| It is HealthLink’s goal that enrollees
have access to qualified, diverse care that offers an appropriate amount of
choice. Toward meeting this goal, HealthLink has established network standards
regarding provider availability and accessibility.
Specifically, the purposes of HealthLink’s participating
provider availability and accessibility standards are as follows:
- To offer an adequate number and type of contracted
or participating providers to meet the health needs of HealthLink enrollees.
- To offer a network of participating providers
that is geographically accessible to HealthLink enrollees.
- To describe the HealthLink participating provider
availability and accessibility standards to state and/or federal regulators,
accreditation agencies, benefit consultants, employers and other health
care purchasers or prospective purchasers of HealthLink services, other
payors of health care benefits offered in conjunction with HealthLink services,
prospective or existing HealthLink HMO enrollees and participating providers.
Provider Network
Adequacy Goals
The number of network providers of different types will vary from one service
region/county to another. HealthLink will recruit and contract with sufficient
providers of all types necessary to provide a full range of covered services.
In general, the HealthLink provider network will:
- Be adequate in numbers and types of providers
to meet the full range of health care service needs of the enrolled population.
- Include at least one community hospital; where
one is available.
- Include at least 50 percent of the primary
care physicians (PCPs) with active staff privileges on the medical staff
of the contracted community hospital, within each county or multi-county
region.
- Include within each county or multi-county
region, enough primary care and specialty care physicians to provide HealthLink
enrollees a choice of physicians.
HMO Specialty
Care Physician Availability
HealthLink HMO shall follow the access standards promulgated by the Missouri
Department of Insurance for all service areas unless otherwise indicated by
more stringent standards in states in which HealthLink HMO is certified to
operate and market its services.
HealthLink HMO
and PPO Networks
Compliance with the distance standards will be achieved if 95% of the population
of the county, or HealthLink’s existing insured HMO membership, is within the
distance standards of the providers with whom HealthLink contracts. The minimum
distance standards for HealthLink PPO enrollees will be achieved if 50% of
the population of the county or HealthLink’s enrolled membership is within
the distance standards of the providers with whom HealthLink contracts. HealthLink’s
provider network for a defined market region shall be open to provider applicants
who meet HealthLink’s criteria for participation until optimum access (i.e.
95%) is available to HealthLink enrollees residing in the area. HealthLink
will attempt to surpass these standards whenever possible. HealthLink’s primary
goal is to offer HealthLink enrollees a wide choice of accessible physicians,
facilities and ancillary providers whenever and wherever there is an adequate
number of such health care providers practicing in the defined service area
or county.
Contracting Criteria - Health Care Facilities,
Ancillary Care Providers, and Other Provider Specialty Networks
Hospitals, other health care facilities,
programs and ancillary care providers who/that desire to contract with HealthLink
are required to meet the following contracting criteria, as applicable:
- Provider must be located within the approved
HealthLink service area (developed or in development as indicated in HealthLink’s
corporate market plan and approved by HealthLink management and board of
directors).
- Provider must provide health care services
covered by HealthLink benefit plans and/or benefit plans administered by
HealthLink affiliated insurance carriers.
PCP and OB/GYN
Accessibility Standards
HealthLink’s PCP and OB/GYN accessibility
standards have been developed to address the fact that population density in
the HealthLink service area varies considerably from one defined market region
to another. One set of standards for each type of area – urban, basic or suburban
and rural – is provided in the Detail Adequacy Standards report (please contact
HealthLink if detailed standards are required).
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