AZ
"23. OTHER PROVIDER
STANDARDS
The Contractor
shall develop and implement policies and procedures to:
a. Recruit
sufficient specialty physicians, dentists, health care professionals, ...to
meet the medical needs of its members." Arizona Contract, page 32.
CA
"6.5.7.10 Unusual
Specialty Services
The Contractor
will arrange for the provision of seldom used or unusual specialty services
from specialists outside the network when determined Medically Necessary."
California Contract, page 99.
"6.6.3 Network
Composition
The Contractor
will maintain an adequate number of inpatient Facilities, Service Locations,
Service Sites, professional, allied, specialist and supportive paramedical
personnel within their network to provide Covered Services to its Members.
6.6.4
Access Requirements
The Contractor
will ensure Members access to all Medically Necessary specialists through
staffing, subcontracting, or referral...
6.6.5 Specialists
The Contractor
will maintain adequate numbers and types of specialists within their network
to accommodate the need for specialty care. Contractor will provide
a recording/tracking mechanism for each authorized, denied, or modified
referral. In addition, the Contractor will offer second opinions
by Specialists to any Member upon request." California Contract,
pages 104-105.
CT
"3.6 Geographic
Coverage...
The MCO shall
ensure that its provider network includes access for each Member to … PCPs…"
Connecticut Contract, page 19.
"3.12
Specialist Providers and the Referral Process
The MCO shall
contract with a sufficient number and mix of specialists so that the Member
population's anticipated specialty care needs can be substantially met
within the MCO's network of providers. The MCO will also be required
to have a system to refer Members to out-of-network specialists if appropriate
participating specialists are not available…" Connecticut Contract,
page 23.
"3.20
Dental Care
a. The
MCO shall contract with a sufficient number of dentists throughout each
county of the state where the MCO has an approved service area to assure
access to oral health care…" Connecticut Contract, page 34.
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...
II.9 PCP
and Specialist Access Standards
The State of
Delaware passed Senate Bill 78, during the 139th Session of the General
Assembly. Senate Bill 78 provides for direct access to OB/GYN services,
without referral, to providers within the MCOs panel. It also requires
that all MCOs allow OB/GYN physicians to choose to be primary care providers.
All of the following access standards apply.
The MCO must use specialists with pediatric expertise for children where the need for pediatric specialty care is significantly different from the need for adult specialists (e.g. a pediatric cardiologist for children with congenital health defects). The MCO must describe how they will assure that children with special health care needs have access, when needed, to pediatric sub-specialty care in a wide range of fields. Such assurance may include contracts, provider arrangements, and procedures for accessing out of network pediatric sub-specialty providers, to include Point of Service (POS) arrangements…" Delaware RFP, pages II.52, II.57, II.58.
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: ...
(2)
adult and pediatric medical sub-specialists..." District of Columbia
Contract, pages 28-29.
FL
"B. Manner
Of Service Provision...
2. Minimum
Standards. Plans shall provide the following: ...
l. Specialists
as required in Attachment I, B.6..." Florida Contact, pages 10-12.
"6. Specialty
Coverage.
a. The
plan shall assure the availability of the following specialists, as appropriate
for both adult and pediatric members, on at least a referral basis:
allergist; cardiologist; endocrinologist; general surgeon; neurologist;
nephrologist; orthopedist; urologist; dermatologist; otolaryngologist;
pulmonologist; chiropractic physician; podiatrist; ophthalmologist; optometrist;
psychiatrist; oral surgeon; physical, respiratory speech and occupational
therapists; and a specialist in AIDS care or an infectious disease
specialist." Florida Contract, page 17.
HI
"30.410 Required
Providers...
The following
is a listing of required components of the provider network...
* Physician
specialty services such as psychiatry, cardiology, neurology, ophthalmology,
pulmonology, orthopedics…" Hawaii RFP, page 9.
