Network Composition Requirements. In compliance with 42 CFR 438.207, which provides assurances of adequate capacity and services, the Contractor shall: Serve the expected enrollment; Offer an appropriate range of services and access to preventive and primary care services for the population expected to be enrolled; and Maintain a sufficient number, mix and geographic distribution of providers as specified below. At the beginning of its Contract with the State, the Contractor shall submit regular network access reports as directed by OMPP. Once the Contractor demonstrates compliance with OMPP’s access standards, the Contractor shall submit network access reports on an annual basis and at any time there is a significant change to the provider network (i.e., the Contractor no longer meets the network access standards). The Contractor shall comply with the policies and procedures for network access reports set forth in Hoosier Healthwise MCE Reporting Manuals. OMPP shall have the right to expand or revise the network requirements, as it deems appropriate. In accordance with 42 CFR 438.12, the Contractor shall not discriminate for the participation, reimbursement or indemnification of any provider who is acting within the scope of the provider's license or certification under applicable State law, solely on the basis of such license or certification. If the Contractor declines to include individual or groups of providers in its network, it shall give the affected providers written notice of the reason for its decision. This does not require the Contractor to contract with providers beyond the number necessary to serve the members’ needs. The Contractor is not precluded from establishing any measure designed to maintain quality and control costs consistent with the Contractor’s responsibilities. As required under 42 CFR 438.206, which relates to availability of services, the Contractor shall ensure that the network providers offer hours of operation that are no less than the hours of operation offered to commercial members, if the Contractor also serves commercial members. The Contractor shall also make covered services available twenty four (24)-hours-a-day, seven (7)-days-a-week, when medically necessary. In meeting these requirements, the Contractor shall: Establish mechanisms to ensure compliance by providers; Monitor providers regularly to determine compliance; and Take corrective action if there is a failure to comply. The Contractor shall provide OMPP written notice at least n...
Network Composition Requirements. In compliance with 42 CFR 438.207, the Contractor must: Serve the expected enrollment; Offer an appropriate range of services and access to preventive and primary care services for the population expected to be enrolled; and Maintain a sufficient number, mix and geographic distribution of providers as specified below. At the beginning of its Contract with the State, the Contractor shall submit regular network access reports as directed by FSSA. Once the Contractor demonstrates compliance with FSSA’s access standards, the Contractor shall submit network access reports on a quarterly basis and at any time there is a significant change to the provider network (i.e., the Contractor no longer meets the network access standards). In accordance with 42 CFR 438.12, the Contractor may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. If the Contractor declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reason for its decision. This does not require the Contractor to contract with providers beyond the number necessary to serve the members’ needs. Contractors are also not precluded from using different reimbursement amounts for different specialties or practitioners within the same specialty. Finally, it does not preclude the Contractor from establishing quality and cost control measures. As required under 42 CFR 438.206, the Contractor must ensure that network providers offer hours of operation that are no less than the hours of operation offered to commercial members, if the Contractor also serves commercial members. The Contractor must also make covered services available twenty four (24)-hours-a-day, seven (7)-days-a-week, when medically necessary. In meeting these requirements, the Contractor must: Establish mechanisms to ensure compliance by providers; Monitor providers regularly to determine compliance; and Take corrective action if there is a failure to comply. The Contractor must provide FSSA written notice at least ninety (90) calendar days in advance of the Contractor’s inability to maintain a sufficient network in any county. FSSA reserves the right to expand or revise the network requirements, as it deems appropriate. For purposes of the subsections below, “urban areas” are count...
