[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.206]



[Page 226-227]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

        Subpart D_Quality Assessment and Performance Improvement

 

Sec.  438.206  Availability of services.



    (a) Basic rule. Each State must ensure that all services covered 

under the State plan are available and accessible to enrollees of MCOs, 

PIHPs, and PAHPs.

    (b) Delivery network. The State must ensure, through its contracts, 

that each MCO, and each PIHP and PAHP consistent with the scope of the 

PIHP's or PAHP's contracted services, meets the following requirements:

    (1) Maintains and monitors a network of appropriate providers that 

is supported by written agreements and is sufficient to provide adequate 

access to all services covered under the contract. In establishing and 

maintaining the network, each MCO, PIHP, and PAHP must consider the 

following:

    (i) The anticipated Medicaid enrollment.

    (ii) The expected utilization of services, taking into consideration 

the characteristics and health care needs of specific Medicaid 

populations represented in the particular MCO, PIHP, and PAHP.

    (iii) The numbers and types (in terms of training, experience, and 

specialization) of providers required to furnish the contracted Medicaid 

services.

    (iv) The numbers of network providers who are not accepting new 

Medicaid patients.

    (v) The geographic location of providers and Medicaid enrollees, 

considering distance, travel time, the means of transportation 

ordinarily used by Medicaid enrollees, and whether the location provides 

physical access for Medicaid enrollees with disabilities.

    (2) Provides female enrollees with direct access to a women's health 

specialist within the network for covered care necessary to provide 

women's routine and preventive health care services. This is in addition 

to the enrollee's designated source of primary care if that source is 

not a women's health specialist.

    (3) Provides for a second opinion from a qualified health care 

professional within the network, or arranges for the enrollee to obtain 

one outside the network, at no cost to the enrollee.

    (4) If the network is unable to provide necessary services, covered 

under the contract, to a particular enrollee, the MCO, PIHP, or PAHP 

must adequately and timely cover these services out of network for the 

enrollee, for as long as the MCO, PIHP, or PAHP is unable to provide 

them.



[[Page 227]]



    (5) Requires out-of-network providers to coordinate with the MCO or 

PIHP with respect to payment and ensures that cost to the enrollee is no 

greater than it would be if the services were furnished within the 

network.

    (6) Demonstrates that its providers are credentialed as required by 

Sec.  438.214.

    (c) Furnishing of services. The State must ensure that each MCO, 

PIHP, and PAHP contract complies with the requirements of this 

paragraph.

    (1) Timely access. Each MCO, PIHP, and PAHP must do the following:

    (i) Meet and require its providers to meet State standards for 

timely access to care and services, taking into account the urgency of 

the need for services.

    (ii) Ensure that the network providers offer hours of operation that 

are no less than the hours of operation offered to commercial enrollees 

or comparable to Medicaid fee-for-service, if the provider serves only 

Medicaid enrollees.

    (iii) Make services included in the contract available 24 hours a 

day, 7 days a week, when medically necessary.

    (iv) Establish mechanisms to ensure compliance by providers.

    (v) Monitor providers regularly to determine compliance.

    (vi) Take corrective action if there is a failure to comply.

    (2) Cultural considerations. Each MCO, PIHP, and PAHP participates 

in the State's efforts to promote the delivery of services in a 

culturally competent manner to all enrollees, including those with 

limited English proficiency and diverse cultural and ethnic backgrounds.