Common use of Network Adequacy Requirements Clause in Contracts

Network Adequacy Requirements. The PIHP must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the PIHP must consider: 1. The anticipated FCMH enrollment; 2. The expected utilization of services, considering member characteristics and health care needs of children in out-of-home placement enrolled in the FCMH; 3. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services. 4. The number of network providers not accepting new patients. 5. The geographic location of providers and members, distance, travel time, normal means of transportation used by members and whether provider locations are accessible to members with disabilities. 6. The experience of providers in caring for children in out-of-home placement in order to assure access to timely and adequate mental health and substance abuse services performed by qualified persons with experience treating children in out-of-home care; 7. Its ability to provide trauma-informed care in one or more treatment modalities as specified in “Creating Trauma-Informed and Developmentally Appropriate Systems of Care in Child Abuse and Neglect Prevention: Guiding Principles of Practice” prepared by the Wisconsin Children’s Trust Fund; 8. The requirement that it have a written policy for contracting on an ad hoc basis with non-network providers, including a process for assuring that the providers are Medicaid-certified and clear procedures for billing and payment. The PIHP must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification or upon request of the Department. The PIHP must submit its provider network and facility file electronically to the State’s FTP monthly. The file must be submitted in the format designated by the Department in the PIHP Provider Network File Submission Specification Guide. The PIHP must also notify the appropriate FCMH Managed Care Analyst of changes related to network adequacy. Changes that could affect network adequacy have been defined by the Department as changes in the PIHP’s operations that would affect adequate capacity and services, including modifications to PIHP benefits, geographic service areas, provider networks, payments, or enrollment of a new population into the PIHP. (42 CFR 438.207(c)(2)(i-ii)) The PIHP must notify the Department of any geographical service area reductions 120 days before the intended decertification date unless DHS agrees to a shorter time period based on extraordinary circumstances beyond the control of the PIHP. The PIHP must submit a member communication/transition plan for all service area reductions.

Network Adequacy Requirements. The PIHP must ensure that its delivery network is sufficient to provide adequate access to all services covered under this Contract. In establishing the network, the PIHP must consider: 1. The anticipated FCMH enrollment; 2. The expected utilization of services, considering member characteristics and health care needs of children in out-of-home placement enrolled in the FCMH; 3. The number and types of providers (in terms of training experience and specialization) required to furnish the Contracted services. 4. The number of network providers not accepting new patients. 5. The geographic location of providers and members, distance, travel time, normal means of transportation used by members and whether provider locations are accessible to members with disabilities. 6. The experience of providers in caring for children in out-of-home placement in order to assure access to timely and adequate mental health and substance abuse services performed by qualified persons with experience treating children in out-of-home care; 7. Its ability to provide trauma-informed care in one or more treatment modalities as specified in “Creating Trauma-Informed and Developmentally Appropriate Systems of Care in Child Abuse and Neglect Prevention: Guiding Principles of Practice” prepared by the Wisconsin Children’s Trust Fund; 8. The requirement that it have a written policy for contracting on an ad hoc basis with non-network providers, including a process for assuring that the providers are Medicaid-certified and clear procedures for billing and payment. The PIHP must provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification or upon request of the Department. The PIHP must also submit its an updated provider network and facility file electronically to the State’s FTP monthlywhen there are significant service area changes. The file must be submitted in the format designated by the Department in and include, at a minimum, the PIHP name, address, Wisconsin Medicaid provider ID number and/or National Provider Network File Submission Specification GuideIdentifier, if applicable, and dates of certification for FCMH. The PIHP must also notify the appropriate FCMH Managed Care Contract Compliance Analyst of changes related to network adequacy. Changes that could affect network adequacy have been defined by the Department as changes in the PIHP’s operations that would affect adequate capacity and services, including modifications to PIHP benefits, geographic service areas, provider networks, payments, or enrollment of a new population into the PIHP. (42 CFR 438.207(c)(2)(i-ii)) The PIHP must notify the Department of any geographical service area reductions 120 days before the intended decertification date unless DHS agrees to a shorter time period based on extraordinary circumstances beyond the control of the PIHP. The PIHP must submit a member communication/transition plan for all service area reductions.