Common use of PROVIDER NETWORK AND ACCESS REQUIREMENTS Clause in Contracts

PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP must provide medical care to its FCMH members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHP. A. Use of Medicaid Enrolled Providers Except in emergency situations, the PIHP must use only Medicaid enrolled providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled providers, at the FFS rate for those services, unless the PIHP can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled at the time the PIHP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. Protocols/Standards to Ensure Access The PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under the FCMH program. The PIHP’s protocols must include methods for identification, outreach to and screening/assessment of members with special health care needs, including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have expertise in the care of children with chronic conditions. C. Written Standards for Accessibility of Care 1. The PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHP. The standards must include the following: a. Waiting times for care at facilities; b. Waiting times for appointments; c. Statement that providers’ hours of operation do not discriminate against FCMH members; and d. Whether or not provider(s) speak the member’s language. 2. The PIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: a. To be no longer than 30 days for an appointment with a PCP; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: a. The enrollee's health status, medical care, or treatment options, including any alternative treatment that may be self-administered. b. Any information the enrollee needs in order to decide among all relevant treatment options. c. The risks, benefits, and consequences of treatment or nontreatment. d. The enrollee's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The PIHP must take corrective action if its standards are not met.

PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP HMO must provide medical care to its FCMH BadgerCare Plus and/or Medicaid SSI members that are as accessible to them, in terms of timeliness, amount, duration, and scope, as those services are to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHPHMO. A. 1. Use of BadgerCare Plus and/or Medicaid Enrolled SSI Certified Providers Except in emergency situations, the PIHP HMO must use only Medicaid enrolled providers who have been certified by the program for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled certified providers, at the FFS rate for those services, unless the PIHP HMO can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled certified by the program at the time the PIHP HMO reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook105, contains information regarding provider certification requirements. The PIHP HMO must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. 2. Protocols/Standards to Ensure Access The PIHP HMO must have written protocols to ensure that members have access to screening, diagnosis and referral referral, and appropriate treatment for those conditions and services covered under the FCMH programBadgerCare Plus and Medicaid SSI programs. The PIHPHMO’s protocols must include methods training and information for identificationproviders in their network in order to promote and develop providers’ skills in responding to the needs of persons with mental, outreach to physical and screening/assessment developmental disabilities. Training should include clinical and communication issues and the role of members care coordinators. For members, with special health care needs, including mental health where it has been determined to need a course of treatment or regular case monitoring, the HMO must have mechanisms in place to allow members to directly access a specialist as appropriate for the member’s condition and substance abuseidentified needs. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and HMO must have expertise written protocols to ensure that all members in the care of children with chronic conditionsCore Plan have access to a comprehensive physical exam within the member’s first certification period. C. 3. Written Standards for Accessibility of Care 1. Care The PIHP HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHPHMO. The standards must include the following: a. : • Waiting times for care at facilities; b. Waiting ; waiting times for appointments; c. ; • Statement that providers’ hours of operation do not discriminate against FCMH BadgerCare Plus and/or Medicaid SSI members; and d. and • Whether or not provider(s) speak the member’s language. 2. The PIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: a. To be no longer than 30 days for an appointment with a PCP; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: a. The enrollee's health status, medical care, or treatment options, including any alternative treatment that may be self-administered. b. Any information the enrollee needs in order to decide among all relevant treatment options. c. The risks, benefits, and consequences of treatment or nontreatment. d. The enrollee's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The PIHP HMO must take corrective action if its standards are not met. 4. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and/or Covered Services a. Dental Providers The HMO that covers dental services must have a dental provider within a 35-mile distance from any member residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. If there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the dentist accepts new patients, and whether full or part-time coverage is available. b. Mental Health or Substance Abuse Providers The HMO must have a mental health or substance abuse provider within a 35-mile distance from any member residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. If there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the providers accept new patients, and whether full or part-time coverage is available. c. High Risk Prenatal Care Services (BadgerCare Plus Only) The HMO must provide medically necessary high risk prenatal care within two weeks of the member’s request for an appointment, or within three weeks if the request is for a specific HMO provider, who is accepting new patients. d. HMO Referrals to Out-of-Network Providers for Services The HMO must provide adequate and timely coverage of services provided out of network, when the required medical service is not available within the HMO network. The HMO must coordinate with out-of-network providers with respect to payment and ensure that cost to the member is no greater than it would be if the services were furnished within the network (42 CFR. §. 