Network Adequacy Standards Clause Samples
The Network Adequacy Standards clause defines the minimum requirements that a network, such as a healthcare provider network or telecommunications system, must meet to ensure sufficient access and service quality for users. Typically, this clause outlines criteria like the number and geographic distribution of service providers, response times, or capacity thresholds that must be maintained. Its core function is to guarantee that users have reasonable and reliable access to necessary services, thereby preventing gaps in coverage or service deficiencies.
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Network Adequacy Standards a) CONTRACTOR shall meet the state standards for timely access to care and services, taking into account the urgency of need for services. CONTRACTOR shall offer hours of operation that are no less than the hours offered to commercial enrollees or that are comparable to Medicaid Fee-For-Service (FFS), if the provider serves only Medicaid enrollees. CONTRACTOR shall make services available twenty-four (24) hours a day, seven (7) days a week, when medically necessary.
b) CONTRACTOR shall establish mechanisms to ensure that it complies with the timely access requirements and shall monitor staff and services regularly to determine compliance with the timely access requirements. CONTRACTOR shall take corrective action if there is a failure to comply with the timely access requirements according to 42 C.F.R. Section 438.206(c)(1)(i)-(vi).
c) CONTRACTOR shall ensure the provision of physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities according to 42 C.F.R. Section 438.203(c)(3).
Network Adequacy Standards. 6.1.1 The PASSE must maintain and monitor a network of appropriate providers that is sufficient to provide adequate access to all services covered under the Agreement for all enrolled members. The network must be supported by written Provider Contracts as described in Section 6.2. The PASSE must submit documentation to DHS, in a format specified by DHS, to demonstrate:
a. That it offers an appropriate range of acute care, preventative, primary care, specialty services, rehabilitative services, LTSS, and HCBS that is adequate for the anticipated number of enrolled members;
b. That it has the capacity to serve the expected enrollment in accordance with DHS’s standards for access and timeliness of care found in the PASSE Manual Section 226.000;
Network Adequacy Standards. 6.1.1 In addition to what is outlined in this section of the Agreement, the PASSE must maintain and monitor an adequate network of qualified providers that is sufficient to meet the Timely Access to Care Standards defined in the PASSE Manual and in the definition of services covered under the Agreement for all Members. The network must be supported by written Provider Contracts as described in Section 6.2. The PASSE must submit documentation to DHS, in a format specified by DHS, to demonstrate:
a. That it offers an appropriate range of acute care, preventative, primary care, specialty services, rehabilitative services, LTSS, and full range of HCBS including both 1915 (i) and 1915 (c) services that is adequate for the anticipated number of Members;
b. That it has the capacity to serve the expected enrollment in accordance with DHS’s standards for access and timeliness of care found in the PASSE Manual Section 226.000. That it maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of Enrolled Members;
c. That it has included at least one Federally Qualified Health Center (FQHC) and at least one Rural Health Clinic (RHC) in its Provider Network.
6.1.2 The PASSE must submit documentation of network adequacy as specified by DHS, but no less frequently than the following: 1) at the time it enters into the Agreement; 2) on an bi-annual basis; 3) at any time there has been a significant change (as defined by DHS) in the PASSE’s operations that would affect the adequacy of capacity and services, including changes in PASSE services, benefits, geographic service area, composition of payments to its Provider Network, or at the enrollment of a new population in the PASSE.
6.1.3 If the PASSE’s Provider Network is unable to ensure the provision of medically necessary services to a particular Member within the Timely Access to Care Standards as set forth in the PASSE Manual for that type of Care which results in:
a. A preventable use of a hospital emergency department;
b. A preventable admission to inpatient hospitalization;
c. A delay in a discharge from a residential setting and re-admission to a different institutional or residential setting; or
d. A preventable institutionalization The PASSE must:
a. provide adequately and timely access to cover the services through one or more out-of-network providers, including through a single case agreement with an out- of- network state providers...
Network Adequacy Standards. The Provider-to-Enrollee Ratios; Provider Per Municipality requirements; Required Network Provider requirements, and Time and Distance requirements developed in accordance with 42 CFR 438.68, as defined by ASES in Section 9.4 to measure the adequacy and appropriateness of the Contractor’s provider network to meet the needs of the enrolled population.
Network Adequacy Standards. The Contractor’s network shall meet or exceed Federal standards in 42 CFR §438.68 and 42 CFR §438.206, as well as the full scope of access standards described in Section 4.7,
Network Adequacy Standards. 6.1.1 The DMO’s network must be supported by written Provider Agreements as described in Section 6.2. The DMO must submit documentation monthly to DHS, in a format specified by DHS, to demonstrate:
a. That it offers an appropriate range of Dental Services for anticipated enrollment;
b. That it has the capacity to serve the expected enrollment in accordance with DHS's standards for access and timeliness of care found in the Agreement and this Amendment; and
c. That it maintains a Network that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of Enrolled Members.
