AZ
"Indian Health Services (IHS): The Contractor may choose to subcontract with and pay an IHS or tribal facility for covered services provided to members. Effective October 1, 1999, the Contractor is responsible for reimbursement to IHS or tribal facilities for emergency services provided to state-only and Title XXI Native American members enrolled with the Contractor. The Contractor has no responsibility for non-emergency services to state-only and Title XXI Native American members unless the Contractor refers or prior authorizes the service…" Arizona Contract, page 13.
"SECTION D:
PROGRAM REQUIREMENTS
1. SCOPE OF
SERVICES…
Emergency services:
The Contractor shall have and/or provide the following as a minimum: ...The
Contractor is encouraged to contract with emergency service facilities
for the provision of emergency services. The Contractor is encouraged
to contract with or employ the services of non-emergency facilities (e.g.
urgent care centers) to address member non-emergency care issues occurring
after regular office hours or on weekends...
Nursing Facility: The Contractor shall provide nursing facility services, including religious nonmedical health care institutions, for members who require short-term convalescent care not to exceed 90 days per contract year. In lieu of a nursing facility, the member may be placed in an alternative living facility or receive home and community based services (HCBS) as defined in R9-28, Article 1 that meet the provider standards described in R9-28, Article 5." Arizona Contract, pages 10, 12, 14.
"23. OTHER
PROVIDER STANDARDS
The Contractor
shall develop and implement policies and procedures to:
a.
Recruit... health care professionals, health care institutions and support
services to meet the medical needs of its members." Arizona Contract,
page 32.
"35. HOSPITAL
SUBCONTRACTING AND REIMBURSEMENT
Maricopa and
Pima counties only: Laws of 1996 Chapter 288 Section 20 authorizes the
Hospital Reimbursement Pilot Program (Pilot), which is effective
from October 1, 1997, through September 30, 2000. The Pilot
as defined by AHCCCS Rule R9-22-718 requires hospital subcontracts to be
negotiated between health plans in Maricopa and Pima counties and hospitals
to establish reimbursement levels, terms and conditions…" Arizona
Contract, page 37.
"R. Other
Outside Medical Services
The CONTRACTOR,
at its discretion and without compromising quality of care, may choose
to provide services in Freestanding Emergency Centers, Surgical Centers
and Birthing Centers." Arizona Contract, page C4.
AZBH
"SECTION C:
DEFINITIONS...
ALTERNATIVE
RESIDENTIAL CARE FACILITY
An ADHS-licensed
facility with 16 or fewer beds. Alternative residential care facilities
include licensed Level II and III facilities as well as Level I facilities
licensed to provide emergency services and detoxification services...
CRISIS STABILIZATION
FACILITY
A behavioral
health alternative residential setting, licensed by ADHS as a Level I or
II behavioral health agency, with sixteen (16) or fewer treatment beds,
which provides twenty-four (24) hour supervision of members who require
a protected supervised environment to reduce or eliminate acute symptoms
of a behavioral health condition. Room and board is not a covered
service in this facility." Arizona Behavioral Health Contract, pages
3-4.
CA
"ARTICLE II
- DEFINITIONS...
JJ. Federally
Qualified HMO means a prepaid health delivery plan that has fulfilled the
requirements of the HMO Act, along with its amendments and regulations,
and has obtained the Federal Government's qualification status under Section
1310(d) of the Public Health Service Act (42 USC S300e)...
SS. Indian Health Service (IHS) Facilities means Facilities operated with funds from the IHS under the Indian Self-Determination Act and the Indian Health Care Improvement Act, through which services are provided, directly or by contract, to the eligible Indian population within a defined geographic area.
TT. Intermediate Care Facility (ICF) means a Facility which is licensed as an ICF by DHS or a hospital or Skilled Nursing Facility which meets the standards specified in Title 22, CCR, Section 51212 and has been certified by DHS for participation in the Medi-Cal program." California Contract, pages 2, 7-8.
