Requirements for Network Adequacy. State Medicaid standards shall be utilized for LTSS, behavioral health services where Medicare is not primary, and prescription drugs that Medicaid covers and are excluded from Medicare Part D, and Medicare standards shall be utilized for Medicare prescription drugs and for other services for which Medicare is primary. Home health and durable medical equipment requirements, as well as any other services for which Medicaid and Medicare may overlap, shall be subject to State Medicaid standards, so long as the State can show that such standards are at least as stringent and beneficiary friendly as Medicare standards.
Requirements for Network Adequacy. State Medicaid standards shall be utilized for LTSS, as described below, or for other services for which Medicaid is exclusive, and Medicare standards shall be utilized for Medicare prescription drugs and for other services for which Medicare is primary, unless applicable Medicaid standards for such services are more stringent. Home health and durable medical equipment requirements, as well as any other services for which Medicaid and Medicare may overlap, shall be subject to State Medicaid standards, so long as the State can show that such standards are at least as stringent and Enrollee friendly as Medicare standards. MMIPs must pay Enrollees’ current service providers for at least the first 90 days of enrollment, as described in Section V.F below. MMIP must provide and arrange for timely access to all medically-necessary services covered by Medicaid, including those under the HCBS waiver. Both the State and the CMS will monitor access to services through survey, utilization, and complaints data to assess needs to MMIPs network corrective actions. In addition to these protections, minimum LTSS standards for MMIPs are stated below. CMS and the State will also monitor access to care and the prevalence of needs indicated through Enrollee assessments, and based on those findings, may require that the MMIPs initiate further network expansion over the course of the Demonstration
