY and American Sign Language (ASL), available upon request of each Enrollee or Potential Enrollee at no cost; and Must ensure that access to Covered Services for Enrollees is consistent with the degree of urgency, as follows: Emergency Services shall be provided immediately (respond to call with a live voice; face-to-face within 60 minutes) on a 24-hour basis, seven days a week, with unrestricted access, to individuals who present at any qualified Provider, whether a Network Provider or a non-Network Provider. ESP Services shall be provided immediately on a 24-hour basis, seven days a week, with unrestricted access, to individuals who present, including Enrollees, uninsured individuals and persons covered by Medicare only. Urgent Care Services shall be provided within 48 hours. Unless otherwise specified in this contract, all other care shall be provided in accordance with usual and customary community standards, and in all cases within 14 calendar days. In accordance with 42 CFR 438.206(c)(1)(iii), the Contractor shall make Covered Services available 24 hours a day, seven days a week when medically necessary. Must ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to individuals with commercial insurance, or comparable to Medicaid Fee-for-Service if the Network Provider serves only MassHealth Members; Must ensure that, in the event the Contractor’s Provider Network is unable to provide necessary services covered under this Contract to a particular Enrollee, the Contractor will adequately and timely cover the services out of network, for as long as the Contractor’s Provider Network is unable to provide such services.
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Sources: Contract for Senior Care Organizations, Senior Care Organization Contract
Enrollee Access to Services. A. General The Contractor: :
1. Must demonstrate its ability to meet the needs of Enrollees competently and promptly; ;
2. Must offer adequate choice and availability of Providers, and allow each Enrollee to choose his or her Provider to the extent possible and appropriate; ;
3. Must provide adequate access to Covered Services (listed in Appendix A), including physical and geographic access. Such access must be designed to accommodate the needs of Enrollees who are disabled or non-English speaking, including access to TTY (for the deaf and hard of hearing) and translation services; ;
4. Must provide all Covered Services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services provided under MassHealth fee for service.
5. Must provide all Covered Services that are medically necessary pursuant to 130 CMR 450.204, including those Covered Services that: :
a. Prevent, diagnose, and treat health impairments; ;
b. Achieve age-appropriate growth and development; ;
c. Attain, maintain, or regain functional capacity; and and
d. Provide an opportunity for an Enrollee receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or choice.
6. Must ensure that all Covered Services are sufficient in an amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; ;
7. May place appropriate limits on a Covered Service for the purpose of utilization control, provided that: :
a. The furnished services can reasonably be expected to achieve their purpose; ;
b. Services supporting Enrollees with ongoing or chronic conditions or who require LTSS are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports; and and
c. Family planning services are provided in a manner that protects and enables the Enrollee’s freedom to choose the method of family planning to be used.
8. May place appropriate limits on a Covered Service on the basis of Medical Necessity. The Contractor’s Medical Necessity guidelines must, at a minimum, be: :
a. Developed with input from practicing physicians throughout the Contractor’s Regions; ;
b. Developed in accordance with standards adopted by national accreditation organizations where applicable and available; ;
c. Developed in accordance with the definition of Medical Necessity in this Contract and therefore no more restrictive than MassHealth Medical Necessity guidelines; ;
d. Updated at least annually or as new treatments, applications and technologies are adopted as generally accepted professional medical practice; ;
e. Evidence-based, if practicable; and and
f. Applied in a manner that considers the individual health care needs of the Enrollee.
9. Must submit changes to its Medical Necessity guidelines, program specifications and services components for all Covered Services to EOHHS no less than 60 days prior to any change, or another timeframe specified by EOHHS; ;
10. Must not arbitrarily deny or reduce the amount, duration, or scope of a required Covered Service solely because of diagnosis, type of illness, or condition of the Enrollee; ;
11. Must comply with all federal requirements regarding the provision of services, including but not limited to 42 CFR 431.51(b)(2) and 42 CFR 441.202; ;
12. Must make interpretation services, including oral interpretation, and auxiliary aids and services, such as TTY/TDY and American Sign Language (ASL), available upon request of each Enrollee or Potential Enrollee at no cost; and and
13. Must ensure that access to Covered Services for Enrollees is consistent with the degree of urgency, as follows: :
a. Emergency Services shall be provided immediately (respond to call with a live voice; face-to-face within 60 minutes) on a 24-hour basis, seven days a week, with unrestricted access, to individuals who present at any qualified Provider, whether a Network Provider or a non-Network Provider. .
b. ESP Services shall be provided immediately on a 24-hour basis, seven days a week, with unrestricted access, to individuals who present, including Enrollees, uninsured individuals and persons covered by Medicare only. .
c. Urgent Care Services shall be provided within 48 hours. .
d. Unless otherwise specified in this contract, all other care shall be provided in accordance with usual and customary community standards, and in all cases within 14 calendar days. .
e. In accordance with 42 CFR 438.206(c)(1)(iii), the Contractor shall make Covered Services available 24 hours a day, seven days a week when medically necessary.
14. Must ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to individuals with commercial insurance, or comparable to Medicaid Fee-Fee- for-Service if the Network Provider serves only MassHealth Members; ;
15. Must ensure that, in the event the Contractor’s Provider Network is unable to provide necessary services covered under this Contract to a particular Enrollee, the Contractor will adequately and timely cover the services out of network, for as long as the Contractor’s Provider Network is unable to provide such services.
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