6.1.2 The DMO must regularly and systematically monitor the adequacy of its Network in accordance with the standards set forth in the Agreement and this Amendment. The DMO must submit documentation of Network adequacy as specified by DHS, but no less frequently than the following:
a. At the beginning of the Agreement term;
b. On an annual basis;
c. Any time there has been a significant change (as defined by DHS) in the DMO's operations that would affect the adequacy of capacity and services, including changes in DMO services, benefits, geographic service area, composition of or payments to its Network; or
d. At the enrollment of a new Medicaid eligibility group in the DMO.
6.1.3 The DMO is prohibited from discriminating against any dental provider (i.e., limiting his or her participation, reimbursement, or indemnification) 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.
6.1.4 If the DMO's Network is unable to provide Medically Necessary Dental Services covered under the Agreement to an Enrolled Member, the DMO must adequately and timely cover the services out of network for as long as the DMO's Network is unable to provide them. This must be provided at no cost to the Enrolled Member.
6.1.5 The DMO must provide for a second opinion of a dental treatment, if requested by an Enrolled Member, from a Network Provider or arrange for the Enrolled Member to obtain a second opinion outside the Network.
Network Adequacy Standards. 6.1.1 The PASSE must maintain and monitor a network of appropriate providers that is sufficient to provide adequate access to all services covered under the Agreement for all enrolled members., The network must be supported by written Provider Contracts as described in Section 6.2. The PASSE must submit documentation to DHS, in a format specified by DHS, to demonstrate:
a. That it offers an appropriate range of acute care, preventative, primary care, specialty services, rehabilitative services, LTSS, and HCBS that is adequate for the anticipated number of enrolled members;
b. That it has the capacity to serve the expected enrollment in accordance with DHS’s standards for access and timeliness of care found in the PASSE Manual Section 226.000;
c. That it maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of enrolled members; and
d. Meets the standards for each provider type.
e. That it has included at least one Federally Qualified Health Center (FQHC) and at least one Rural Health Clinic (RHC) in its Provider Network.
6.1.2 The PASSE must submit documentation of network adequacy as specified by DHS, but no less frequently than the following: 1) at the time it enters into the Agreement;
Network Adequacy Standards. 9.4.1 The Contractor must maintain an Island-wide provider network that complies with the Network Adequacy Standards specified in Section 9.4. The Contractor must use Geographical-access and thermomapping to demonstrate that the contracted network is distributed across Puerto Rico such that it meets the needs of Enrollees. The Contractor shall provide adequate Access to Enrollees at all times.
9.4.2 In the event the Contractor cannot meet a Network Adequacy Standard in Section 9.4, an exception must be requested and approved in writing by ASES. The request must provide detailed information justifying the need for an exception and actions underway to meet compliance. The exception does not relieve the Contractor from remedying non-compliance with defined Network Adequacy Standards within a reasonable timeframe, or complying with a Corrective Act Plan established in collaboration with ASES. All approved exceptions must be reported in the annual Provider Network and Evaluation plan described in Section 18.3
2.1 The standard by which ASES will evaluate the exception request will be based, at a minimum, on the number of Providers in that specialty practicing in Puerto Rico.
9.4.3 The Contractor shall comply with the following Provider-to-Enrollee Ratios, Provider Per Municipality requirements, and Required Network Providers standards for the General Network:
9.4.3.1 PCP Provider-to-Enrollee Ratios
9.4.3.1.1 The following specialties are considered PCPs: Family Practice, Internal Medicine (for Adults), General Medicine, and Pediatrics.
9.4.3.1.2 The Contractor’s provider network must have one (1) PCP per one thousand seven hundred (1,700) Enrollees (excluding Gynecologists);
9.4.3.1.3 The Contractor’s provider network must have one (1) Gynecologist (selected as the Enrollee’s PCP, if the Enrollee is female and twelve (12) years of age or older) per two thousand eight hundred (2,800) Enrollees (1:2,800);
9.4.3.1.4 In the event the Contractor assigns Enrollees to a PCP that exceeds the stated Provider-to-Enrollee Ratio requirement, the Contractor must obtain prior written approval for an exception from ASES to continue to assign Enrollees to the PCP. All approved exceptions must be reported in the annual Provider Network and Evaluation plan described in Section 18.3.
Network Adequacy Standards. The Contractor’s network shall meet or exceed Federal standards in 42 CFR §438.68 and 42 CFR §438.206, as well as the full scope of access standards described in Section 4.6, Access to Care Standards. The Contractor shall regularly assess and certify through submission of quarterly reports to the Department the adequacy of its provider network and notify the Department of any major initiatives or changes to program design (e.g., expanded benefits). Refer to the Medallion