RFP 250000002670 - Schedule I - Network Adequacy Procedure Document.docx

Michigan.gov/MiProcurement

SCHEDULE I – NETWORK ADEQUACY PROCEDURE

Request for Proposal No. 250000002670 Prepaid Inpatient Health Plan (PIHP)

MDHHS Specialty Behavioral Health Network Adequacy Standards The Code of Federal Regulations at 42 CFR Parts 438.68 and 457.1218 requires the states holding managed care contracts to develop and implement network adequacy standards. Furthermore, 42 CFR 438.68(b)(iii) indicates that standards pertinent to behavioral health must be developed for the children, youth, and adult populations. Pursuant to the federal rules, Michigan’s specialty behavioral health standards reflect time/distance standards and Medicaid provider-to-enrollee ratios for services congruent with community need and statewide strategic priorities. The following adult, children and youth services have been identified for reporting beginning in Fiscal Year 2027.

Autism Services (97151, 97155, 97156, 97157, 97158, 0373T)

Community Living Supports (H2015)

Partial Hospitalization Programs (0912, 0913)

Targeted Case Management (T1017)

Outpatient Clinical Mental Health

Time/distance standards are categorized by Large Metro, Metro, Micro, Rural, and Counties with Extreme Access Considerations (CEAC) 1. The provider-to-enrollee ratio standards apply to all services except inpatient psychiatric services and partial hospitalization programs. In adherence to the federal rules and MSA Policy 18-49, the following standards are in effect for all PIHP contracts beginning in the Fiscal Year 2027 reporting period:

Time and Distance Standards:

Adults/Children and Youth

Inpatient Psychiatric2 and Partial Hospitalization Programs

All other services include the following services: Psychosocial Rehabilitation, Crisis Residential, and Opioid Treatment Programs.

Medicaid Provider-to- Enrollee Ratio Standards for Select Services Adult Standards

*Excludes Substance Use Treatment beds.

Children and Youth Standards

Please see provider definitions for further information on how “provider” is defined for each service type.

The term "enrollee" is defined as “any new or existing Medicaid Beneficiary assigned to the PIHP. This includes all beneficiaries the PIHP is contracted to serve." For network adequacy children and youth services purposes, "children" are defined as those "who are less than 18 on the last day of the reporting period" with the exception of the following services: Respite, Home-Based, Youth Peer Supports, ICCW, ICSS, Autism Services, Targeted Case Management, and Parent Support Partners, which will utilize a subpopulation of individuals 21 years old and younger on the last day of the reporting period.

Please be advised that MDHHS will include Outpatient Clinical Mental Health Services in Network Adequacy measurements beginning in FY26 (collected as informational only). More information related to these services will be released by October 1, 2025. All standards and services are subject to change. Any service indicated as “informational only” will have standards developed and implemented in FY2027 based on baseline data collected. Contractors must ensure all covered and medically necessary services are delivered to beneficiaries in a timely and appropriate manner, regardless of whether those services are included in network adequacy standards.

Compliance – Time/Distance and Provider-to-Enrollee Ratios

· At least 85 percent of the beneficiaries residing in counties classified as micro, rural, or counties with extreme access considerations (CEAC) have access to at least one provider/facility of each specialty type within the published time and distance standards. 42 CFR 422.116 (d)(4)(i)

· At least 90 percent of the beneficiaries residing in large metro and metro counties have access to at least one provider/facility of each specialty type within the published time and distance standards. 42 CFR 422.116 (d)(4)(ii)

· Both time and distance must be met.

· Regions must meet provider-to-enrollee ratios as established by the MDHHS.

· For services with both time and distance and provider-to-enrollee ratios, both standards must be met.

Provider Network Exceptions

Provider Network Exceptions can be requested and require approval from MDHHS. Approval is at the sole discretion of MDHHS. Exceptions do not negate the PIHP’s responsibility to deliver all covered and medically necessary services to enrollees in a timely manner. Exceptions must include a plan for how the PIHP will reasonably deliver covered services to enrollees who are impacted by the exception as well as how the PIHP will work to increase access to the applicable provider type in the designated county or counties. PIHPs must monitor, track, and report to MDHHS the delivery of services to enrollees affected by the exception. Exceptions are valid for one year, unless otherwise noted/approved and submissions must be accompanied by an updated Network Access Plan.

American Society of Addiction Medicine (ASAM) Level of Care (LOC) for Network Providers

· PIHPs must enter into network provider agreements for Substance Use Disorder (SUD) Treatment with organizations that provide services based on the American Society of Addiction Medicine (ASAM) Level of Care (LOC).

· Providers must be reported on the Network Adequacy Profile File.

· Contractor must ensure that to the extent licensing allows all the following LOCs are available for adult and youth populations:

Timely Access Standards 438.68(e)

*Individuals with a disposition of 1 will be included.

Compliance - Timeliness Plans must meet at least a 90% compliance rate for timeliness standards (42 CFR 438.68(e)(2)) for all services except for Crisis Residential, Pre-Admission Screen, and Inpatient Psychiatric Services. PIHPs must meet at least 95% compliance rate for these services.

MDHHS will measure timeliness of services on a quarterly basis based on encounter data for all services except for Crisis Residential, Inpatient Psychiatric Services, Pre-Admission Screen, and ICSS Mobile Crisis. ICSS reporting will be submitted via Schedule E reporting. Timeliness of youth, children, and adult Crisis Residential, Inpatient Psychiatric Services, and Pre-Admission Screen must be collected and reported by the PIHPs on the Network Access Plan.

Reporting The contractor must complete and submit the Network Adequacy Profile (NAP) file on a quarterly basis. Quest analytics will utilize this file to measure network standards. MDHHS will analyze results and share with contractors on a quarterly basis.

The Network Access Plan report is due annually and anytime an exception request is deemed necessary. The Network Access Plan outline will be provided to PIHPs in accordance with 438.68(b)(3) including, but not limited to, information on maximum time and distance, timely appointments and language, cultural competence, and physical accessibility.

Provider Definitions

Licensed Assistant Behavior Analyst

The NAP File will include instructions on employment parameters (i.e. full-time equivalent, responsibility allocations, etc.)

*Crisis Residential does not include Substance Use Treatment Residential Beds.

Applicable Standards by Service

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1. US Census Bureau 2020 Decennial Population Data

2. 42 CFR 422.116

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