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[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"form revised 2/24/2021"]
[]
[]
[null,"MANAGED CARE SYSTEMS"]
[null,"P.O. Box 64975, St. Paul, MN 55164-0975"]
[null,"Telephone: 651-201-5100"]
[null,"Email:",null,"health.managedcare@state.mn.us"]
[]
[null,"Request for Waiver"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Plan Year:",null,2025]
[]
[null,"Please ensure that information contained on this waiver request coincides with information provided on the"]
[null,"geographical access maps and provider list submitted with this application."]
[]
[null,"1.","Name and Title of Person Submitting this Document:"]
[]
[null,null,"Carrier",null,null,null,null,null,null,null,null,"Name Network",null,null,null,null,null,null,null,null,"Network ID",null,null,null,null,null,"Network Structure*"]
[null,null,"<enter carrier>",null,null,null,null,null,null,null,null,"<enter network name>",null,null,null,null,null,null,null,null,"<enter network id starts with MNN>",null,null,null,null,null,"<select one>"]
[null,null,"Name",null,null,null,null,null,null,null,null,"Title",null,null,null,null,null,null,null,null,"Date",null,null,null,null,null,"Enrollees in Network*"]
[null,null,"<enter name>",null,null,null,null,null,null,null,null,"<enter title>",null,null,null,null,null,null,null,null,"<enter date in month/day/year>"]
[]
[null,"2.","By submitting this form, the above-referenced confirms:"]
[]
[null,null,"A.","That person submitting this request has personal knowledge of the network contracting process involved in this submission; and"]
[]
[null,null,"B.","That access cannot be met for the following provider type(s).  Include the county and reason(s) for not meeting the requirements.  "]
[]
[]
[null,null,"Provider Type",null,null,null,null,null,null,null,null,"County",null,null,"Reason Code",null,"Notes",null,null,null,null,null,null,null,null,null,"Affected Enrollees*",null,null,"Percent Total Enrollees Affected",null,null,"Percent Not Covered*",null,null,"Percent Available Providers Included in Network"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[]
[]
[null,null,null,"For additional rows, please see the “Additional” tab of this document. DO NOT add rows to this sheet."]
[]
[null,null,null,"For all reason codes, carriers must demonstrate with specific data that geographic access standards cannot be met.  Carriers must state what steps were and will be taken to address network inadequacies"]
[null,null,null,"(MN Statutes § 62K.10, subdivision 5)."]
[]
[]
[]
[null,null,null,"Allowable Waiver Reason Codes and Guidelines for Initial Approval"]
[null,null,null,"Applications to waive the requirements in Minnesota Statutes 62K.10 Subd. 2 or 3 must fit one of the following reason codes. Waivers automatically expire after one year.  The commissioner shall only approve a"]
[null,null,null,"subsequent waiver application that satisfies the requirements in Minnesota Statutes 62K.10 Subd. 5, demonstrates that the carrier took the steps it proposed to address network inadequacy, "]
[null,null,null,"and explains why the carrier continues to be unable to satisfy the requirements."]
[]
[null,null,null,"Reason Code 1:"]
[]
[null,null,null,"Carrier has conducted a search for providers and determined that, for each county in the plan service area, there are no providers physically present of the type requested in the waiver."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Provide a description of physical geography and/or other factors that affect the location of providers (as relevant)"]
[null,null,null,null,"2.","Demonstrate consultation of at least two provider directories and/or data sources. Provide a description of the provider directories and/or data sources consulted,"]
[null,null,null,null,null,"including a brief explanation of why the sources are believed to be accurate and complete. Examples of acceptable provider directories and data sources include, but are not limited to:"]
[null,null,null,null,null,"a.","NPPES NPI Registry"]
[null,null,null,null,null,"b.","Medicare Physician Compare"]
[null,null,null,null,null,"c.","Minnesota Health Care Programs Provider Directory"]
[null,null,null,null,null,"d.","Healthgrades"]
[null,null,null,null,null,"e.","SAMHSA Behavioral Health Provider Directories"]
[null,null,null,null,null,"f.","National Institute of Health (NIH) U.S. National Library of Medicine MedlinePlus Directories"]
[null,null,null,null,null,"g.","Quest Analytics"]
[null,null,null,null,"3.","For Primary Care, Pediatric Services (Primary Care), General Hospital and Mental Health provider types:"]
[null,null,null,null,null,"a.","State the total number and percentage of estimated enrollees affected in the county not meeting the geographic standard as of the submission date of waiver. Select only one county per line."]
[null,null,null,null,null,"b.","State how access will be provided for this provider type for enrollees of the affected county."]
[null,null,null,null,null,null,"For example, does the carrier provide transportation services/vouchers, in-home care options, virtual care services, and/or telemedicine services?"]