"MINIMUM PROVIDER
REQUIREMENTS
SPECIALISTS
(PHYSICIANS)
Specialty/
Number or providers required
Cardiology/
1 per 5,000 members
Nephrology/
1 per 10,000 members
Neurology/
1 per 10,000 members
Gastroenterology/
1 per 7,500 members
Hematology,
Oncology/ 1 per 10,000 members
SURGICAL SPECIALIST
(PHYSICIANS)
Specialty/
Number or providers required
Ophthalmology/
1 per 5,000 members
Otolaryngology/
1 per 10,000 members
Surgery/ 1
per 5,000 members
Orthopedics/
1 per 5,000 members
Ob-gyn/ 1 per
3,000 women members
Urology/ 1
per 10,000 members
Neurosurgeon/
1 Other
Behavioral
Health Providers/ 1 per 1,200 members…
MINIMUM SPECIALIST
PROVIDER NETWORK for Maui, Kauai, and Hawaii
The following
providers must be available ON ISLAND
Provider Type/
Minimum # required
Cardiology/
1 per hospital
Ob-gyn/ 2 per
island
Gastroenterology/
1 per hospital
Otolaryngology/
1 per hospital
Ophthalmology/
1 per hospital
Surgery/ I
per hospital
Orthopedics/
1 per hospital
Psychiatrist/
1=Maui, Kauai; 2=Hawaii
Hospital/ 1=Maui,
Kauai; 2=Hawaii
The physician specialties must be available at the hospital to which the plan's PCPs admit if the specialty is available in the community. If the specialty is not available in the community, the requirement is not applicable...
The health plan may either have contracts which meet the minimum numbers in the table above or pay for emergency services, urgent outpatient services, and inpatient acute services provided without prior authorization by non-participating physician specialists." Hawaii RFP, Appendix B, page 2.
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...
• Behavioral
healthcare specialist services such as psychiatrists, psychologists, geriatricians,
QMRPs or other professionals trained to manage MR/DD members, social workers,
certified substance abuse counselors and nurses trained in psychiatry…"
Hawaii Behavioral Health RFP, page 15.
IL
"(o) Choice
of Physicians
The Contractor
shall afford to each Beneficiary a physician who will supervise and coordinate
his/her care, and to the extent feasible, within appropriate limits established
by the Contractor and approved by the Department, shall afford the Beneficiary
a choice of a physician.
In each Contracting Area, there shall be at least one full-time equivalent physician for each 1,200 Beneficiaries, including one full-time equivalent, board certified primary care physician for each 2,000 Beneficiaries. Primary Care Providers shall have specialties in obstetrics/gynecology, general practice, pediatrics, internal medicine or family practice. In each Contracting Area, there shall be at least one Women's Health Care Provider for each 2,000 female Beneficiaries between the ages of 18 and 44, at least one physician specializing in obstetrics for each 300 pregnant female Beneficiaries and at least one pediatrician for each 2,000 Beneficiaries under age 17.
All physicians providing services shall have and maintain admitting privileges and, as appropriate, delivery privileges at an affiliated Plan hospital; or, in lieu of these admitting and delivery privileges, the physicians shall have a written referral agreement with a Department-approved physician who is in the Contractor's network and who has such privileges at an affiliated Plan hospital. The agreement must provide for the transfer of medical records and Coordination of Care between physicians." Illinois HMO Contract, page 45.
IA
"1.3 Definitions...
- Specialist
- a physician who has successfully completed advanced training in a specialty
approved by the Accreditation Council for Graduate Medical Education or
its predecessors." Iowa Contract, pages 6, 10.
ME
"3.4 SERVICE
DELIVERY
A. PROVIDER
NETWORKS...
The Contractor
shall ensure that, at a minimum, its provider networks are comprised of...specialists,
and other providers in sufficient numbers to make available all covered
services in a timely, effective and efficient manner." Maine Contract,
pages 25-26.
MD
"Chapter 62
Maryland Medicaid Managed Care Program: Definitions
.01 Definitions…
(166)
'Specialty care' means health care services that are either outside the
PCP's scope of practice or, in the judgment of the PCP, are not services
that the PCP customarily provides, is specifically trained for, or is experienced
in...
(167) 'Specialty mental health services' means any mental health services other than primary mental health services." Maryland COMAR 10.09.62.01.
"10.09.66.05…
B. Adequacy
of Provider Network.
(1) An
MCO shall develop and maintain a complete network of… specialty care… and
any other providers..." Maryland COMAR 10.09.66.05.
MA
"Section 2.3
Enrollment Activities...
E. Participation
in RC III and RC IV
1. The
Contractor must be determined by the Division to have: ...
b. A
sufficient number of geographically accessible specialists with experience
working in multidisciplinary teams…" Massachusetts Contract, pages
25-30.
"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: … specialists,
sub-specialists… and ancillary service Providers…" Massachusetts
Contract, pages 39-40.