"L2. Skilled Nursing Facility (SNF) means, as defined in Title 22, CCR, Section 51121(a), any institution, place, building, or agency which is licensed as a Skilled Nursing Facility by DHS or is a distinct part or unit of a hospital, meets the standard specified in Section 51215 of these regulations (except that the distinct part of a hospital does not need to be licensed as a Skilled Nursing Facility) and has been certified by DHS for participation as a Skilled Nursing Facility in the Medi-Cal program." California Contract, page 13.
"6.6.3 Network
Composition
The Contractor
will maintain an adequate number of inpatient Facilities… within
their network to provide Covered Services to its Members." California
Contract, page 104.
"6.6.14 Utilization
of DSH Hospitals
Contractor
shall increase Utilization of Disproportionate Share Hospitals (DSH) by
Members to a level specified by DHS upon notification. DHS shall
only impose this requirement if the Utilization of DSH has decreased in
such magnitude as to jeopardize DSH supplemental payments in the county."
California Contract, pages 106-107.
CO
"I. DEFINITIONS
The following
terms as used in this Contract shall be construed and interpreted as follows
unless the context otherwise expressly requires a different construction
and interpretation: …
AQ. 'Hospital'
shall mean an institution which:
1. is
licensed by the State as a hospital;
2. has
a Utilization Review program which meets Medicare conditions of participation;
3. is
primarily engaged in providing medical care and treatment for sick and
injured persons on an inpatient basis through medical, diagnostic and major
surgical facilities, under the supervision of a staff of Physicians and
with twenty-four- hour-a-day nursing service; and,
4. is
certified by Medicare; or
5. in
the case of a specialty care center not eligible for Medicare certification,
meets criteria established or recognized by the Department in accordance
with any applicable state and federal statute or regulation." Colorado
Contract, page 7.
DE
"II.8
Provider Networks
The MCO must
establish and maintain provider networks in geographically accessible locations
for the populations to be served. These networks must be comprised of hospitals,
physicians, behavioral health providers, and other specialists in sufficient
numbers to make available all covered services in a timely manner…"
Delaware RFP, page II.52.
DC
"I. SERVICE
AND ACCESS
1.
Network Composition and Capabilities
a.
Provider's network shall be sufficient to furnish all services covered
under this contract and at a minimum must include the following classes
of providers: ...
(3)
hospitals located in the District of Columbia ..." District of Columbia
Contract, pages 28-29.
FL
"B. Manner
Of Service Provision...
2. Minimum
Standards. Plans shall provide the following: ...
c. One
fully accredited general acute care hospital bed per 275 HMO members.
The agency may waive, in writing, the accreditation requirement in rural
areas..." Florida Contact, pages 10-11.
FLMH
"2.3 Medicaid
Service Requirements...
C. Physician
Services...
"2.5 Minimum
Staffing and Access Standards...
5. The
contractor shall have access to no less than one fully accredited psychiatric
community hospital bed per 2, 000 prepaid members, as appropriate for both
children and adults." Florida Mental Health RFP, page 29.
"2.5 Minimum
Staffing and Access Standards...
6. The
contractor shall provide a designated emergency service facility per county
to ensure unrestricted access to emergency care on a 24 hours a day, seven
days a week basis. Such designated emergency service facility shall
have 24 hours a day, seven days a week, registered nurse coverage and on-call
coverage by a mental health professional, as defined in the Baker Act,
Chapter 394, Part I, F.S." Florida Mental Health Contract, page 29.
HI
"30.410
Required Providers
The following
is a listing of required components of the provider network...
* Home
health agency services
* Hospital
services
* Outpatient
hospital services…" Hawaii RFP, page 9.
HIBH
"30.410
Required Providers
The BHMC plan
shall develop and maintain a provider network statewide capable of providing
a 24 hour a day comprehensive behavioral health and substance abuse services
to approximately 4,000 members statewide...
The following
is a listing of required components of the provider network. It is
not meant to be an all-inclusive listing of the components of the network
and additional components may be required based on the needs of the members.
• Hospital
services...
• State hospital…"
Hawaii Behavioral Health RFP, page 15.
"30.700
Scope of Behavioral Health Services
The behavioral
health services to be provided by the BHMC plan includes basically all
medically necessary behavioral health services for QUEST adults who are
SMI and children and youth who are SED…Services may be provided or arranged
for in a variety of ways such as through…mental health agencies, general
hospitals…" Hawaii Behavioral Health RFP, page 25.
