Network Composition. The Contractor must ensure that its Provider Network is adequate to provide its Members in the HealthChoices zone with access to quality Member care through participating professionals, in a timely manner, and without the need to travel excessive distances. Upon request from the Department, the Contractor must supply geographic access maps detailing the number, location and specialties of their Provider Network to the Department in order to verify accessibility of Providers within their Network. The Department may require additional numbers of specialists and ancillary providers should it be determined that geographic access is not adequate. The Contractor must make all reasonable efforts to honor a Member's choice of Providers who are credentialed in the Network. Additional requirements for establishing and maintaining an acceptable Provider Network are as follows: a. The Contractor must ensure the provision of services to persons who have special health needs or who face access barriers to health care. If the Contractor does not have at least two (2) specialists or sub-specialists qualified to meet the particular needs of the individuals, then the Contractor must allow Members to pick an Out-of-Network Provider if not satisfied with the Network Provider. The Contractor must develop a system to determine prior authorization for Out-of-Plan Services, including provisions for informing the MA Consumer of how to request this authorization for Out-of-Plan Services. For children with special health needs, the Contractor must offer at least two (2) pediatric specialists or pediatric sub-specialists. b. The Contractor must ensure and must demonstrate its ability to: i. Make available to every Member a choice of at least two (2) appropriate PCPs whose offices are located within a travel time no greater than thirty (30) minutes (urban) and sixty (60) minutes (rural). This travel time is measured via public transportation, where available. Members may, at their discretion, select PCPs located further from their homes. ii. Ensure an adequate number of pediatricians to permit all Members who want a pediatrician as a PCP to have a choice of two (2) for their child(ren) within the travel time limits (30 minutes urban, 60 minutes rural). iii. Demonstrate its attempts to contract in good faith with a sufficient number of Certified Registered Nurse Practitioners (CRNP) to ensure access to CRNP services. While the Contractor may contract with a primary care practice in which the majority of primary care services are performed by CRNP's, the number of CRNPs in such practices may not exceed 10 percent of the total number of PCPs in the Contractor's Network. iv. Limit its PCP Network to appropriately qualified Providers. The PH-MCO's PCP Network must meet the following: - Seventy-five to one hundred percent (75-100%) of the Network consists of PCPs who have completed an approved primary care residency in family medicine, osteopathic general medicine, internal medicine or pediatrics; and - No more than twenty-five percent (25%) of the Network consists of PCPs without appropriate residencies but who have, within the past seven (7) years, five (5) years of post-training clinical practice experience in family medicine, osteopathic general medicine, internal medicine or pediatrics. Post-training experience is defined as having practiced at least as a 0.5 full-time equivalent in the practice areas described; and - No more than ten percent (10%) of the Network consists of PCPs who were previously trained as specialist physicians and changed their areas of practice to primary care, and who have completed Department-approved primary care retraining programs. c. The Contractor must ensure a choice of at least two (2) pharmacies (excluding mail-order entities) within the travel time limits (30 minutes urban, 60 minutes rural). d. The Contractor must ensure a choice of at least two (2) hospitals within the Provider Network, at least one (1) of which must be within the travel limits (30 minutes urban, 60 minutes rural). e. The Contractor must ensure a choice of at least two (2) home health agencies within the HealthChoices zone. f. The Contractor must ensure a choice of at least two (2) DME suppliers within the HealthChoices zone. g. The Contractor must ensure a choice of at least two (2) rehabilitation facilities within the Provider Network, at least one (1) of which must be located within the HealthChoices zone. h. The Contractor must ensure a choice of at least two (2) nursing facilities within the Provider Network. i. The Contractor must ensure a choice of at least two (2) general practice dentists within the Provider Network. For Members needing anesthesia for dental care, the Contractor must ensure a choice of at least two (2) dentists within the Provider Network with privileges or certificates to perform specialized dental procedures under general anesthesia. j. The Contractor must ensure access to Certified Nurse Midwives (CNMs) and CRNPs. k. The Contractor must demonstrate its ability to offer its Members freedom of choice in selecting a PCP. At a minimum, the Contractor must have or provide one (1) full-time equivalent (FTE) PCP who serves no more than one thousand (1,000) MA Consumers (cumulative across all HealthChoices PH-MCO plans in the zone) and PCP sites which serve no more than five thousand (5,000) MA Consumers (cumulative across all HealthChoices PH-MCO plans in the zone). The Department will develop a system to notify the Contractor of a Provider reaching maximum panel limits. The number of Members assigned to a PCP may be decreased by the Contractor if necessary to maintain the appointment availability standards. l. The Contractor and the Department will work together to avoid the PCP having a caseload or medical practice composed predominantly of HC Members. In addition, the Contractor must organize its PCP sites so as to ensure continuity of care to Members and must identify a specific PCP within the site for each Member. The Contractor may apply to the Department for a waiver of these requirements on a site-specific basis. The Department may waive these requirements for good cause demonstrated by the Contractor. m. The Contractor must demonstrate its ability to provide adequate access to physician specialists for PCP referrals, and must employ or contract with adult and pediatric specialists in sufficient numbers to ensure that specialty services are made available in a timely, geographically, and physically accessible manner, particularly for those Members in Special Needs populations. The Contractor must