MO
"b. Eligible Specialties: The health plan must agree to limit its primary care providers to licensed residents specializing in family and general practice, pediatrics, obstetrics and gynecology, and internal medicine; registered nurses who are advanced practice nurses with specialties in family practice, pediatric practice, and obstetric and gynecology practice; and licensed physicians in the following specialties: family and general practitioners, pediatricians, obstetricians and gynecologists (OB/GYN) and internists. The state agency strongly encourages the health plan to include all of these specialties in its primary care provider network…
g. Physician Specialists: Because of the large number of physician specialists that exist, the health plan is not required to maintain specific member-to-specialist provider ratios. However, it must agree to provide adequate access to physician specialists for primary care provider referrals ad to employ or contract with specialists in sufficient numbers to ensure specialty services can be made available in a timely manner." Missouri RFP, pages 24-26.
MT
"2.4.2
Participating Providers: ...
B. Providers
Contracts Must be Extended to or Contractor Must Allow Access to:
1) Targeted
Case Managers for High-Risk Pregnant Women:
The CONTRACTOR
shall offer Medicaid-enrolled targeted case managers for high-RISK pregnant
women who serve RECIPIENTS in the enrollment area terms and conditions
at least as favorable as those offered to other PARTICIPATING PROVIDERS
providing this service, providing the Medicaid-enrolled targeted case managers
for high-risk pregnant women substantially meet the same access and credentialing
criteria as the CONTRACTOR's like providers, as specified in-Appendix 2,
2.4.3 and 2.6.4 of Attachment 1, respectively." Montana Contract,
page 35.
NE
"13.34 Medical Specialists: The plan shall provide for an adequate numbers of medical specialists to meet the needs of its members. Clients with chronic or severe medical conditions, e.g., HIV/AIDS, may be allowed to go directly to a qualified specialist within the plan’s network pursuant to Section 13.5.3 and 13.5.4." Nebraska Contract, page 87.
"13.42 HEALTH
CHECK (EPSDT): The plan shall develop a program to ensure the delivery
of HEALTH CHECK (i.e., Early and Periodic Screening, Diagnosis and Treatment
or EPSDT services)...
(a) HEALTH
CHECK (EPSDT) Screening: ...
(g) The plan
shall use specialists with pediatric expertise for children where the need
for pediatric specialty care is significantly different from the need for
adult specialists, e.g., pediatric cardiologist for children with congenital
heart defects." Nebraska Contract, page 91.
"13.51 Certified Nurse Midwife Services: A certified nurse midwife may contract directly with the plan or the client must be informed in writing that the services are available outside the plan on a fee-for-service basis." Nebraska Contract, page 100.
NEBH
"11.36 Specialists: The PHP shall provide an adequate number of mental health/substance abuse specialists to meet the needs of its members." Nebraska Behavioral Health Contract, page 60.
NV
"O. Physician Specialists. Because of the large number of physician specialists that exist, the Contractor will be required to maintain specific specialist to participant provider ratios for non-PCPs. The Contractor must provide access to all types of physician specialists for PCP referrals, and it must employ or contract with specialists, or arrange for access to specialty care outside of the Contractor's network if necessary, in sufficient numbers to ensure specialty services are available in a timely manner…" Nevada Contract, page 36.
NJ
"ARTICLE 20
PROVIDER CONTRACTS...
20.2
The contractor must ensure that its provider network includes, at a minimum:
F.
Providers who are trained in treating individuals with special needs including,
but not limited to; persons with physical disabilities, mental illness,
drug and alcohol addictions, HIV/AIDS, mental retardation…This includes
dentists who provide service to the physically and mentally disabled and
who may have to take additional time in providing a specific service.
G.
One (1) Full time equivalent dentist...
I.
Sufficient number, available and accessible, of physician and non-physician
providers of health care to cover all services in amount, duration, and
scope included in the benefits package under this contract…" New
Jersey Contract, pages 110-111.
NM
"2.C.5 Specialty
Providers:
The CONTRACTOR
shall contract with a sufficient number of specialists with the applicable
range of expertise to ensure that the needs of MCO members will be met
within the MCO network of providers. The MCO shall also have a system
to refer members to providers who are not affiliated with the MCO network
if providers with the necessary qualifications or certifications do not
participate in the network." New Mexico Contract, page 28.
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, physicians
(…specialists)...allied health professionals, ancillary providers, DME
providers and home health providers.
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...
21.15
Dental Networks
If the Contractor
includes dental services in it's Benefit Package, the Contractor’s dental
network shall include geographically accessible general dentists sufficient
to offer each Enrollee a choice of two (2) primary care dentists in their
Service Area...Networks must also include at least one (1) pediatric dentist
and one (1) oral surgeon...The network should include dentists with expertise
in serving special needs populations (e.g., HIV+ and developmentally disabled
patients)…" New York Contract, pages 21-1-21-8.