IN
"3.1.4
Provider Types
There are over
18,000 active providers in the Indiana Medicaid program. Basic provider
types include:
*
Hospitals (general, acute, secondary, and tertiary)
*
Psychiatric hospitals
*
Rehabilitation hospitals
*
Long-term care facilities (skilled and intermediate care)
*
Intermediate care facilities for the mentally retarded (ICF/MRs)
*
Community residential facilities for the developmentally disabled (CRF/DDs)…"
Indiana RFP, pages 3-5 - 3-6.
IA
"4.2.5.2.
Contracts with Title V and Title X providers
The HMO shall
make a reasonable effort in its enrollment area to subcontract with health
care providers receiving funds from titles V and X of the Social Security
Act (i.e., Maternal health Centers, Child Health Centers, Family Planning
Clinics, etc.), and that meet the HMO's credentialing criteria...
The HMO shall
make a reasonable effort to subcontract with family planning clinics and
centers in the Enrollment Area…" Iowa Contract, page 24.
IABH
"Halfway House:
Low intensity substance abuse addiction treatment in a supportive living
environment to facilitate the individual's reintegration into the community,
most often following completion of primary substance abuse treatment...
PMIC: Psychiatric
medical institutions for children as described in Iowa Code Chapter 135H"
Iowa Behavioral Health Contract, pages 48-50.
"ATTACHMENT
ON MEMTAL HEALTH SERVICES
Covered Mental
Health Services...
* Services
provided through a community mental health center including:
services of a psychiatrist
services of a clinical psychologist
services of a licensed social worker
services of a psychiatric nurse…" Iowa Behavioral Health Contract,
page 79.
"III.
SPECIAL CONSIDERATIONS FOR SUBSTANCE ABUSE SERVICES...
3. Substance
Abuse Treatment services at a Mt. Pleasant State Mental Health Hospital
State mental health institutes shall be part of the Contractor's provider
panel…" Iowa Behavioral Health Contract, pages 86-87.
KY
"1.2 Applications
and Eligibility...
To be the eligible applicant, Kentucky's Health Care Partnership (a.k.a.
The Partnership) must meet the following requirements:
• have
at least one teaching hospital in The Partnership if applicable for The
Partnership region..." Kentucky RFA, page 10.
"The Partnership
shall include at least the specified providers in its Program as follows:
(a)
Teaching hospitals located in The Partnership region...
(b)
Children's Hospitals providing services under traditional Medicaid that
practice outside of the Commonwealth." Kentucky RFA, page 49.
ME
"3.4 SERVICE
DELIVERY
A. PROVIDER
NETWORKS...
The Contractor
shall ensure that, at a minimum, its provider networks are comprised of
hospitals… and other providers in sufficient numbers to make available
all covered services in a timely, effective and efficient manner."
Maine Contract, pages 25-26.
MA
"Section 2.5
Provider Network
A. General...
6. The
Contractor shall maintain a Provider Directory (or Directories) that identifies
the Contractor's Providers, including at a minimum the following: … hospitals…"
Massachusetts Contract, pages 39-40.
MABH
"SELECTIVE PROVIDER
CONTRACTING PROCUREMENT
The Contractor
shall maintain and utilize the current MH/SAP provider network and DEP's,
until such time as the Contractor has completed the competitive procurement
process for each type of service, as set forth below, or as otherwise agreed
to by the Division...
The Division shall require the Contractor to select and procure a Provider Network according to the purchasing specifications set forth in Section 2.0 of Appendix B to this Contact entitled 'Provider Network Development, Administration and Management' and the following timetable:
Type of Service...
Acute inpatient
mental health services..
Acute inpatient
detoxification services...
Designated
Emergency Programs…
Residential
and Day Treatment…" Massachusetts MH/SAP Contract, Appendix J.
MN
"Section 9.2.9. Home Visiting Services. The HEALTH PLAN shall contract with programs receiving grants under Minnesota Statutes, Section 145A.16: Universally Offered Home Visiting Programs for Infant Care, for covered home visiting services…" Minnesota Contract, page 85.
