Medicaid Contract Purchasing SpecificationsPart 5Provider NetworkTable of Contents §501. General Requirements Commentary: These sample purchasing specifications do not address the issues relating to payment by an MCO to providers participating in its provider network. However, the sample specifications at §510(c) do address the issue of payment arrangements between Contractors and out-of-network providers in certain circumstances. If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on provider networks is for your consideration. §501. General Requirements K(a) Provider Network (1) Basic Duty — Contractor shall maintain a provider network through which Contractor furnishes items and services covered under Part 1 to enrolled children that complies with the requirements of this Part. (2) Duty to Notify Purchaser — Contractor shall, on the basis of the notifications received from primary care providers under §502(c)(8) and pediatric specialists under §503(c)(4), notify Purchaser at any time that there is no further capacity to accept additional enrolled children as patients: (A) consistent with §502(b), among primary care providers participating in Contractor's provider network; or (B) consistent with §503(b), among pediatric specialists participating in Contractor's provider network or otherwise affiliated with Contractor for purposes of treating enrolled children. Contractor understands and agrees that Purchaser, upon receipt of such notification, may suspend new enrollment of children under [drafter insert name of purchasing document] until additional primary care provider or pediatric specialist capacity becomes available. (3) Monitoring of Participating Providers — Contractor shall monitor the performance of providers participating in Contractor's provider network on an ongoing basis and undertake a formal review of each provider's performance [ ]. (b) Written Agreements with Participating Providers (1) In General — Contractor shall enter into and maintain an enforceable written agreement with each provider participating in Contractor's provider network that: K(A) sets forth the provider's duties: (i) to submit accurate and complete data to Contractor as required under Part 9;1 (ii) under other provisions of [drafter insert name of purchasing document]; and (iii) under applicable federal and state law; K(B) requires performance of such duties as a condition of participation in Contractor's provider network; and L(C) requires Contractor to comply with the requirements of §1932(f) of the Social Security Act, 42 U.S.C. §1396u-2(f), relating to timely payment of claims for payment to providers for items and services which are covered under Part 1 and are furnished to enrolled children under [drafter insert name of purchasing agreement].2 K(c) Credentialling Requirements and Profiling — Contractor shall not apply any credentialling requirements, measures of financial or other performance, or any other participation criteria to applicants for, or participants in, Contractor's provider network that: (1) discriminate against particular providers that specialize in conditions that require costly treatment; or (2) are otherwise inconsistent with the requirements of this Part. K(d) Cultural Competence of Practitioners — Contractor shall ensure that a sufficient number of practitioners who participate in Contractor's provider network furnish covered items and services in a culturally competent (as defined in §1401(i)) manner. K(e) Participation in the Vaccines for Children Program (VFC) — Contractor shall ensure that all providers who participate in Contractor's provider network and who furnish immunization services for children participate in the Vaccines for Children Program under §1928 of the Social Security Act, 42 U.S.C. §1396s, and comply with the requirements in Part 11. K(f) Racial, Ethnic, and Cultural Diversity — Contractor shall ensure that the racial, ethnic, and cultural composition of practitioners participating in Contractor's provider network reflect, to the extent feasible, the racial, ethnic, and cultural composition of enrolled children under [drafter insert name of purchasing document]. K(g) Access to Providers — Contractor shall, consistent with the selection and assignment procedures under Part 4, make available to an enrolled child under [drafter insert name of purchasing document] the services of any provider participating in: (1) the provider network described in subsection (a); and (2) any other provider network offered by Contractor under any other plan purchased by a group sponsor and which covers the service area described in [drafter insert name of purchasing document].3 K(h) Coordination with WIC — Contractor shall ensure that each provider participating in Contractor's provider network cooperate, consistent with §1002 relating to confidentiality protections, with requests by [drafter insert names of WIC programs serving the area served by Contractor] for medical information relating to an enrolled child who is also receiving services through the WIC program.
