DCS Comprehensive Health Plan

Material Changes to Business Operations and Provider Network

Policy Statement

The Arizona Department of Child Safety Comprehensive Health Plan (DCS CHP) identifies and evaluates material changes to its business operations and provider network and notifies applicable regulators and members prior to implementing material changes.

DCS CHP and its subcontracted Managed Care Organization (MCO) require efficient and effective business operations and a provider network to make certain that performance and provider network standards are met and support a member’s individual needs.

Definitions

Administrative Services Subcontracts: An agreement that delegates any of the requirements of the Contract with AHCCCS as outlined in ACOM 438, including, but not limited to the following:

• Claims processing, including pharmacy claims,

• Credentialing, including those for only primary source verification (i.e. Credential Verification Organization),

• Management Service Agreements,

• Service Level Agreements with and Division or Subsidiary or a corporate parent owner, and

• DDD acute care subcontractors.

A person (individual or entity) who holds an Administrative Services Subcontract is an Administrative Services Subcontractor. Providers are not Administrative Services Subcontractors.

Material Change to Business Operations: Any change in overall operations that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as required in Contract including, but not limited to, any change that would impact or is likely to impact more than five percent of total membership and/or provider network in a specific GSA. Changes to business operations may include, but are not limited to, policy, process, and protocol, such as prior authorization or retrospective review. Additional changes may also include the addition or change in:

1. PBM,

2. Dental Benefit Manager,

3. Transportation vendor,

4. Claims Processing system,

5. System changes and upgrades

6. Change to Organization Name,

7. Member ID Card vendor,

8. Call center system,

9. Covered benefits delivered exclusively through the mail, such as mail ordered pharmaceuticals or delivery of medical equipment,

10. MSA, and

11. Any other Administrative Services Subcontract.

Material Changes to Provider Network: Any change in composition of or payments to a Contractor’s provider network that affects, or can reasonably be foreseen to affect, the Contractor’s adequacy of capacity and services necessary to meet the performance and/or provider network standards as specified in Contract. Changes to provider network may include but are not limited to:

• Any change that would cause or is likely to cause more than 5% of the members in a Geographic Service Agreement (GSA) to change the location where services are received or rendered.

• A change impacting 5% or less of the membership but involving a provider or provider group who is the sole provider of a service in a service area or operates in an area with limited alternate sources of the service.

Unexpected Material Change to the Provider Network or Business Operations: A material change that was not anticipated by the Contractor. Examples of unexpected changes to the provider network include a provider giving less than 30 days to the Contractor that they would no longer serve Medicaid members, or the Contractor’s failure to reach an agreement with a provider on a contract renewal less than 30 days before the previous contract expires. An example of an unexpected material change to business operations includes the unexpected closure of an administrative services subcontractor.

Policy

DCS CHP and its subcontracted MCO assess and identify material changes to its business operations and provider network and requests in writing, approval of the material change by the appropriate regulatory agency and within required timeframes. Upon approval, written notification of a material change, as defined in this policy, is provided to members and providers within required timeframes to ensure continuity of care.

AHCCCS-initiated changes, such as changes in reimbursement methodologies (e.g., All Patients Refined - Diagnosis Related Groups [APR-DRG]) or changes to reference tables impacting claims payment, and industry-initiated changes, such as Current Procedural Terminology (CPT)/diagnosis code changes, are excluded from these Policy requirements.

Procedure

Evaluation of Material Changes

All functional areas within DCS CHP and its subcontracted MCO are responsible for assessing and identifying changes to business operations and the provider network, including unexpected and significant changes, to determine the impact on members and providers.

DCS CHP and its subcontracted MCO evaluate business operational and provider network changes, including unexpected changes, to determine when changes to business operations or to the provider network constitute a material change, and maintain documentation of evaluations for all changes, even if they are determined not to constitute a material change.

DCS CHP and its subcontracted MCO determine if the change meets the definition of a material change based on the evaluation results as outlined in ACOM 439 or the AHCCCS Contract and Policy Dictionary.

Impact Assessment

For provider network changes, an impact assessment of the change to membership is conducted by identifying the number of unique members served by the provider over the previous six months and comparing it to the number of unique members enrolled over the same period.

For business operations changes; the impact of the change to membership and providers is evaluated by Geographic Service Area (GSA).

For services the member shall travel to receive – DCS CHP shall provide the average time and distance that members in the impacted areas shall travel for the service before and after the change. If time and distance travel is measured under ACOM Policy 436, compliance with ACOM Policy 436 shall be reported before and after the change.

For services provided in the member’s home – DCS CHP shall address the geographic coverage and sufficiency of providers in the impacted area before and after the change.

For transportation services – DCS CHP shall address the availability of vehicles dedicated to the Contractor’s line of business in the impacted area before and after the change.

Reporting Requirements

The DCS CHP Compliance Function Area is responsible for submitting written notification of any planned or expected material changes to AHCCCS, Division of Health Care Management Services (DHCM), prior to implementing the identified change.

A draft notification to affected members and providers is included in the notification to AHCCCS. AHCCCS evaluates the change and responds within thirty (30) days of receipt of the written notification. If AHCCCS does not respond within 30 days, the request and notices are deemed approved.

A request for approval of major system changes must include a system change plan with a timeline, milestones, and adequate testing to be completed before implementation.

Unexpected material changes (any material change not defined above) are submitted to AHCCCS in writing within one (1) business day of knowledge of the material change. AHCCCS expedites the evaluation process and determines the notification requirements to affected members and providers.

Notification shall be submitted as specified in Contract and include requirements identified in attachment 439A. If Attachment 439A requirements cannot be provided in the initial notification, the remaining requirements shall be submitted within one week of the initial notification.

Implementation of Material Changes

DCS CHP members and providers receive thirty (30) days’ advance notice of material changes prior to implementing the material change. In the event of unforeseen circumstances, DCS CHP and its subcontracted MCO comply with the notification requirements identified by AHCCCS.

AHCCCS reserves the right to identify any operations or network change as a material change. DCS CHP and its subcontracted MCO may also be required to provide periodic updates, conduct meetings with providers and/or members, and submit additional information as requested by AHCCCS.