MO
"2.2.2 Provider Networks: The health plan must establish and maintain provider networks… comprised of hospitals…" Missouri RFP, page 24.
NH
"Article I
Definitions...
1.27
The term 'Hospital' means a facility as defined by the New Hampshire Public
Health Law RSA 151:2 or defined under the statute of the state in which
it operates. Excluded are institutions operated by the Veteran's Administration
or other U.S. governmental agencies, rest homes, convalescent centers (even
if part of the hospital itself), homes for the aged or insane, or institutions
for the care and treatment of chronic alcoholism or drug addiction."
New Hampshire General Service Agreement, page 5.
NJ
"10.10
Emergency Services...
C.
The contractor shall ensure and demonstrate that it has provider contracts
with a sufficient number (in accordance with access standards in Appendix
L) of the hospital emergency and urgent health care services within and
around its basic service area to provide emergency service to its enrollees…"
New Jersey Contract, pages 53-54.
NM
"2.C PROVIDERS:
The CONTRACTOR
must establish and maintain a comprehensive network of providers capable
of serving all members who enroll in the MCO." New Mexico Contract, page
27.
"2.C.9 University
of New Mexico Health Sciences Center
The CONTRACTOR
shall contract with the University of New Mexico Health Sciences Center
for specialty services provided by Carrie Tingley Hospital and the University
of New Mexico Hospital including transplants. neonate. bran and trauma,
level I trauma center. and other specialized pediatric services."
New Mexico Contract, page 30.
"2.C.11
School-Based Providers:
The CONTRACTOR
shall make every effort to include school- based health clinics as network
providers or provide the same level of access in the school setting…
2.C.12
State-Run Institutions
The CONTRACTOR
may access a limited amount of services at State-run institutions. At no
cost to the CONTRACTOR, through a State centralized admissions process.
These institutions include Sequoyah Adolescent Treatment Center and the
CARE Unit of the Las Vegas Medical Center which are administered by the
Department of Health (DOH), and Casa Amigos community Residential Treatment
Center. La Placita community Residential Treatment Center, Albuquerque
Girls' Community Residential Treatment Center and Carlsbad community Residential
Treatment Center, which are administered by the Children, Youth and Families
Department (CYFD), HSD shall continue to make direct payment to DOH and
CYFD for the limited services rendered at these facilities." New
Mexico Contract, pages 31-32.
NY
"21. PARTICIPATING
PROVIDERS
21.1 Network
Requirements
a) Sufficient
Number
i) The
Contractor will establish and maintain a network of Participating Providers.
ii) The Contractor's
network must contain all of the provider types necessary to furnish the
prepaid Benefit Package, including but not limited to: hospitals...
iii) To be
considered accessible, the network must contain a sufficient number and
array of providers to meet the diverse needs of the Enrollee population.
This includes being geographically accessible (meeting time/distance standards)
and being accessible for the disabled.
iv) The Contractor
shall not include in its network any provider who has been sanctioned or
prohibited from serving Medicaid recipients or receiving Medical Assistance
payments…" New York Contract, page 21-1.
"21. Participating
Providers...
21.14
Hospitals
a) Tertiary
Services
The Contractor
will establish hospital networks capable of furnishing the full range of
tertiary services to Enrollees…" New York Contract, pages 21-1-21-8.
OH
"(b) Non-PCP
Minimum Provider Network
During the
verification phase, each MCP will also be required to submit documentation
or have documentation available to verify adequate capacity of the remainder
of its provider network within the following categories: hospitals…
Hospitals
For the purposes
of meeting the minimum provider network requirement, MCPs will be required
to verify that they have contracted with at least one hospital in the service
area and that this hospital, alone or in combination with other hospitals
within the service area, is able and agrees to provide all of the following
services during the contract period: general medical/surgical services
for both the adult and pediatric population; obstetrical services; nursery
services; adult, pediatric and neonatal (Levels I and II) intensive care;
cardiac care; outpatient surgery; and emergency room services." Ohio
RFP, pages 24-25.
"Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - During the documentation phase, all MCPs will be required to document an affiliation with at least one CNM and one CNP within each county included in the service area, if such provider types are present within the counties in the service area…" Ohio RFP, page 28.