K(i) MCH (Title V) and Medicaid (Title XIX) Interagency Agreement4 — Contractor shall ensure that each provider participating in Contractor's provider network complies with [drafter insert the requirements applicable to the Purchaser under its Interagency Agreement with the State Title V agency under §1902(a)(11)(B) of Social Security Act (42 U.S.C. §1396a(a)(11)(B)) relating to coordination between Title V and EPSDT]. K(j) Provider Integrity — Contractor shall ensure that each provider through which Contractor furnishes an item or service to an enrolled child (whether or not the provider participates in Contractor's provider network) complies with the requirements of §512. L(k) Physician Incentive Plans — Contractor shall ensure that each provider participating in Contractor's provider network complies with the requirements of §004(c) of the Overview. K(l) Professional Competence — Contractor shall ensure that each provider through which Contractor furnishes an item or service to an enrolled child (whether or not the provider participates in Contractor's provider network) complies with the requirements of §004(e) of the Overview. KCompliance measure: Contractor shall make available to Purchaser on request: (1) the credentialling rules and other criteria for selection of providers participating in Contractor's provider network; (2) the name, area of practice, provider number, address (including zip code) at which the provider offers services, current office telephone number(s), office hours of each practice site, of each provider participating in Contractor's provider network; (3) agreements with participating providers; (4) provider manuals pertaining to Contractor operations; and (5) the name and practice site address (including zip code) of each provider that sought and was denied participation in Contractor's provider network and the reason for denial.
K§502. Primary Care Providers (a) General Rule — Contractor shall include in its provider network a sufficient number of primary care providers (as defined in §1401(u)). (b) Measures of Sufficiency — In determining the sufficiency of the number of primary care providers participating in Contractor'sprovider network under subsection (a), the following measures shall apply: (1) The ratio of (A) the number of primary care providers participating in Contractor's provider network to (B) the number of enrolled children shall not be less than [ ]; (2) Each provider who is available as a primary care provider participating in Contractor's provider network shall maintain office hours of no fewer than [ ] hours per week at any location shown in Contractor's provider network listing and shall offer [ ]-hour-per day, [ ] days-per-week staffing coverage; (3) A provider who limits his or her practice to pediatrics and who serves as a primary care provider may have a cumulative maximum registered patient load of no more than [ ] children regardless of source of payment. If the health professional employs for no fewer than [ ] hours per week one or more [drafter insert references to categories of non-physician clinician practitioners under state law] in his or her practice, such cumulative maximum registered patient load may be increased by [ ] children for each such practitioner; and (4) A provider in a family practice who serves persons of all ages and who serves as a primary care provider for children may have a cumulative maximum registered patient load of no more than [ ] patients regardless of source of payment. If the health professional employs for no fewer than [ ] hours per week one or more [drafter insert references to categories of non-physician clinician practitioners under state law] in his or her practice, such cumulative maximum registered patient load may be increased by [ ] children for each such practitioner. (c) Requirements for Primary Care Provider — Contractor shall ensure that each primary care provider (as defined in §1401(u)) participating in Contractor's provider network: (1) furnishes primary care to, and monitors the growth and development of, an enrolled child; (2) arranges for the furnishing of specialized medical services to the enrolled child; (3) coordinates the furnishing of primary care with the provision of specialized medical services; (4) ensures continuity of care to the enrolled child; (5) maintains a medical record for the enrolled child that records the furnishing of both primary care and specialized medical and health services; (6) in the case of a child under an IEP (as defined in §1401(o)), furnishes, or arranges for the furnishing of, special education, health, medical, and other related services identified in the IEP and covered under Part 1; (7) in the case of a child under an IFSP (as defined in §1401(p)), furnishes, or arranges for the furnishing of, early intervention services identified in the IFSP and covered under Part 1; and (8) if the provider is unable to accept additional enrolled children as patients because the provider no longer has the capacity to accept any additional children as patients, the provider notifies Contractor at least [ ] days in advance of reaching capacity. KCompliance measure: Contractor shall make available to Purchaser on a [ ] basis:
K§503. Pediatric Specialists (a) In General — Contractor shall include in its provider network a sufficient number of pediatric specialists (as defined in §1401(s)). (b) Measures of Sufficiency — Contractor shall ensure that its provider network has sufficient pediatric specialist capacity to meet the following requirements: (1) Enrolled Children with Special Health Care Needs — Contractor shall ensure that the number of pediatric specialists participating in Contractor's provider network is sufficient to enable an enrolled child with special health care needs to select a pediatric specialist as a primary care provider under §402(a)(2) of Part 4; and (2) Enrolled Children — Contractor shall ensure that the number of pediatric specialists participating in Contractor's provider network is sufficient to enable each enrolled child to have reasonable and timely access to a pediatric specialist. (c) Requirements for Pediatric Specialist — Contractor shall ensure that each pediatric specialist (as defined in §1401(s)) participating in Contractor's provider network: (1) provides specialized medical and health services to an enrolled child upon referral by the primary care provider under §502(c)(2); (2) coordinates the provision of specialized medical and health services with the primary care provider; (3) maintains a medical record for the enrolled child that records the provision of specialized medical and health services; and (4) if the specialist is unable to accept additional enrolled children as patients because the specialist no longer has the capacity to accept any additional children as patients, the specialist notifies Contractor at least [ ] days in advance of reaching capacity.
