Section 457.495 - State assurance of access to care and procedures to assure quality and appropriateness of careA State plan must include a description of the methods that a State uses for assuring the quality and appropriateness of care provided under the plan, including how the State will assure:
(a) Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations.(b) Access to covered services, including emergency services as defined at §457.10.(c) Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition.(d) That decisions related to the prior authorization of health services are completed as follows:(1)Before January 1, 2026.(i) In accordance with the medical needs of the patient, within 14 days after receipt of a request for services. A possible extension of up to 14 days may be permitted if the enrollee requests the extension or if the physician or health plan determines that additional information is needed; or(ii) In accordance with existing State law regarding prior authorization of health services.(2)On or after January 1, 2026.(i) In accordance with the medical needs of the enrollee, but no later than 7 calendar days after receiving the request for a standard determination and by no later than 72 hours after receiving the request for an expedited determination. A possible extension of up to 14 days may be permitted if the enrollee requests the extension or if the physician or health plan determines the additional information is needed; or(ii) In accordance with existing State law regarding prior authorization of health services.(3)Enrollee notification. Provide the enrollee with- (i) Notice of the State's prior authorization decision; and(ii) Information on the enrollee's right to a review process, in accordance with § 457.1180 .(e) Access to and delivery of services in a culturally competent manner to all beneficiaries, as described in 42 CFR 440.262 .66 FR 2678, Jan. 11, 2001, as amended at 66 FR 33824, June 25, 2001; 89 FR 8982, Feb. 4, 2024 89 FR 8982, 4/8/2024; 89 FR 41692, 7/5/2024