OK
"2.7.5
Hospitals
Health Plan
must establish hospital networks capable of furnishing the full range of
tertiary services to members…" Oklahoma RFP, page 37.
ORMH
"f. Acute
Inpatient Psychiatric Care
Contractor
shall maintain agreements with local and regional hospitals to ensure provisions
of emergency and non emergency hospitalization for OMAP Members with mental
disorders which require Acute Inpatient Hospital Psychiatric Care.
If Contractor uses hospitals other than those under contract with the Division,
then the Contractor shall assure that the hospitals selected comply with
OAR 309-032-0850 through OAR 309-032-0890, standards for Regional Acute
Care Facilities for Adults." Oregon Mental Health Contract, page
16.
"DEFINITIONS
With the following
exceptions and additions, the terms in this agreement have the same definitions
as those terms appearing in Oregon Administrative Rules(OARs)...
Mental Health
Organization (MHO): A prepaid Health Plan Under Contract with Division
to provide Covered Services under the OHP Medicaid Demonstration Project
and Children's Health Insurance Program. MHOs can be FCHPs, CMHPs
or private MHOs or combinations thereof...
Residential/Medical Youth Care Residential Care Residential Center: A facility providing treatment under a physician approved plan to children and adolescents(ages 3 through 20) with mental or emotional disorder as identified in a mental health Assessment. These children and adolescents are placed by OYA and SOSCF in cooperation with the county mental health authority. Adolescents receiving this service have a DSM-IV, Axis I Diagnosis and reside in a SOSCF licensed youth care center. This service includes an Appropriate mix and intensity of individual and group therapies and skills Development to reduce or eliminate the symptoms of the disorder and restore the individual's ability to function, to the best possible level, in home, school and community settings...
Residential Treatment Facility: A facility that is operated to provide supervision, care and treatment on a 24-hour basis for six or more residents consistent with ORS 443.400 through ORS 443.455.
Residential
Treatment Home: A home that is operated to provide supervision, care
and treatment on a 24-hour basis for five or fewer residents consistent
with ORS 443.400 through ORS 443.455...
State Hospital:
State-operated psychiatric hospitals including Oregon State Hospital in
Salem and Portland, and Eastern Oregon Psychiatric Center in Pendleton."
Oregon Mental Health Contract, Appendix K, pages K1, K13, K19-K20.
PA
"I. PROVIDER
NETWORKS...
2. Network
Composition
The HMO must
establish and maintain adequate provider networks to serve all of the eligible
HealthChoices populations in geographically accessible locations within
the service area for the HealthChoices populations to be served, to include,
but not be limited to, hospitals, children's tertiary care hospitals, specialty
clinics, trauma centers…" Pennsylvania RFP, pages 63-64.
RI
"2.08.01
Network Composition
Contractor
shall establish and maintain geographically accessible provider networks,
comprised of hospitals… in sufficient numbers to make available all services
in a timely manner…" Rhode Island RFP, page 32.
SC
"4.11.2
Adequacy of Providers...
The Contractor
shall make available and accessible, as determined by SCDHHS, hospitals,
facilities, and professional personnel sufficient to provide the required
core benefits." South Carolina Contract, page 23.
"CORE BENEFITS
FOR THE SOUTH CAROLINA MEDICAID HMO PROGRAM...
OUTPATIENT
SERVICES...
Outpatient/ambulatory
care facilities include Hospital Outpatient Departments, Diagnostic/Treatment
centers, Ambulatory Surgical Centers, Emergency Rooms, End Stage Renal
Disease Clinics (ESRD) and Outpatient Pediatric AIDS Clinic (OPAC)…"
South Carolina Contract, Appendix C, Tab 1, pages 1-2.
"Provider Certification and Licensing
Medical service providers must meet certification and licensing requirements...
Inpatient Hospitals - Inpatient hospital providers must be surveyed and licensed by the Department of Health and Environmental control (DHEC)...
Outpatient Hospitals - Outpatient hospital providers must be surveyed and licensed by the Department of Health and Environmental Control (DHEC)...
Ambulatory Surgical Centers - Ambulatory surgical centers must be surveyed and licensed by the Department of Health and Environmental Control (DHEC)...