K§504. Dental Care Providers (a) In General — Contractor shall include in its provider network a sufficient number of dental care providers (as defined in §1401(j)). (b) Measures of Sufficiency — Contractor shall ensure that its provider network includes a number of dental care providers (as defined in §1401(j)) that is sufficient to furnish dental services covered under §102(b)(3) of Part 1 (relating to the EPSDT benefit) to enrolled children consistent with the frequency and periodicity standards set forth under the [drafter insert name of State Medicaid Plan]. (c) Requirements for Dental Care Providers — [To be supplied upon completion of provider network provisions in sample purchasing specifications for dental and oral health]
§505. Accessibility of Network Providers to Children with Special Health Care Needs K(a) In General — Contractor shall ensure that all providers participating in Contractor's provider network comply with the requirements of the Americans with Disabilities Act, 42 U.S.C. §12101 et seq., and §504 of the Rehabilitation Act of 1973, 29 U.S.C. §794. (b) Access Standards [See CHSRP's Optional Purchasing Specifications for Children with Special Health Care Needs (forthcoming)].
K§506. Language-Appropriate Providers (a) General Requirement — In the case of an enrolled child (or the child's family or caregiver acting on behalf of the child) who does not speak English, Contractor shall ensure that the services offered by providers participating in Contractor's provider network are accessible to the child (and the child's family or caregiver). (b) Language-Appropriate Providers or Interpreters — In order to comply with the requirement of subsection (a), Contractor shall: (1) include in its provider network a sufficient number of providers who speak languages which are spoken by at least [ ] of Contractor's enrollees to permit an enrolled child a choice of at least [ ] primary care providers; and (2) make available professional interpreter services at any clinical encounter involving an enrolled child when such services are: (A) necessary in the judgment of the treating professional; or (B) requested by the enrolled child or the child's family or caregiver.5 KCompliance measure: Contractor shall make available to Purchaser on request: (1) the name and practice site of each provider participating in Contractor's provider network who is fluent in a language other than English (or who has at his or her practice site a health care professional who is fluent in a language other than English) and the language(s) in which such provider (or professional) is fluent; and (2) the name and work telephone number of the individuals through whom Contractor, or providers participating in Contractor's provider network, makes professional interpreter services available.
K§507. School-based Providers In August 1997, HCFA published Medicaid and School Health: A Technical Assistance Guide, www.hcfa.gov/medicaid/scbintro.htm, which notes: "Some states have instituted state laws which require coordination between MCOs and school-based health providers. In addition, some school-based health providers have developed formal arrangements, including legal contracts; protocols for referral and treatment; authorization for school-based providers to provide services to managed care enrollees and bill Medicaid directly; and commitments to expedite the treatment of patients referred by school-based health providers. Some states in their waivers "carve-out" school health services and reimburse those services under the "traditional" Medicaid fee-for-service program." States are not required to make MCOs responsible for the provision of school-based services. The following illustrative language is for those Purchasers interested in contracting with MCOs for this purpose. (a) School-based Health and Related Services Provider (1) Participation in Provider Network —Contractor shall include in its provider network (consistent with paragraph (2)) each school-based health and related services provider (as defined in paragraph (3)) that: (A) furnishes services to children under an IEP (as defined in §1401(o)) or an IFSP (as defined in §1401(p)); and (B) is willing to participate in Contractor's provider network (2) Scope of Participation — Unless otherwise agreed to by Contractor and a school-based health and related services provider, the provider's participation in Contractor's provider network shall be solely for the purpose of furnishing items and services to an enrolled child that: (A) are listed in an IEP (as defined in §1401(o)) or an IFSP (as defined in §1401(p));6 (B) are enumerated under Part 1;and (C) meet the requirements of Part 1A. (3) Definition —A school-based health and related services provider is a provider (as defined in §014(f) of the Overview) that furnishes items and services to children under an IEP (as defined in §1401(o)) or an IFSP (as defined in §1401(p)) at a practice site located in or adjacent to a school. (b) School-based Health Center7 (1) Out-of-Plan Services —Contractor shall comply with the requirements of §005(g) of the Overview relating to payment for items and services covered under Part 1 furnished by a school-based health center (as defined under paragraph (2)) that does not participate in Contractor's provider network. (2) Definition —A school-based health center is a public or private non-profit provider (as defined in §014(f) of the Overview) that furnishes health care services to children attending school.
