Common use of Network Capacity Clause in Contracts

Network Capacity. The Contractor shall maintain and monitor an appropriate and adequate provider network, supported by written agreements, sufficient to provide all Contracted Services under this Contract. The Contractor may provide Contracted Services through Non-Participating Providers, at a cost to the individual that is no greater than if the Contracted Services were provided by Participating Providers, if its network of Participating Providers is insufficient to meet the Behavioral Health needs of Individuals in a manner consistent with this Contract. This provision shall not be construed to require the Contractor to cover such services without authorization. To the extent necessary to provide non-crisis Behavioral Health services covered under this Contract, the Contractor may offer contracts to providers in other RSAs in the state of Washington and to providers in bordering states. The Contractor may not contract for Crisis Services (SUD or Mental Health) or ITA-related services out of Washington State. For non-crisis behavioral health services funded by GFS: The Contractor shall provide non-crisis Behavioral Health services funded by GFS, within Available Resources, to Individuals who meet financial eligibility standards in this Contract and meet one of the following criteria: Have insurance, but are unable to pay the co-pay or deductible for services; Are using excessive Crisis Services due to inability to access non-crisis behavioral health services; and Have more than five (5) visits over six (6) months to the emergency department, withdrawal management facility, or a sobering center due to a SUD. The Contractor must submit a network of contracted service providers adequate to serve the population in the Contractor’s RSA annually by November 1. If the Contractor fails to provide evidence of or HCA is unable to validate contracts with a sufficient number of providers, HCA may terminate this Contract. The network must have sufficient capacity to serve the RSA and include, at a minimum: 24/7/365 Telephone Crisis Intervention; Designated Crisis Responder (DCR); Evaluation and treatment (E&T) and Secure Withdrawal Management and Stabilization capacity to serve the RSA’s non-Medicaid population; Psychiatric inpatient beds to serve the RSA’s non-Medicaid population, including direct contracts with community hospitals at a rate no greater than that outlined in the HCA Fee-for-Service schedule; The Contractor shall notify HCA ninety (90) calendar days prior to terminating any of its Subcontracts or entering into new Subcontracts with entities that provide direct services, including Crisis Services providers. This notification shall occur prior to any public announcement of this change, and should include: The reason for termination The Contractor’s plan for notification of necessary stakeholders of the change in network. How the Contractor will ensure network adequacy with the loss of the subcontractor. If a Subcontract is terminated or a site closure occurs in less than the ninety (90) calendar days, the Contractor shall notify HCA as soon as possible. When a Subcontract is terminated or a site closes unexpectedly, the Contractor shall submit additional information to HCA in writing within seven (7) calendar days that includes: Notification to Ombuds services and Individuals; A provision for uninterrupted services; and Any information released to the media. HCA reserves the right to impose sanctions, in accordance with the Sanctions subsection of this Contract, if the Contractor was notified by the terminating provider in a timely manner and does not comply with the notification requirements of this section. If the Contractor does not receive timely notification from the terminating provider, the Contractor shall provide documentation of the date of notification along with the notice of loss of a terminating provider. Provider network information will be reviewed by HCA for: Completeness and accuracy; Removal of providers who no longer contract with the Contractor; and The effect the change(s) in the provider network will have on the Contractor’s compliance with the network requirements of this section. The Contractor shall meet the following requirements when developing its network: Only licensed or certified Behavioral Health Providers shall provide behavioral health services. Licensed or certified Behavioral Health Providers include, but are not limited to: Health Care Professionals, licensed agencies or clinics, or professionals operating under an agency affiliated license. Within Available Resources, establish and maintain contracts with office-based opioid treatment providers that have obtained a waiver under the Drug Addiction Treatment Act of 2000 to practice medication-assisted opioid addiction therapy. Assist the State in expanding community-based alternatives for crisis stabilization, such as mobile crisis outreach or crisis residential and respite beds. Assist the State in expanding community-based, Recovery-oriented services, use of Certified Peer Counselors and Research- and Evidence-Based Practices. If the Contractor, in HCA’s sole opinion, fails to maintain an adequate network for Crisis Services, HCA reserves the right to immediately terminate this Contract. In establishing, maintaining, monitoring and reporting of its network, the Contractor must consider the following: The expected utilization of services, the characteristics and health care needs of the population, the number and types of providers (training, experience and specialization) able to furnish services, and the geographic location of providers and Individuals (including distance, travel time, means of transportation ordinarily used by Individuals, and whether the location is ADA accessible) for all Contractor funded behavioral health programs and services based on Available Resources. The anticipated needs of priority populations identified in this Contract. The Contractor and its Subcontractors shall: Ensure that all services and activities provided under this Contract shall be designed and delivered in a manner sensitive to the needs of the diverse population; Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract as identified in their needs assessment. The Contractor shall require that providers offer hours of operation for Individuals that are no less than the hours of operation offered to any other patient.