[null,null,null,null,null,null,"i.","If, in its waiver application, a health carrier demonstrates to the commissioner that there are no providers of a specific type or specialty in a county, the commissioner may approve a waiver in which"]
[null,null,null,null,null,null,null,"the health carrier is allowed to address network inadequacy in that county by providing for patient access to providers of that type or specialty via telemedicine"]
[null,null,null,null,null,null,"ii.","If telemedicine is used to provide access:"]
[null,null,null,null,null,null,null,"1.","These services must meet the definition of “telemedicine” in Minnesota Statutes"]
[null,null,null,null,null,null,null,null,"62A.671, subdivision 9."]
[null,null,null,null,null,null,null,"2.","Carrier must describe the extent to which telemedicine services are available"]
[null,null,null,null,null,null,null,null,"a.","How many network providers of the impacted provider type have contracts to conduct/provide telemedicine services?"]
[null,null,null,null,"4.","Describe how they will assess the availability of providers who begin practice in the service area where the standard cannot currently be met and agree to conduct this assessment quarterly"]
[null,null,null,null,null,"a.","Assessment of availability must include consultation of at least two provider directories and/or data sources, as described in item 2, above"]
[]
[null,null,null,"Reason Code 2:"]
[]
[null,null,null,"Provider does not meet carrier’s credentialing requirements."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Cite the reason(s) provider does not meet credentialing requirements"]
[null,null,null,null,"2.","For Primary Care, Pediatric Services (Primary Care), General Hospital, and Mental Health provider types"]
[null,null,null,null,null,"a.","State the total number and percentage of estimated enrollees affected in the county not meeting the geographic standard as of the submission date of waiver. Select only one county per line."]
[null,null,null,null,"3.","State how access will be provided for this provider type for enrollees of the affected county. For example, does the carrier allow enrollees to receive out-of-network"]
[null,null,null,null,null,"care at in-network rates, provide transportation services/vouchers, in-home care options, virtual care services, and/or telemedicine services?"]
[null,null,null,null,null,null,"i.","If telemedicine is used to provide access:"]
[null,null,null,null,null,null,null,"1.","These services must meet the definition of “telemedicine” in Minnesota Statutes"]
[null,null,null,null,null,null,null,null,"62A.671, subdivision 9"]
[null,null,null,null,null,null,null,"2.","Carrier must describe the extent to which telemedicine services are available"]
[null,null,null,null,null,null,null,null,"a.","How many network providers of the impacted provider type have contracts to conduct/provide telemedicine services?"]
[]
[null,null,null,"Reason Code 3:"]
[]
[null,null,null,"Carrier has made a good faith effort to contract with provider and provider has refused to accept a contract."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Cite the reason(s) provider state(s) for refusing contract(s) "]
[null,null,null,null,"2.","For Primary Care, Pediatric Services (Primary Care), General Hospital and Mental Health provider types"]
[null,null,null,null,null,"a.","State the total number and percentage of estimated enrollees affected in the county not meeting the geographic standard as of the submission date of waiver. Select only one county per line."]
[null,null,null,null,"3.","State how access will be provided for this provider type for enrollees of the affected county. For example, does the carrier allow enrollees to receive out-of-network"]
[null,null,null,null,null,"care at in-network rates, provide transportation services/vouchers, in-home care options, virtual care services, and/or telemedicine services?"]
[null,null,null,null,null,null,"i.","If telemedicine is used to provide access:"]
[null,null,null,null,null,null,null,"1.","These services must meet the definition of “telemedicine” in Minnesota Statutes"]
[null,null,null,null,null,null,null,null,"62A.671, subdivision 9"]
[null,null,null,null,null,null,null,"2.","Carrier must describe the extent to which telemedicine services are available"]
[null,null,null,null,null,null,null,null,"a.","How many network providers of the impacted provider type have contracts to conduct/provide telemedicine services?"]
[]
[null,null,null,"Reason Code 4:"]
[]
[null,null,null,"Network is an Accountable Care Organization (ACO) or Narrow Network."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Specify the network structure: Accountable Care Organization (ACO) or Narrow Network"]
[null,null,null,null,null,"a.","If the network is an ACO, provide a brief description of the major health systems participating in the network"]
[null,null,null,null,null,"b.","If the network is a narrow network, describe the features of the network that restrict access"]
[null,null,null,null,null,"c.","For both ACOs and Narrow Networks, state what percentage of available Primary Care, Pediatric Services (Primary Care), General Hospital, "]
[null,null,null,null,null,null,"and Mental Health providers are included in the county and of the provider type for which a waiver is requested"]
[null,null,null,null,"2.","State what, if any, steps are taken to inform enrollees of restricted access"]
[null,null,null,null,"3.","State the total number of estimated enrollees in the network as of the submission date of the waiver"]
[null,null,null,null,"4.","State why the geographic access standards cannot be met. Explain why full geographic access is not possible with this network design"]
[null,null,null,null,"5.","State how access will be provided for this provider type for the enrollees of the affected county. For example, does the carrier allow enrollees to receive out-of-network "]
[null,null,null,null,null,"care at in-network rates, provide transportation services/vouchers, in-home care options, virtual care services, and/or telemedicine services?"]