K§508. Traditional Medicaid Providers (a) Requirement — Contractor shall include in its provider network each traditional Medicaid provider (as defined in subsection (b)) that furnishes items and services in Contractor's service area and that is willing to participate in Contractor's provider network unless Contractor demonstrates to Purchaser that the provider is not capable of carrying out the duties required of primary and specialty care providers in Contractor's provider network under the same terms and conditions as Contractor offers to such other providers. (b) Traditional Medicaid Provider Defined — A traditional Medicaid provider is a hospital, clinic, or practitioner that serves a substantial number of Medicaid-eligible children and includes: (1) federally qualified health centers as defined in §1905(l)(2)(B) of the Social Security Act, 42 U.S.C. §1396d(l)(2)(B); (2) rural health clinics as defined in §1861(aa)(1) of the Social Security Act, 42 U.S.C. §1395x(aa)(1), and as referenced in §1905(l)(1) of the Social Security Act, 42 U.S.C. §1396d(l)(1); (3) family planning clinics receiving funds under Title X of the Public Health Service Act, 42 U.S.C. §300 et seq.; (4) providers receiving funds under the Ryan White Comprehensive AIDS Research and Education Act, Title 26 of the Public Health Service Act, 42 U.S.C. §300ff et seq.; (5) [drafter insert name of city or county health departments operating clinics in Contractor's service area]; and (6) [drafter insert name of maternal and child health clinics receiving funds from the state under Title V of the Social Security Act]. (c) Reimbursement of Traditional Medicaid Providers — Contractor shall reimburse providers described in subsection (b) for furnishing items and services covered under Part 1 to enrolled children in at least the same amount and on terms at least as favorable as apply to other providers of the same type that participate in Contractor's provider network. KCompliance measure: Contractor shall make available on request to Purchaser the name and practice site of each provider that has traditionally served Medicaid-enrolled children and that participates in Contractor's provider network.
K§509. Certain Providers Identified in Federal Law (a) Providers Identified in Federal Law — Contractor shall include in its provider network at least [ ] providers in each of the following classes who are located in or serve Contractor's service area and who are willing to participate in Contractor's provider network: (1) federally qualified health centers (FQHCs) as defined in §1905(l)(2)(B) of the Social Security Act, 42 U.S.C. §1396d(l)(2)(B); (2) rural health clinics (RHCs) described in §1861(aa)(1) of the Social Security Act, 42 U.S.C. §1395x(aa)(1), and as referenced in §1905(l)(1) of the Social Security Act, 42 U.S.C. §1396d(l)(1); (3) nurse-midwives described in §1905(a)(17) of the Social Security Act, 42 U.S.C.§1396d(a)(17); and (4) certified pediatric nurse practitioners and certified family nurse practitioners described in §1905(a)(21) of the Social Security Act, 42 U.S.C. §1396d(a)(21). (b) Reimbursement — Contractor shall reimburse providers described in subsection (a) for furnishing items and services covered under Part 1 to enrolled children in at least the same amount and on terms at least as favorable as apply to other providers of the same type that participate in Contractor's provider network. KCompliance measure: Contractor shall make available to Purchaser on request the name and practice site of each FQHC, RHC, nurse midwife, certified pediatric nurse practitioner, and certified family nurse practitioner participating in Contractor's provider network.