End Stage Renal Disease Clinics - End stage renal disease clinics must be surveyed and licensed by the Department of Health and Environmental Control (DHEC)...
Laboratory Certification - In accordance with Federal regulations, all laboratory testing facilities providing services must have a Clinical Laboratory Improvement Amendment )CLIA) Certificate of Waiver of Certificate of Registration with DLIA identification number…
Mobil Ultrasound - No license or certification required.
Physiology Labs - Providers must be enrolled with Medicare" South Carolina Contract, Appendix C, Tab 3, pages 1, 3.
"Network Providers
and Subcontractors...
For each county
utilize the following to describe the provider's type of service and specialty.
1. Type of Service*** Provider Type/Practice Specialty
Ancillary Services***Ambulance, Durable Medical Equipment, Home Health, Independent Laboratory, Independent X-Ray, Infusion Center…, SC Department of Health and Environmental Control...Other (specify type)...
Institutional Services***Ambulatory Surgical Center, Comprehensive Outpatient, Rehabilitation Facility, End Stage Renal Disease Clinic, Inpatient Hospital, Long Term Care/Nursing Home, Outpatient Hospital, Other (specify type)" South Carolina Contract, Appendix D, Tab 1, pages 1-2.
TX
"Significant traditional provider (STP) means all hospitals receiving disproportionate share hospital funds (DSH) in FY ‘95 and all other providers in a county that, when listed by provider type in descending order by the number of recipient encounters, provided the top 80 percent of recipient encounters for each provider type in FY '95.
Special hospital
means an establishment that:
(a) offers
services, facilities, and beds for use for more than 24 hours for two or
more unrelated individuals who are regularly admitted, treated, and discharged
and who require services more intensive than room, board, personal services,
and general nursing care;
(b) has
clinical laboratory facilities, diagnostic x-ray facilities, treatment
facilities, or other definitive medical treatment;
(c) has
a medical staff in regular attendance; and
(d) maintains
records of the clinical work performed for each patient." Texas Contract,
page 11.
"6.5 EMERGENCY
SERVICES...
6.5.7 HMO must
provide access to the TDH-designated Level I and Level II trauma centers
within the State or Hospitals meeting the equivalent level of trauma care.
HMOs may make out-of-network reimbursements arrangements with the TDH-designated
Level I and Level II trauma centers to satisfy this access requirement."
Texas Contract, pages 37-38.
"7.7 PROVIDER
QUALIFICATIONS - GENERAL...
The providers
in HMO network must meet the following qualifications: ...
Hospital -
An institution licensed as a general or special hospital by the State of
Texas under Chapter 241 of the Health and Safety Code and Private Psychiatric
Hospitals under Chapter 577 of the Health and Safety Code (or is a provider
which is a component part of a State or local government entity which does
not require a license under the laws of the State of Texas), which is enrolled
as a provider in the Texas Medicaid Program. HMO will require that
all facilities in the network used for acute inpatient specialty care for
people under age 21 with disabilities or chronic or complex conditions
will have a designated pediatric unit; 24-hour laboratory and blood bank
availability; pediatric radiological capability; meet JCAHO standards;
and have discharge planning and social service units…
Local Mental Health Authority (LMHA) - Under Section 531.002(8) of the Health and Safety Code, the local component of the TXMHMR system designated by TDMHMR to carry out the legislative mandate for planning, policy development, coordination, and resource development/allocation and for supervising and ensuring the provision of mental health care services to persons with mental illness in one or more local service areas.
Non-Hospital Facility Provider - A provider of health care services which is licensed and credentialed to provide services, and enrolled in the Texas Medicaid Program." Texas Contract, pages 61-63.
"7.18
DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs)
7.18.1
All HMO contracts with any of the entities described in Texas Insurance
Code Article 20A.02(ee) and a group of providers who are licensed to provide
the same health care services or an entity that is wholly-owned or controlled
by one or more hospitals and physicians including a physician-hospital
organization (delegated network contracts) must:
7.18.1.1
contain the mandatory contract provisions for all subcontractors in Article
3.2 of this contract;
7.18.1.2
comply with the requirements, duties and responsibilities of this contract;
7.18.1.3
not create a barrier for full participation to significant traditional
providers;
7.18.1.4
not interfere with TDH’s oversight and audit responsibilities including
collection and validation of encounter data; or
7.18.1.5
be consistent with the federal requirement for simplicity in the administration
of the Medicaid program." Texas Contract, page 76.
