Provider Network Standards

110.1.1 – Provider Network Standards (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) MAOs are required to establish and maintain provider networks that: • Define the types of providers to be used when more than one type of provider can furnish a particular item or service; • Identify the types of mental health and substance abuse providers in their network; • Specify the types of providers who may serve as an enrollee’s primary care physician; • Are accurately reflected in up-to-date directories. Plans are responsible for verifying and regularly updating their network directories to ensure that providers included in the directories are available to their enrollees (i.e., listed providers accept new patients who are enrolled in the plan). Please see section 110.2 below for more information on provider directory updating requirements. • Employ written standards for timeliness of access to care and member services that meet or exceed such standards as may be established by CMS, make these standards known to all first tier and downstream providers, continuously monitor its provider networks’ compliance with these standards, and take corrective action as necessary. These standards must ensure that the hours of operation of the plan’s providers are convenient to, and do not discriminate against, enrollees. The plan must also ensure that, when medically necessary, services are available 24 hours a day, 7 days a week. This includes requiring primary care physicians to have appropriate backup for absences. The standards should consider the enrollee’s need and common waiting times for comparable services in the community. (Examples of reasonable standards for primary care services are: (1) urgently needed services or emergency - immediately; (2) services that are not emergency or urgently needed, but in need of medical attention - within one week; and (3) routine and preventive care - within 30 days); • Establish, maintain, monitor and validate credentials for a panel of primary care providers from which the enrollee may select a personal primary care provider. All MA plan enrollees may select and/or change their primary care provider within the plan without interference. Plans that require enrollees to obtain a referral before receiving specialist services typically require this referral be obtained from a primary care provider. However, some enrollees do not select primary care providers. Consequently, plans must ensure that there is a mechanism for assigning primary care providers (for purposes of referral) to enrollees who do not select a primary care provider; • Regardless of the MA plan type being offered, arrange for medically necessary care outside of the network, but at in-network cost-sharing, in order to provide all Medicare Part A and Part B benefits. That is, if an enrollee requires a medically necessary covered service that is not provided by the providers in the network, the plan must arrange for that service to be provided by a qualified non-contracted provider; • Provide or arrange for necessary specialist care, and in particular give female enrollees the option of direct access to a women’s health specialist within the network for women’s routine and preventive health care services; • Ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all enrollees, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how a plan may meet these accessibility requirements include, but are not limited to provision of translator services, interpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection; • Establish and maintain written standards, including coverage rules, practice guidelines, payment policies and utilization management protocols that allow for individual medical necessity determinations. These standards must be available to both enrollees and providers. Section 90.5 of this chapter provides guidance and criteria for formulating such standards; • Provide coverage for ambulance services, emergency and urgently needed services, and post-stabilization care services in accordance with the requirements in section 20 above; and • Have a quality improvement program plan as outlined in chapter 5 of the MMCM. The quality improvement program plan must include a Chronic Care Improvement Program (CCIP) and a Quality Improvement Project (QIP). Plans may not implement utilization management protocols that create inappropriate barriers to needed care. Prior authorization and referral are two utilization management approaches frequently used by plans and are entered in the PBP; the following definitions and requirements clarify the meaning and appropriate use of these two approaches: • Prior Authorization: A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the enrollee is not responsible for obtaining (prior) authorization. • Referral: A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or instructs the enrollee to obtain an item or service from another physician or other provider type.