K§510. Access to Certain Items and Services Out-of-Network (a) In General — If Contractor is unable to furnish items and services covered under Part 1 to an enrolled child through its provider network, Contractor shall: (1) consistent with subsection (b)(2), arrange for the furnishing of such items and services to the child through a provider that is not participating in Contractor's provider network and meets the requirements described in subsection (b)(1) and (b)(3); and (2) notify the child and the child's family or caregiver of the arrangements that Contractor has made under paragraph (1). (b) Requirements for Out-of-Network Providers — A provider meets the requirements of this subsection if it: (1) has the necessary primary or specialty expertise which the enrolled child's care requires; (2) has been selected by the enrolled child or child's family or caregiver; and (3) meets Contractor's quality and data reporting requirements. (c) Reimbursement of Out-of-Network Providers — Contractor shall reimburse providers described in subsection (a)(1) for furnishing covered items and services under Part 1 to enrolled children in at least the same amount and on terms as at least as favorable as apply to providers of the same type that participate in Contractor's provider network. (d) Exception for Emergency and Public Health Services — The requirements of this section shall not apply with respect to emergency or public health services enumerated in §005(e) and (f) of the Overview. KCompliance measure: Contractor shall make available on request to Purchaser the names, practice sites, and provider numbers of the providers not participating in Contractor's provider network from whom an enrolled child may receive covered items and services.
K§511. Access to Out-of-Network Providers Commentary: This section sets forth the cross references to the provisions in this agreement relating to out-of-network providers. These provisions generally set forth options for Purchaser to consider concerning payment to such providers. Purchasers considering giving enrolled children access to out-of-network providers in one or more of the circumstances enumerated in this section may also wish to adjust their premium payments to reflect additional costs which Contractor may incur in complying with these duties. (a) Emergency Services — As required by §005(e) of the Overview, Contractor shall not restrict access by an enrolled child to providers participating in Contractor's provider network for emergency services (as defined in §1401(l)). (b) Public Health Services — As required by §005(f)(1) of the Overview, Contractor may not restrict access by an enrolled child to certain public health services to providers participating in Contractor's provider network. (c) Health Care Services at School-based Health Centers — As required by §005(g)(1) of the Overview, Contractor may not restrict access by an enrolled child to primary care services furnished by school-based health centers (as defined in §507(b)(2) of Part 5) to providers participating in Contractor's provider network. (d) Access to Out-of-Network Primary Care Providers by Children in Migratory or Seasonal Agricultural Worker Families — Contractor shall comply with the requirements of §403(c)(2) of Part 4 relating to access to out-of-network primary care providers for children in migratory or seasonal agricultural worker families. (e) Access to Out-of-Network Primary Care Providers by Children in Homeless Families — Contractor shall comply with the requirements of §403(d)(2) of Part 4 relating to access to out-of-network primary care providers for children in homeless families. (f) Access to Out-of-Network Primary Care Providers by Children in Foster Care — Contractor shall comply with the requirements of §403(e)(2) of Part 4 relating to access to out-of-network primary care providers for children in foster care or other out-of-home placement.
K§512. Provider Integrity (a) Provider Number (1) In General — As required by §1903(m)(2)(A)(xi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi) (relating to the identification of the physician providing a service), 42 C.F.R. §431.107 (relating to required provider agreement), and §1173(b)(1) of the Social Security Act, 42 U.S.C. §1320d-2(b)(1) (relating to the standard unique health identifier for each health care provider), Contractor shall not make payment to a provider (whether or not the provider participates in Contractor's provider network) for the furnishing of an item or service covered under Part 1 to an enrolled child unless: (A) the provider has been assigned a unique provider number by Purchaser; and (B) is not excluded from participation in [drafter insert name of state Medicaid program] under §1128 or §1128A of the Social Security Act, 42 U.S.C. §1320a-7 or 42 U.S.C. §1320a-7a.8 (2) Construction — Paragraph (1) shall not be construed to require a provider to furnish items or services to individuals enrolled in the [drafter insert name of state Medicaid program] on a fee-for-service basis. (b) True and Accurate Information — [RESERVED] (c) Claims — [RESERVED] Endnotes
|
 |  |   |
Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under , §1902(a)(13)(C) of the Social Security Act, 42 U.S.C. §1396a(a)(13)(C) and §1903(m)(2)(A)(ix) of the Social Security Act, 42 U.S.C. 1396b(m)(2)(A)(ix) relating to payment for services provided by Federally-qualified health centers and rural health clinics subcontracting with Medicaid MCOs.
If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on provider networks is for your consideration.Purchasers may also find it useful to review Negotiating the New Health System (3rd Ed.) which provides other options relating to provider networks used by state agency purchasers in contracting with Medicaid MCOs. These options may be found at Table 3.1, Vol. 2, Part 3, pages 3-14 through 3-78, and Table 3.6, Vol. 2, Part 3, pages 3-284 through 3-357 (www.gwu.edu/~chsrp).