NC
"6.8 Choice
of Health Professional...
The Plan shall
allow children with special needs who utilize Specialists frequently for
their health care to maintain these types of Specialists as PCPs, or be
allowed direct access to these Specialists for the needed care.
A Member who has received prior authorization from the Plan for referral to a Specialist… shall be allowed to choose from among all the available Specialists and hospitals within the Plan, to the extent reasonable and appropriate." North Carolina Contract, page 9.
"6.10
Facilities and Resources
The Plan must
provide directly or by contract the following:
a. Specialists
for adult…" North Carolina Contract, page 10.
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: …dentists…vision
care providers…allergists, general surgeons, otolaryngologists, orthopedists…
All Medicaid-serving MCPs are to provide all Medicaid-covered services to enrollees and therefore their complete provider network will include many other additional specialists and provider types." Ohio RFP, page 24.
"Vision Care Providers - In order to meet the minimum provider network requirement for vision care, MCPs must verify during the documentation phase that they are contracting with the specified number of ophthalmologists/optometrists for each service area...
Dental Care Providers - In order to meet the minimum provider network requirement for dental care, MCPs must verify during the documentation phase that they are contracting with the specified number of general practice dentists for each service area." Ohio RFP, page 29.
OK
"2.7.3
Specialty Care Providers
Members must
have access to network care for at least the following specialty and subspecialty
areas:
• Allergy
• Anesthesiology
• Cardiology
• Dermatology
• Developmental
Pediatrics
• Endocrinology
• Gastroenterology
• General surgery
• Hematology/Oncology
• Infectious
Diseases
• Neonatology
• Nephrology
• Neurology
• Neurosurgery
• Obstetrics/Gynecology
• Ophthalmology
• Optometry
• Orthopedic
surgery
• Otolaryngology
• Pathology
• Physiatry
• Psychiatry
• Psychology
• Podiatry
• Pulmonology
• Radiology
• Rheumatology
• Urology
• Vascular
surgery...
2.7.6
Dental Providers
Health Plan
must establish a dental network to deliver preventive and restorative services
to enrolled members...
2.7.7
Vision Providers
Health Plan
must maintain a network of ophthalmologists and optometrists to deliver
vision
services to enrolled members...
2.7.9
Certified Nurse Midwives
Health Plan
must make certified nurse midwife services available unless there are no
Certified Nurse Midwives located in the service area...
2.7.11
Specialty Service Providers
Health Plan
must negotiate in good faith with a Specialty Service Provider that desires
to contract with the Health Plan...Specialty Service Providers are the
J. D. McCarty Center for Children with Developmental Disabilities…"
Oklahoma RFP, pages 35-40.
PA
"6. DIFFERENTLY
ACCESSED SERVICES...
The HMO must
assure the provision of services to persons who have special health needs
or who face access barriers to health care. If the HMO does not have at
least two (2) specialists or sub-specialists qualified to meet the particular
needs of the individuals, then the HMO must pay for the service out-of-network…"
Pennsylvania RFP, pages 49-50.
"I. PROVIDER
NETWORK...
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…Specialists...
•
A choice of at least two (2) specialists for each specialty including pediatric
specialists.
•
An adequate number of PCPs specializing in the treatment of persons with
HIV and AIDS…" Pennsylvania RFP, pages 63-64.
PABH
"4. Provider
Network/Relations
a.
The MCO must provide access to all covered services for members through
a network of qualified professionals and facilities. The MCO
must not discriminate among classes of behavioral health providers on grounds
unrelated to effectiveness of efficiency. The network must have the
following features: ...
3)
Timely access to covered services and needed specialists…geriatric clinical
specialists..." Pennsylvania Behavioral Health RFP, pages 61-62.
RI
"2.08.01
Network Composition
Contractor
shall establish and maintain geographically accessible provider networks,
comprised of… dentists… in sufficient numbers to make available all services
in a timely manner. In designing its network, Contractor shall take
into account the multi-lingual, multi-cultural nature of the population
to be served." Rhode Island RFP, page 32.
