Library: Policy

317:55-3-13. Time, distance, and access standards

Revised 7-1-23

(a) The CE and DBM must meet all time and distance standards as established by the OHCA in accordance with 42 C.F.R. § 438.68. The time and distance standards will apply to all geographic areas in which the CE or DBM operates, with standards varying for urban and rural areas, which will include, at a minimum:

(1) Anticipated enrollment;

(2) Expected utilization of services;

(3) Characteristics and health care needs of all covered populations;

(4) Provider-to-Enrollee ratios;

(5) Travel time or distance to providers;

(6) Percentage of contracted providers that are accepting new patients;

(7) Ability to communicate with limited English proficiency Enrollees;

(8) Ability to ensure physical access, reasonable accommodations, and accessible equipment for Enrollees with physical or mental disabilities;

(9) Maximum wait times; and

(10) Hours of operations.

(b) The standards listed in (a)(1) B (10) of this Section apply to the following medical provider types, in accordance with 42 C.F.R. § 438.68(b) and specified in the Medical and Children's Specialty Contract:

(1) Adult and pediatric PCPs;

(2) Obstetrics and Gynecology (OB/GYN) providers;

(3) Adult and pediatric mental health providers;

(4) Adult and pediatric substance use disorder (SUD) providers;

(5) Adult and pediatric specialists;

(6) Hospitals;

(7) Pharmacies; and

(8) Essential community providers.

(c) The standards listed in (a)(1) B (10) of this Section apply to the following dental provider types, in accordance with 42 C.F.R § 438.68(b) and specified in the DBM Contract:

(1) General dentistry providers;

(2) Pediatric specialty dental providers;

(3) Specialty dental providers; and

(4) Essential community providers.

(d) If the CE or DBM fails to comply with the standards as set forth in this Section, the OHCA may impose any or all the CE intermediate sanctions, found at OAC 317:55-5-10 and the CE Contract, or DBM administrative remedies, found at OAC 317:55-5-11 and the DBM Contract.