Access and Availability Standards
||Policy/Procedure Number: OP5000
|Policy Manual Section:
Provider Network Management
Medicare Operations/Provider Network Management
Vice President, Provider Network Development and Business Intelligence
|Original Procedure Date:
January 1, 2013
|Replaces Procedure Number:
5000pr and PNM05pr
I. Procedure Purpose/Statement of Intent/Background
- "HealthPlus" shall refer to HealthPlus of Michigan, Inc. and its affiliated entity,
HealthPlus Insurance Company, unless otherwise stated.
- "MedicarePlus" shall refer to the HealthPlus Medicare Advantage Prescription Drug
branded products, individual or employer group, which it operates per annual contracts
with the Centers for Medicare and Medicaid Services.
- The policy shall pertain to the Commercial, Medicaid and Medicare product lines
and their respective products e.g., HMO, POS, PPO, and Medicare Part D.
- To assure that the organization complies with all applicable state and federal laws
and regulations, including, but not limited to, those pertaining to the Medicaid,
Medicare and Medicare Part D programs.
- To provide direction and processes in regard to the implementation of Centers for
Medicare and Medicaid Services (CMS) standards for provider access and availability.
- Chapter 4, Benefit and Beneficiary Protections, of the Medicare Managed Care Manual
(Section 110) specifies that a Medicare Advantage Organization (MAO) ensure that
beneficiaries have access to providers to receive Medicare-covered services. To
do this MAOs maintain and monitor a network of appropriate providers, supported
by written arrangements, in a geographic and specialty mix sufficient to secure
available and accessible services. Included with the accessible/available service
standards are other requirements specified by CMS. The MAO must also arrange for
specialty care outside the plan provider network when network providers are unavailable
or in adequate to meet the member's medical needs.
|Centers for Medicare and Medicaid Services (CMS)
The federal agency that runs the Medicare program and oversees Medicare Advantage
and Part D plans. In addition, CMS works with the States to run the Medicaid program.
CMS aims to ensure that the beneficiaries in these programs are able to get high
quality health care.
National Committee for Quality Assurance-accrediting agency for health plans.
|Employer group waiver plan (EGWP)
A type of employer group plan where membership is restricted solely to employer
or union sponsored group plan members. There are two basic categories of EGWPs:
(1) "800 series" EGWPs - plans offered by Prescription Drug Plans (PDP), Medicare
Advantage Organizations (MAO), or Part D Cost Plan Sponsors to employer and union
group sponsors (these plans are known as "800 series" plans because of the way they
are enumerated in CMS systems); and (2) Direct Contract EGWPs - employers or unions
that directly contract with CMS to themselves become a PDP or Medicare Advantage
(MA) plan for their members.
|Medicare Advantage Organization (MAO)
A public or private entity organized and licensed by a State as a risk-bearing entity
(with the exception of provider-sponsored organizations receiving waivers) that
is certified by CMS as meeting the MA contract requirements.
|Medicare Advantage (MA) plan
Health benefits coverage offered under a policy or contract by an MA organization
that includes a specific set of health benefits offered at a uniform premium and
uniform level of cost-sharing to all Medicare beneficiaries residing in the service
area (or segment of the service area) of the MA plan.
A professional who provides health care services. Practitioners are usually licensed
as required by law.
An institution or organization that provides services for health plan members. A
provider is is licensed or certified by the State to engage in that activity in
that State if such licensure or certification is required by State law or regulation.
The providers with which a MA organization contracts or makes arrangements to furnish
covered health care services to Medicare enrollees under an MA coordinated care
or private fee for service (PFFS) plan that has a contracted network under §422.114(c).
|Primary Care Practitioners (PCP)
A primary care provider or physician (PCP) is a physician/medical doctor who provides
both the first contact for a person with an undiagnosed health concern as well as
continuing care of varied medical conditions, not limited by cause, organ system,
or diagnosis. A PCP must be licensed by the State and meet MAO credentialing requirements
to be part of an MAO's provider network.
|High Volume Specialty Practitioners
Physicians in a specialty with an annual HealthPlus referral rate of greater than
45 referrals per thousand, plus Obstetrics / Gynecology physicians.
|Behavioral Health Practitioners
Psychiatrists, PhD-level Psychologists and Master-Prepared Therapists
III. Policy Statement
IV. Procedure Statement
- HealthPlus shall follow rules, regulations, and, if applicable, the HealthPlus Bylaws
pertaining to this policy.
- This policy is written to assure compliance with CMS and NCQA requirements related
to provider access and availability.
- HealthPlus staff shall establish procedures for the administration of this policy.
- The Issuing Department(s) and all applicable staff involved in the implementation
of this procedure shall follow the rules and regulations directed by CMS and NCQA
and directions set forth in the supporting policy.
- This procedure explains how HealthPlus determines provider access and availability
through following CMS and NCQA access standards, and to assure consistency and compliance
with CMS rules and regulations.
- HealthPlus staff shall follow the steps outlined in this procedure for the administration
of provider access and availability as directed by CMS in Chapter 4 of the Medicare
Managed Care Manual1, as well as in 42 CFR 422.1122.
- HealthPlus follows CMS rules and regulations regarding ensuring that HealthPlus
members have access to and availability for providers within its identified network.
- This procedure explains how HealthPlus complies with CMS access standards, and applies
to individual and employer group waiver plans. Access standards do not necessarily
apply for EGWP/800 Series plans, as CMS consider this a matter between MA plan and
employer sponsor. However, CMS reserves the right to review EGWP provider networks
at its discretion.
- HealthPlus defines which practitioners and providers a Medicare Advantage member
should seek for covered services and when services can be obtained from more than
one type of provider/practitioner.
- HealthPlus maintains a network of practitioners and providers for members that includes
but is not limited to, primary care, high volume specialty and behavioral health
practitioners, and hospitals, behavioral health providers, skilled nursing facilities,
home health agencies, ambulatory clinics, radiology centers, and rehabilitation
HealthPlus staff is responsible for establishing, publishing, and maintaining procedures
and work rules to implement this procedure.
 NCQA 2012 HP Standards and Guidelines. QI 4 & 5;
 NCQA 2012 Medicare Advantage Deeming Module, MA 13