"2.08.04
Substance Abuse Providers
2.08.04.01
Provider Composition
Contractor
shall include licensed substance abuse treatment programs and licensed
substance abuse professionals its substance provider network. The
network shall include providers experienced in serving low income populations,
persons with polypharmacy and dual diagnosis in sufficient numbers to meet
the needs of the population to be served in a timely manner. The
Contractor shall include providers with expertise in the management of
substance abuse during pregnancy and provide appropriate residential services,
as medically necessary, for mother and infant. The composition of
the network shall also recognize the multi-lingual, multi-cultural nature
of the population to be served and include providers in locations where
members are concentrated. In order to accomplish this, Contractor
may ease customary credentialing standards provided this does not jeopardize
Contractor's licensure or accreditation status. Contractor shall
assure access to confidential substance abuse treatment services for minors
as provided for in Chapter 14-5-4 of the RI General Laws...
2.08.05
Physician Specialists
Because of
the large number of physician specialists that exist, Contractor is not
required to maintain specific member-to-specialist provider ratios.
However, Contractor agrees to provide adequate access to physician specialists
for PCP referrals, and to employ or contract with specialists in sufficient
numbers and locations to ensure specialty services can be made available
in a timely manner. Networks shall include specialists experienced
with child health specialty needs.
2.08.06
Dentists
Although dental
services are an out-of-plan benefit, Contractor agrees to have no more
than two thousand (2,000) members for each dental team in its network.
Dental teams are defined to consist at a minimum of a dentist, dental hygienist,
and optionally, a dental assistant. Contractor agrees to assist a
member in obtaining dental services from its network, when so requested
by the member…" Rhode Island RFP, pages 35-36.
SC
"4.8.2
Adequacy of Providers
The Contractor
shall maintain appropriate levels, as determined by SCDHHS, of organizational
components, including, but not limited to...specialty providers...necessary
for the provision of the services under this Contract." South Carolina
Contract, page 23.
"DIABETES EDUCATION...
Appropriate
Staff:
Diabetes education
staff must have the following minimum qualification: a Diabetes Program
Instructor/Coordinator must be under direct supervision of a physician,
be a certified Diabetes Educator, and be able to deliver education services
that meet 'Goal for Diabetes Education', as described by the American Diabetes
Association (ADA); or be under direct supervision of a physician, be a
college graduate with a health related degree or license, a recipient of
twenty-four hours special instructions specifically in diabetes and educational
principle, and a recipient of six ours of continuing education in these
subject areas on an annual basis; or be under direct supervision of a physician
and certified by the National Certification Board for Diabetes Education."
South Carolina Contract, Appendix B, page 5.
"Provider Certification
and Licensing...
Infusion Centers
- There is no licensing requirements or certification for infusion centers."
South Carolina Contract, Appendix C, Tab 3, page 2.
"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...
Specialist***Allergy/Immunology,
Anesthesiology, Cardiology, CRNA/AA, Dermatology, Emergency Medicine, Endocrinology
and Metab., Gastroenterology, Geriatrics, Hematology, Infectious Disease,
Internal Medicine, Midwife, Nephrology, Neonatology, Neurology, Neuropathology,
Nuclear Medicine, Nurse Practitioner, Occupational Medicine, Oncology,
Ophthalmology, Optician, Optometrist, Orthopedics, Osteopathy, Otolaryngology,
Otorhinolaryngology, Pathology, Pediatrics, Pediatrics, Allergy, Pediatrics,
Cardiology, Pediatric Nurse Practitioner, Physical Medicine and Rehabilitation,
Physician Assistant, Podiatry, Private Duty Nursing, Psychiatry, Psychiatry,
Child, Psychologist, Pulmonary Medicine, Radiology, Diagnostic, Radiology,
Therapeutic, Rheumatology, Social Worker, Surgery - Cardiovascular, Surgery
- Colon and Rectal, Surgery - General, Surgery - Neurological, Surgery
- Oral, Surgery - Orthopedic, Surgery - Pediatric, Surgery - Plastic, Surgery
- Thoracic and CV, Surgery - Urological, Other (specify type)" South
Carolina Contract, Appendix D, Tab 1, pages 1-2.
TN
"2-3.
Benefit/Services Requirements and Limitations...
b. Availability
and Accessibility of Services...
2.
Minimum standards for this agreement shall be: ...
(c)
The CONTRACTOR shall establish and maintain a network of physician specialists
who accept new TennCare enrollees, adequate and reasonable in number, in
specialty, and in geographic distribution to meet the medical needs of
its enrollees (adults and children) without excessive time and travel requirements.
Specialist’ services must be available on at least a referral basis…"
Tennessee Contract, pages 7-14.
TX
"6.13
PEOPLE WITH DISABILITIES OR CHRONIC OR COMPLEX CONDITIONS...