ensure Members a choice of at least two (2) appropriate specialists. n. The Contractor must contract with a sufficient number of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to ensure access to FQHC and RHC services, provided FQHC and RHC services are available, within a travel time of thirty (30) minutes (urban) and sixty (60) minutes (rural). If the Contractor's primary care Network includes FQHCs and RHCs, these sites may be designated as PCP sites. A listing of FQHCs and RHCs for HealthChoices is included in Exhibit QQ of this Agreement, HealthChoices Federally Qualified Health Centers and Rural Health Clinics. If a Contractor cannot contract with a sufficient number of FQHCs and RHCs, the Contractor must demonstrate in writing it has attempted to reasonably contract in good faith. o. The Contractor must comply with the provisions of Act 112 of 1996 (H.B. 1415, P.N. 3853, signed July 11, 1996),the Balanced Budget Reconciliation Act of 1997 and Act 68 of 1998, the Quality Health Care Accountability and Protection Provisions, 40 P.S. 991.2101 et seq. pertaining to coverage and payment of Medically Necessary Emergency Services. The definition of such services is set forth herein at Section II. p. The Contractor must inspect the office of any PCP or dentist who seeks to participate in the Contractor's Provider Network (excluding offices located in hospitals) to determine whether the office is architecturally accessible to persons with mobility impairments. Architectural accessibility means compliance with ADA accessibility guidelines with reference to parking (if any), path of travel to an entrance, and the entrance to both the building and the office of the provider, if different from the building entrance. If the office or facility is not accessible under the terms of this paragraph, the PCP or dentist may participate in the Contractor's Provider Network provided that the PCP or dentist: 1) requests and is determined by the Contractor to qualify for an exemption from this paragraph, consistent with the requirements of the ADA, or 2) agrees in writing to remove the barrier to make the office or facility accessible to persons with mobility impairments within six (6) months after the Contractor identified the barrier. q. The PH-MCO must ensure that all laboratory testing sites providing services have either a Clinical Laboratory Improvement Amendment (CLIA) certificate of waiver or a certificate of registration along with a CLIA identification number in accordance with CLIA 1988. Those laboratories with certificates of waiver will provide only the eight (8) types of tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory tests. The PCP must provide all required demographics to the laboratory when submitting a specimen for analysis.
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Network Composition. The Contractor must ensure that its Provider Network network is adequate to provide its Members in the HealthChoices HC-L/C zone with access to quality Member care through participating professionals, in a timely manner, and without the need to travel excessive distances. Upon request from the Department, the Contractor must supply geographic access maps detailing the number, location and specialties of their Provider Network network to the Department in order to verify accessibility of Providers within their Networknetwork. The Department may require additional numbers of specialists and ancillary providers should it be determined that geographic access is not adequate. The Contractor must make all reasonable efforts to honor a Member's choice of Providers who are credentialed in the Networknetwork. Additional requirements for establishing and maintaining an acceptable Provider Network network are as follows:
a. The Contractor must ensure the provision of services to persons who have special health needs or who face access barriers to health care. If the Contractor does not have at least two (2) specialists or sub-specialists qualified to meet the particular needs of the individuals, then the Contractor must allow Members to pick an Out-of-Network Provider if not satisfied with the Network Provider. The Contractor must develop a system to determine prior authorization for Out-of-Plan Services, including provisions for informing the MA Consumer of how to request this authorization for Out-ofat-Plan Services. For children with special health needs, the Contractor must offer at least two (2) pediatric specialists or pediatric sub-specialists.
b. The Contractor must ensure and must demonstrate its ability to:
i. Make available to every Member a choice of at least two (2) appropriate PCPs whose offices are located within a travel time no greater than thirty (30) minutes (urban) and sixty (60) minutes (rural). This travel time is measured via public transportation, where available. Members may, at their discretion, select PCPs located further from their homes.
ii. Ensure an adequate number of pediatricians to permit all Members who want a pediatrician as a PCP to have a choice of two (2) for their child(ren) children within the travel time limits (30 minutes urban, 60 minutes rural).
iii. Demonstrate its attempts to contract in good faith with a sufficient number of Certified Registered Nurse Practitioners (CRNP) to ensure access to CRNP services. While the Contractor may contract with a primary care practice in which the majority of primary care services are performed by CRNP's, the number of CRNPs in such practices may not exceed 10 percent of the total number of PCPs in the Contractor's Networknetwork.
iv. Limit its PCP Network network to appropriately qualified Providers. The PH-MCO's PCP Network network must meet the following: - o Seventy-five to one hundred percent (75-100%) of the Network consists of PCPs who have completed an approved primary care residency in family medicine, osteopathic general medicine, internal medicine or pediatrics; and - o No more than twenty-five percent (25%) of the Network consists of PCPs without appropriate residencies but who have, within the past seven (7) years, five (5) years of post-training clinical practice experience in family medicine, osteopathic general medicine, internal medicine or pediatrics. Post-training experience is defined as having practiced at least as a 0.5 full-time equivalent in the practice areas described; and - o No more than ten percent (10%) of the Network consists of PCPs who were previously trained as specialist physicians and changed their areas of practice to primary care, and who have completed Department-approved primary care retraining programs.
