Provider Choice and Access

Without an adequate provider network, managed care organizations (MCOs) cannot achieve the objectives of providing beneficiaries with appropriate, person-centered, quality long term services and supports (LTSS).  Network requirements should be established based on the needs, preferences, and existing provider relationships of beneficiaries in the plan service area.   Networks must ensure that a broad range of LTSS is available, and maximize choice among providers of a given service.

  • CMS and the state must develop clear standards for LTSS network adequacy.
  • To develop standards, CMS, the state and MCOs must undertake a comprehensive LTSS needs and capacity assessment at the beginning of the demonstration project and update it annually. The needs assessment would provide information on such areas as community health needs, health disparities, existing resources, typical patterns of health care utilization, and barriers to beneficiaries living safely and independently in the community. Plans would then use the information to assess whether their provider networks and points of access are sufficient to meet the needs of beneficiaries in their local communities. Where capacity is under or over-developed, MCOs would develop transitional plans with specific targeted timelines to strengthen or adjust network capacity as needed beyond the stated minimum standards. Such plans may require provider workforce development or redesign to address and eliminate disparities over time.
  • Plans must have an adequate network of all relevant LTSS providers including, center-based adult day health care providers, personal care attendants, home health providers, occupational, physical, and speech therapists, skilled nursing facilities and more.
  • MCOs must have an adequate network of providers specializing in care for nursing facilities to care for the population residing in nursing homes.
  • Providers must meet relevant Medicare and federal and state Medicaid professional qualification standards, but such standards cannot supplant or interfere with the individual’s right to hire, train and supervise personal assistance providers of his or her choice. (See also discussion of Self Direction).
  • CMS and the state must ensure that beneficiary access to providers, as measured in the community needs assessments, does not decrease over the course of the demonstration.  Criteria must be developed to evaluate the degree to which HCBS entities utilized by the MCO are integrated in the community and are capable of providing necessary services.
  • MCOs must be rewarded for increasing their home and community-based service provider capacity, with extra incentives attached to doing so in rural contexts and in other circumstances such as recruiting providers who are fluent in needed minority languages or American Sign Language and whose offices are physically and programmatically accessible.
  • MCOs must be required to contract with community-based organizations, such as independent living centers, recovery learning communities, aging services access points, deaf and hard of hearing independent living services programs, the ARC, and similar organizations that serve particular subgroups of the demonstration population.
  • LTSS entities, especially smaller ones, must not be disqualified for the sole reason that they lack the billing or other administrative capacity required by the model’s operations. Rather, once any LTSS entities meet an MCO’s community integration criteria, the MCO must provide technical support to such LTSS entities to assist them in developing any needed administrative capacities.
  • Consumers must have the right to obtain assistance from alternative independent organizations specializing in providing LTSS at home where available.
  • MCOs must provide beneficiaries with an opportunity to meet with various LTSS providers to determine which provider would best suit their needs.  Participants must have the right to change providers immediately if they are not satisfied with the services delivered.
  • In addition to meeting specific LTSS network adequacy requirements, MCOs must meet general network adequacy requirement for providing all covered services.  Basic principles for determining network adequacy include:
    • Enrollees must have a choice of at least two available and appropriately experienced providers or provider organizations for every category of service identified in the plan benefit package.
    • Time and travel distance standards of no greater than 30 minutes and 30 miles (with exceptions for very rural areas, and possibly for highly specialized expertise or ancillary capacities such as language).
    • Travel time calculations must take into account transportation available in the community for individuals who are unable to drive.
    • A provider is only available if she or he is actively accepting employment or patients.
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