6.13.4
HMO must provide primary care and specialty care provider network for persons
with disabilities or chronic or complex conditions. Specialty and
subspecialty providers serving all Members must be Board Certified/Board
Eligible in their specialty. HMO may request exceptions from TDH
for approval of traditional providers who are not board-certified or board-eligible
but who otherwise meet HMO’s credentialing requirements.
6.13.5 HMO must have in its network PCPs and specialty care providers that have documented experience in treating people with disabilities or chronic or complex conditions, including children. For services to children with disabilities or chronic or complex conditions, HMO must have in its network PCPs and specialty care providers that have demonstrated experience with children with disabilities or chronic or complex conditions in pediatric specialty centers such as children’s hospitals, medical schools, teaching hospitals and tertiary center levels...
6.13.8 HMO must include TDH approved pediatric transplant centers, TDH designated trauma centers, and TDH designated hemophilia centers in its provider network…" Texas Contract, pages 48-49.
"7.10
SPECIALTY CARE PROVIDERS
7.10.1
HMO must maintain specialty providers, including pediatric specialty providers,
within the network in sufficient numbers and areas of practice to meet
the needs of all Members requiring specialty care or services...
7.10.3 HMO must ensure availability and accessibility to appropriate specialists...
7.11 SPECIAL
HOSPITALS AND SPECIALTY CARE FACILITIES
7.11.1
HMO must include all medically necessary specialty services through its
network specialists, subspecialists and specialty care facilities (e.g.,
children’s hospitals, and tertiary care hospitals)...
7.11.3
HMO must have appropriate multidisciplinary teams for people with disabilities
or chronic or complex medical conditions. These teams must include
the PCP and any individuals or providers involved in the day-to-day or
on-going care of the Member.
7.11.4
HMO must include in its provider network a TDH-designated perinatal care
facility, as established by §32.042, Texas Health and Safety Code,
once the designated system is finalized and perinatal care facilities have
been approved for the service area (see Article 6.9.1)." Texas Contract,
pages 67-68.
UT
"3. Enrollees
with Special Health Care Needs...
d.
Referrals and Access to Specialty Providers
The
CONTRACTOR will ensure there is access to appropriate specialty providers
to provide Medically Necessary Covered Services for adults and children
with special health care needs. If the CONTRACTOR does not employ
or contract with a specialty provider to treat a special health care condition
at the time the Enrollee needs such Covered Services, the CONTRACTOR will
have a process to allow the Enrollee to receive Covered Services from a
qualified specialist who may not be affiliated with the CONTRACTOR."
Utah Contract, Attachment B, pages 16-17.
VA
"5. Specialist
Services
The Contractor
shall maintain in its network and in its referral listing a number of specialists
in the following specialties which is adequate to provide covered services
to its Medallion II enrollees:
Adolescent Medicine
Anesthesiology
Child Psychiatry
Colon/Rectal
Surgery
Dermatology
General Surgery
Genetics Metabolism
Internal Medicine
Neonatal/Perinatal
Medicine
Neurological
Surgery
Neurology
Opthalmology
Orthopedic
Surgery
Otolaryngology
Pediatric Physical
Medicine and Rehabilitation
Pediatrics
Pediatric Sub
specialists
Periodontists
Physical Medicine/Rehabilitation
Plastic Surgery
Preventive
Medicine
Psychiatry
Psychology
Radiology
Thoracic Surgery
Urology"
Virginia Contract, pages 64-65.
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.
"3.6.8 Handicapped
Children's Services (HCS) Providers
The Handicapped
Children's Services (HCS) Program provides specialty medical care, diagnosis
and treatment for handicapped children and those who may be at risk of
handicapping conditions.
The MCP is encouraged, but not required, to contract with HCS providers. However, if the MCP does not contract with HCS providers, the MCP must provide the same level and types of services as those currently available through the HCS program. This includes access to multidisciplinary care. The HCS eligibility criteria and services are listed in Appendix M. DHHR will monitor the MCPs' compliance with this requirement as part of the quality oversight program." West Virginia RFA, page 24.
"3.3
Specialty Care Providers, Hospitals and Other Providers
The MCP must
contract with a sufficient number and mix of specialists and hospitals
so that the enrolled population's anticipated specialty and inpatient care
needs can be substantially met within the MCP's network of providers. The
MCP must also have a system to refer enrollees to out-of-network providers
if appropriate participating providers are not available.
The MCP must make referrals available to enrollees when it is medically appropriate. The MCP must have policies and written procedures for the coordination of care and the arrangement, tracking and documentation of all referrals." West Virginian RFA, page 17.