c. The Contractor must ensure a choice of at least two (2) pharmacies (excluding mail-order entities) within the travel time limits (30 minutes urban, 60 minutes rural).
d. The Contractor must ensure a choice of at least two (2) hospitals within the Provider Network, at least one (1) of which must be within the travel limits (30 minutes urban, 60 minutes rural).
e. The Contractor must ensure a choice of at least two (2) home health agencies within the HealthChoices HC-L/C zone.
f. The Contractor must ensure a choice of at least two (2) DME suppliers within the HealthChoices zone.
g. The Contractor must ensure a choice of at least two (2) rehabilitation facilities within the Provider Network, at least one (1) of which must be located within the HealthChoices zone.
h. The Contractor must ensure a choice of at least two (2) nursing facilities within the Provider Network.
i. The Contractor must ensure a choice of at least two (2) general practice dentists within the Provider Network. For Members needing anesthesia for dental care, the Contractor must ensure a choice of at least two (2) dentists within the Provider Network with privileges or certificates to perform specialized dental procedures under general anesthesia.
j. The Contractor must ensure access to Certified Nurse Midwives (CNMs) and CRNPs.
k. The Contractor must demonstrate its ability to offer its Members freedom of choice in selecting a PCP. At a minimum, the Contractor must have or provide one (1) full-time equivalent (FTE) PCP who serves no more than one thousand (1,000) MA Consumers (cumulative across all HealthChoices PH-MCO plans in the zone) and PCP sites which serve no more than five thousand (5,000) MA Consumers (cumulative across all HealthChoices PH-MCO plans in the zone). The Department will develop a system to notify the Contractor of a Provider reaching maximum panel limits. The number of Members assigned to a PCP may be decreased by the Contractor if necessary to maintain the appointment availability standards.
l. The Contractor and the Department will work together to avoid the PCP having a caseload or medical practice composed predominantly of HC Members. In addition, the Contractor must organize its PCP sites so as to ensure continuity of care to Members and must identify a specific PCP within the site for each Member. The Contractor may apply to the Department for a waiver of these requirements on a site-specific basis. The Department may waive these requirements for good cause demonstrated by the Contractor.
m. The Contractor must demonstrate its ability to provide adequate access to physician specialists for PCP referrals, and must employ or contract with adult and pediatric specialists in sufficient numbers to ensure that specialty services are made available in a timely, geographically, and physically accessible manner, particularly for those Members in Special Needs populations. The Contractor must ensure Members a choice of at least two (2) appropriate specialists.
n. The Contractor must contract with a sufficient number of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to ensure access to FQHC and RHC services, provided FQHC and RHC services are available, within a travel time of thirty (30) minutes (urban) and sixty (60) minutes (rural). If the Contractor's primary care Network includes FQHCs and RHCs, these sites may be designated as PCP sites. A listing of FQHCs and RHCs for HealthChoices is included in Exhibit QQ of this Agreement, HealthChoices Federally Qualified Health Centers and Rural Health Clinics. If a Contractor cannot contract with a sufficient number of FQHCs and RHCs, the Contractor must demonstrate in writing it has attempted to reasonably contract in good faith.
o. The Contractor must comply with the provisions of Act 112 of 1996 (H.B. 1415, P.N. 3853, signed July 11, 1996),the Balanced Budget Reconciliation Act of 1997 and Act 68 of 1998, the Quality Health Care Accountability and Protection Provisions, 40 P.S. 991.2101 et seq. pertaining to coverage and payment of Medically Necessary Emergency Services. The definition of such services is set forth herein at Section II.
p. The Contractor must inspect the office of any PCP or dentist who seeks to participate in the Contractor's Provider Network (excluding offices located in hospitals) to determine whether the office is architecturally accessible to persons with mobility impairments. Architectural accessibility means compliance with ADA accessibility guidelines with reference to parking (if any), path of travel to an entrance, and the entrance to both the building and the office of the provider, if different from the building entrance. If the office or facility is not accessible under the terms of this paragraph, the PCP or dentist may participate in the Contractor's Provider Network provided that the PCP or dentist: 1) requests and is determined by the Contractor to qualify for an exemption from this paragraph, consistent with the requirements of the ADA, or 2) agrees in writing to remove the barrier to make the office or facility accessible to persons with mobility impairments within six (6) months after the Contractor identified the barrier.
q. The PH-MCO must ensure that all laboratory testing sites providing services have either a Clinical Laboratory Improvement Amendment (CLIA) certificate of waiver or a certificate of registration along with a CLIA identification number in accordance with CLIA 1988. Those laboratories with certificates of waiver will provide only the eight (8) types of tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory tests. The PCP must provide all required demographics to the laboratory when submitting a specimen for analysis.
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Sources: Health Services Agreement (Health Risk Management Inc /Mn/)