UT
"5. Maternity
Stays
c.
Post-Delivery Care
Post-delivery
care will be provided to a mother and her newborn child by... in a hospital,
or (2) another setting determined appropriate under regulations promulgated
by the Secretary of Health and Human Services, (including a birthing center
or an intermediate care facility)..." Utah Contract, Attachment B,
pages 19-20.
UTMH
"Article I
DEFINITIONS...
'Institution
for Mental Disease' means a hospital, nursing facility or other institution
of more than 16 beds that is primarily engaged in providing diagnosis,
treatment or care of person with mental diseases, including medical attention,
nursing care and related services." Utah Mental Health Contract,
page 1.
VA
"ARTICLE I -
DEFINITIONS...
Health Maintenance
Organization (HMO) - A separate legal entity that is licensed by the Virginia
Bureau of Insurance (BOI) and undertakes to provide or arrange for one
or more prepaid health care plans and that meets certain State provisions.
This entity also provides or arranges for one or more health care delivery
plans.
Hospital - A facility that meets the requirements of 42 C.F.R. 482 as amended...
Primary Care Case Management (PCCM) - One of the State's managed care programs, MEDALLION, wherein recipients are linked to a Primary Care Provider (PCP) who contracts directly with the Commonwealth of Virginia. The PCP is responsible for coordinating selected covered services, is reimbursed on a fee-for-service basis, and receives a case management fee for each enrollee in his her panel." Virginia Contract, pages 7, 9-12.
"J. PROVIDER
NETWORK COMPOSITION AND ACCESS TO CARE STANDARDS
1. Network
Provider Composition
a. The Contract will be solely responsible for arranging for and administering covered services to enrolled recipients and shall ensure that its delivery system shall provide available, accessible and adequate numbers of facilities, locations and personnel for the provision of covered services. The Contractor shall include in its network or otherwise arrange care by providers specializing in early childhood, youth and geriatric services. The Contractor is encouraged to develop and maintain a list of referral sources which includes community agencies, State agencies, "safety net" providers, teaching institutions and facilities that are needed to assure that the enrollees are able to access and receive the full continuum of treatment and rehabilitative medical and outpatient mental health services and supports needed." Virginia Contract, page 62.
"7. Inpatient
Hospital Access
The Contractor
shall maintain in its network a sufficient number of inpatient hospital
facilities which is adequate to provide covered services to its enrollees.
The Contractor shall notify the Department within fifteen (15) calendar
days of any changes to its contracts with hospitals if those changes impact
the scope of covered services, the number of individuals covered and/or
the units of service covered." Virginia Contract, page 65.
"3. Assurance
of Expertise for Child Abuse and Neglect and Domestic Violence
The Contractor
shall arrange for the provision of examination and treatment services by
providers with expertise, capability, and experience in dealing with the
medical/psychiatric aspects of caring for victims and perpetrators of child
abuse and neglect and domestic violence… The Contractor shall include such
providers in its network and forward to the Department the qualifications
and proof of expertise of the providers for review and approval by the
Department prior to adding the provider to the Contractor's network.
The Contractor shall utilize human services agencies or appropriate providers
in their community...
Services provided shall include but are not limited to court-ordered physical, psychological, and mental or developmental examinations, and psychiatric treatment appropriate for victims and perpetrators of child abuse and neglect." Virginia Contract, page 80.
WV
"3.1.1
Network Capable of Full Array of Services
The MCP must
establish and maintain provider networks in geographically accessible locations
for the populations to be served. These networks must be comprised of hospitals,
primary care providers (PCPs) and specialty care providers (SCPs) in sufficient
numbers to make available all covered services in a timely manner…"
West Virginia RFA, page 14.
"3.6.3
Rural Primary Care Hospitals
DHHR will provide
financial incentives for the MCP to contract with Rural Primary Care Hospitals
(RPHCs)." West Virginia RFA, page 23.