438.206(b) (v) (5)). e. Primary Care Providers The HMO may define other types of providers as primary care providers. If they do so, the HMO must define these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the HMO certification process. The HMO must have a certified primary care provider within a 20- mile distance from any member residing in the HMO service area, unless there is no certified provider within the specified distance. In that case, the travel distance shall be no more than for a non- enrolled member. A service area for the HMO will be specified down to the zip code. Therefore, all portions of each zip code in the HMO service area must be within 20 miles from a certified primary care provider. This access standard does not prevent a member from choosing an HMO when the member resides in a zip code that does not meet the 20-mile distance standard. However, the member will not be automatically assigned to that HMO. If the member has been assigned to the HMO or has chosen the HMO and becomes dissatisfied with the access to medical care, the member may disenroll from the HMO because of distance. f. Second Medical Opinions The HMO must upon member request, provide members the opportunity to have a second opinion from a qualified network provider subject to referral procedures approved by the Department. If an appropriately qualified provider is not available within the network, the HMO must arrange for a second opinion outside the network at no charge to the member.

PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP HMO must provide medical care to its FCMH members BadgerCare Plus and/or Medicaid SSI enrollees that are as accessible to them, in terms of timeliness, amount, duration, and scope, as those services are to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHPHMO. A. 1. Use of BadgerCare Plus and/or Medicaid Enrolled SSI Certified Providers Except in emergency situations, the PIHP HMO must use only Medicaid enrolled providers who have been certified by the program for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled certified providers, at the FFS rate for those services, unless the PIHP HMO can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled certified by the program at the time the PIHP HMO reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth HandbookHFS 105, contains information regarding provider certification requirements. The PIHP Every HMO must require every physician providing services to members enrollees to have a Provider Number or National Provider Identifier (NPI). B. 2. Protocols/Standards to Ensure Access The PIHP HMO must have written protocols to ensure that members enrollees have access to screening, diagnosis and referral referral, and appropriate treatment for those conditions and services covered under the FCMH programBadgerCare Plus and Medicaid SSI programs. The PIHPHMO’s protocols must include methods training and information for identificationproviders in their network in order to promote and develop providers’ skills in responding to the needs of persons with mental, outreach to physical and screening/assessment developmental disabilities. Training should include clinical and communication issues and the role of members care coordinators. For enrollees, with special health care needs, including mental health and substance abuse. The PIHP must identify and provide care coordination where it has been determined to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physicalneed a course of treatment or regular case monitoring, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and the HMO must have expertise mechanisms in place to allow enrollees to directly access a specialist as appropriate for the care of children with chronic conditionsenrollee’s condition and identified needs. C. 3. Written Standards for Accessibility of Care 1. Care The PIHP HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHPHMO. The standards must include the following: a. : • Waiting times for care at facilities; b. Waiting ; waiting times for appointments; c. ; • Statement that providers’ hours of operation do not discriminate against FCMH BadgerCare Plus and/or Medicaid SSI members; and d. and • Whether or not provider(s) speak the member’s language. 2. The PIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: a. To be no longer than 30 days for an appointment with a PCP; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: a. The enrollee's health status, medical care, or treatment options, including any alternative treatment that may be self-administered. b. Any information the enrollee needs in order to decide among all relevant treatment options. c. The risks, benefits, and consequences of treatment or nontreatment. d. The enrollee's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The PIHP HMO must take corrective action if its standards are not met. 4. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and/or Covered Services a. Dental Providers The HMO that covers dental services must have a dental provider within a 35-mile distance from any enrollee residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. If there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the dentist accepts new patients, and whether full or part-time coverage is available. b. Mental Health or Substance Abuse Providers The HMO must have a mental health or substance abuse provider within a 35-mile distance from any enrollee residing in the HMO service area or no further than the distance for non-enrolled members residing in the service area. If there is no certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled member. The HMO must also consider whether the providers accept new patients, and whether full or part-time coverage is available. c. High Risk Prenatal Care Services (BadgerCare Plus Only) The HMO must provide medically necessary high risk prenatal care within two weeks of the enrollee’s request for an appointment, or within three weeks if the request is for a specific HMO provider, who is accepting new patients. d. HMO Referrals to Out-of-Network Providers for Services The HMO must provide adequate and timely coverage of services provided out of network, when the required medical service is not available within the HMO network. The HMO must coordinate with out-of-network providers with respect to payment and ensure that cost to the enrollee is no greater than it would be if the services were furnished within the network (42 CFR. §. 438.206(b) (v) (5)). e. Primary Care Providers The HMO may define other types of providers as primary care providers. If they do so, the HMO must define these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the HMO certification process. The HMO must have a certified primary care provider within a 20- mile distance from any enrollee residing in the HMO service area, unless there is no certified provider within the specified distance. In that case, the travel distance shall be no more than for a non- enrolled member. A service area for the HMO will be specified down to the zip code. Therefore, all portions of each zip code in the HMO service area must be within 20 miles from a certified primary care provider. This access standard does not prevent a member from choosing an HMO when the member resides in a zip code that does not meet the 20-mile distance standard. However, the member will not be automatically assigned to that HMO. If the member has been assigned to the HMO or has chosen the HMO and becomes dissatisfied with the access to medical care, the member may disenroll from the HMO because of distance. f. Second Medical Opinions The HMO must upon enrollee request, provide enrollees the opportunity to have a second opinion from a qualified network provider subject to referral procedures approved by the Department. If an appropriately qualified provider is not available within the network, the HMO must arrange for a second opinion outside the network at no charge to the enrollee.

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The PIHP must provide medical care to its FCMH members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHP. A. Use of Medicaid Enrolled Providers Providers‌ Except in emergency situations, the PIHP must use only Medicaid Wisconsin ForwardHealth enrolled providers for the provision of covered services. The Department reserves the right to withhold from payment development and reconciliation the capitation payments the monies costs related to services provided by non-enrolled providers, at the FFS rate for those servicesservice, unless the PIHP can demonstrate that it reasonably believed, based on the information provided by the Departmentdepartment, that the provider was Medicaid ForwardHealth enrolled at the time the PIHP time PHIP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). The Department requires that Medicaid-enrolled providers undergo periodic revalidation. During revalidation providers update their enrollment information with ForwardHealth, and sign the Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation. Providers who fail to revalidate are terminated from Wisconsin Medicaid. B. Protocols/Standards to Ensure Access Access‌ The PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under the FCMH program. The PIHP’s protocols must include methods for identification, outreach to and screening/assessment of members with special health care needs, including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have expertise in the care of children with chronic conditions. C. Written Standards for Accessibility of CareCare‌ 1. The PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHP. The standards must include the following: a. Waiting times for care at facilities; b. Waiting times for appointments; c. Statement that providers’ hours of operation do not discriminate against FCMH members; and d. Whether or not provider(s) speak the member’s language. 2. The PIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: a. To be no longer than 30 days for an appointment with a PCP; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay.; c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee member who is his or her patient, for the following: a. The enrollee's member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. b. Any information the enrollee member needs in order to decide among all relevant treatment options. c. The risks, benefits, and consequences of treatment or nontreatment. d. The enrolleemember's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The PIHP must take corrective action if its standards are not met. D. Monitoring Compliance‌ The PIHP must develop policies and procedures regarding wait times for appointments and care. The PIHP shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the PIHP or by the Department, the PIHP must take corrective action so that providers meet the PIHP’s standards and improve access for members. The Department will investigate complaints received of PIHPs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Providers and/or Covered Services‌ Per 42 CFR § 438.207, PIHPs must provide assurances to the State that demonstrates that the PIHP has the capacity to serve the expected enrollment in its service area per the State standards for access to care provided below. All PIHP network reviews are based on the number of providers accepting new patients. 1. Primary Care Provider Network Adequacy Standards

PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP must provide medical care to its FCMH BadgerCare Plus and/or Medicaid SSI members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHP. A. Use of Medicaid Enrolled Certified Providers Except in emergency situations, the PIHP must use only Medicaid enrolled certified providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled certified providers, at the FFS rate for those services, unless the PIHP can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled certified at the time the PIHP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. Protocols/Standards to Ensure Access The PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under the FCMH program. The PIHP’s protocols must include methods for identification, outreach to and screening/assessment of members with special health care needs, including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have expertise in the care of children with chronic conditions. C. Written Standards for Accessibility of Care 1. The PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHP. The standards must include the following: a. Waiting times for care at facilities; b. Waiting times for appointments; c. Statement that providers’ hours of operation do not discriminate against FCMH members; and d. Whether or not provider(s) speak the member’s language. 2. The PIHP’s standards for waiting times for appointments must be as follows for the indicated provider types: a. To be no longer than 30 days for an appointment with a PCP; b. To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. c. To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The PIHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: a. The enrollee's health status, medical care, or treatment options, including any alternative treatment that may be self-administered. b. Any information the enrollee needs in order to decide among all relevant treatment options. c. The risks, benefits, and consequences of treatment or nontreatment. d. The enrollee's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the PIHP from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The PIHP must take corrective action if its standards are not met.

PROVIDER NETWORK AND ACCESS REQUIREMENTS. ‌ The PIHP HMO must provide medical care to its FCMH BadgerCare Plus and/or Medicaid SSI members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHPHMO. A. Use of BadgerCare Plus and/or Medicaid SSI Enrolled Providers Providers‌ Except in emergency situations, the PIHP HMO must use only Medicaid enrolled providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled providers, at the FFS rate for those services, unless the PIHP HMO can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled at the time the PIHP HMO reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The PIHP HMO must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). B. Protocols/Standards to Ensure Access Access‌ The PIHP HMO must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under the FCMH programBadgerCare Plus and Medicaid SSI programs. The PIHPHMO’s protocols must include methods training and information for identificationproviders in their network, outreach in order to promote and screening/assessment develop provider skills in responding to the needs of persons with mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physicalwhere a course of treatment or regular case monitoring is needed, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and the HMO must have expertise mechanisms in place to allow members to directly access a specialist, as appropriate, for the care of children with chronic conditionsmember’s condition and identified needs. C. Written Standards for Accessibility of CareCare‌ 1. The PIHP HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHPHMO. The standards must include the following: a. : • Waiting times for care at facilities; b. ; • Waiting times for appointments; c. ; • Statement that providers’ hours of operation do not discriminate against FCMH BadgerCare Plus and/or Medicaid SSI members; and d. and • Whether or not provider(s) speak the member’s language. 2. The PIHPHMO’s standards for waiting times for appointments must be as follows for the indicated provider types: a. : • To be no longer than 30 days for an appointment with a PCP; b. ; • To be no longer than 30 days for an appointment with a Mental Health provider for follow-up after an inpatient mental health stay. c. . • To be no longer than 90 days for an appointment with a dental provider for a routine dental appointment in regions 5 and 6. 3. The PIHP HMO may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following: a. : • The enrollee's ’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered. b. . • Any information the enrollee needs in order to decide among all relevant treatment options. c. . • The risks, benefits, and consequences of treatment or nontreatment. d. non- treatment. • The enrollee's ’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the PIHP HMO from the requirement to provide or arrange for the provision of any medically necessary covered service required by its members. The PIHP HMO must take corrective action if its standards are not met. D. Monitoring Compliance‌ The HMO must develop policies and procedures regarding wait times for appointments and care. The HMO shall conduct surveys and site visits to monitor compliance with these standards and shall make them available to DHS upon request. If issues are identified, either by the HMO or by the Department, the HMO must take corrective action so that providers meet the HMO’s standards and improve access for members. The Department will investigate complaints received of HMOs that exceed standards for waiting times for care and waiting time for appointments. E. Access to Selected BadgerCare Plus and/or Medicaid SSI Providers and Covered Services‌ 1. Dental Providers