La. Admin. Code tit. 50 § I-3505

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-3505 - Network Access Standards and Guidelines

A. The MCO must maintain and monitor a provider network that is supported by written agreements and is sufficient to provide adequate access of healthcare to enrollees as required by federal law and the terms as set forth in the contract. The MCO shall adhere to the federal regulations governing access standards as well as the specific requirements of the contract and all department issued guides.

B. The MCO must provide for service delivery out-of-network for any core benefit or service not available in network for which the MCO does not have an executed contract for the provision of such medically necessary services. Further, the MCO must arrange for payment so that the Medicaid enrollee is not billed for this service.

C. The MCO shall cover all medically necessary services to treat an emergency medical condition in the same amount, duration, and scope as stipulated in the Medicaid State Plan.

1. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

a. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

b. serious imp airment to bodily functions; or

c. serious dysfunction of any bodily organ or part.

2. Emergency services means covered inpatient and outpatient services that are as follows:

a. furnished by a provider that is qualified to furnish these services under this Section; and

b. needed to evaluate or stabilize an emergency medical condition.

3. Post-stabilization care services means covered services, related to an emergency medical condition, that are provided after an member is stabilized in order to maintain the stabilized condition or, under the circumstances described in 42 CFR §438.114, to improve or resolve the member's condition.

D. The MCO must maintain a provider network and in -area referral providers in sufficient numbers, as determined by the department, to ensure that all of the required core benefits and services are available and accessible in a timely manner in accordance with the terms and conditions in the contract and department issued guide.

E. Any pharmacy or pharmacist participating in the Medicaid Program may participate as a network provider if licensed and in good standing with the Louisiana State Board of Pharmacy and accepts the terms and conditions of the contract offered to them by the MCO.

1. The MCO shall not require its members to use mail service pharmacy.

La. Admin. Code tit. 50, § I-3505

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:1585 (June 2011), amended LR 39:92 (January 2013), LR 41:935 (May 2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.