DCS Comprehensive Health Plan

Material Changes to Business Operations and Provider Network

Statement/Purpose

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.

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 any Division or Subsidiary of 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 order 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:

1. 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.

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

DCS CHP and its contracted MCO shall develop a process 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.

Impact Assessment

• For provider network changes: conduct an impact assessment of the change on membership by identifying the number of unique members served by the provider over the previous six months and comparing it to the total enrolled membership.

• For business operations changes: evaluate the impact by Geographic Service Area (GSA) and overall membership.

• For accessibility: provide average travel time/distance for services before and after the change, address geographic coverage for home-based services, and address vehicle availability for transportation services.

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, 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) advance notice of material changes prior to implementing the material change. In the event of unforeseen circumstances, DCS CHP and its contracted 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 contracted MCO may also be required to provide periodic updates, conduct meetings with providers and/or members, and submit additional information as requested by AHCCCS.