[null,null,null,null,null,null,"i.","If telemedicine is used to provide access:"]
[null,null,null,null,null,null,null,"1.","These services must meet the definition of “telemedicine” in Minnesota Statutes"]
[null,null,null,null,null,null,null,null,"62A.671, subdivision 9"]
[null,null,null,null,null,null,null,"2.","Carrier must describe the extent to which telemedicine services are available"]
[null,null,null,null,null,null,null,null,"a.","How many network providers of the impacted provider type have contracts to conduct/provide telemedicine services?"]
[null,null,null,null,"6.","For Primary Care, Pediatric Services (Primary Care), General Hospital and Mental Health provider types,"]
[null,null,null,null,null,"a.","State the total number and percentage of estimated enrollees affected in the county not meeting the geographic standard as of the submission date of waiver. Select only one county per line."]
[null,null,null,null,null,"b.","State the estimated percentage of area in that county that is not covered"]
[]
[]
[]
[null,null,null,"Allowable Waiver Reason Codes and Guidelines for Subsequent Approval (Renewals)"]
[null,null,null,"In accordance with 62K.10 Subd. 5 (d), waivers will automatically expire after one year. "]
[null,null,null,"Carriers seeking identical, subsequent waivers for plan year 2022 will be required to show steps taken to address network inadequacies in plan year 2021 (see below)."]
[]
[null,null,null,"Reason Code 1:"]
[]
[null,null,null,"Carrier has conducted a search for providers and determined that, for each county in the plan service area, there are no providers physically present of the type requested in the waiver."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Meet all of the requirements set forth for initial approval"]
[null,null,null,null,"2.","Provide a description of how access was provided for affected enrollees in the previous approval year"]
[null,null,null,null,"3.","Show evidence of quarterly efforts to assess provider availability throughout the last calendar year. Did new providers become available in affected areas? If so, describe any efforts to pursue contracts."]
[null,null,null,null,null,"If new providers became available and new contracts were not pursued, explain why."]
[]
[null,null,null,"Reason Code 2:"]
[]
[null,null,null,"Provider does not meet carrier’s credentialing requirements. "]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Meet all of the requirements set forth for initial approval"]
[null,null,null,null,"2.","Provide a description of how access was provided for affected enrollees in the last approval year"]
[]
[null,null,null,"Reason Code 3:"]
[]
[null,null,null,"Carrier has made a good faith effort to contract with provider and provider has refused to accept a contract."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Meet all of the requirements set forth for initial approval"]
[null,null,null,null,"2.","Provide a description of how access was provided for affected enrollees in the last approval year"]
[]
[null,null,null,"Reason Code 4:"]
[]
[null,null,null,"Network is an Accountable Care Organization (ACO) or Narrow Network."]
[]
[null,null,null,"Carriers must:"]
[null,null,null,null,"1.","Meet all of the requirements set forth for initial approval"]
[null,null,null,null,"2.","Provide a description of how access was provided for affected enrollees in the last approval year"]
[]
[]
[]
[]
[null,null,null,null,null,"                                                                Attestation for the Request for Waiver"]
[]
[null,null,null,null,null,"The undersigned attests that he/she is a representative of the carrier with personal knowledge of the network  "]
[null,null,null,null,null,"and reasons for the above waiver requests, and that the waiver requests meet the requirements for the waiver, "]
[null,null,null,null,null,"as outlined above.  The undersigned also attests that good faith efforts have been made to locate and contract with providers,"]
[null,null,null,null,null,"as outlined above, and that if providers become available in the service area, carrier will make a good faith effort to contract with "]
[null,null,null,null,null,"said providers.  "]
[]
[]
[null,null,null,null,null,"_____________________________________     _____________________________________________"]
[null,null,null,null,null,"Name, Company, Title                                                 Date Attestation Signed"]

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[]
["MANAGED CARE SYSTEMS"]
["P.O. Box 64975, St. Paul, MN 55164-0975"]
["Telephone: 651-201-5100"]
["Email: health.managedcare@state.mn.us"]
[]
[]
["Please review the following instructions prior to completing the Request for Waiver form. If you encounter issues editing or uploading to CloudDrive, "]
["email health.managedcare@state.mn.us"]
[]
["1.","Before editing, download the Request for Waiver form and save locally as an Excel Macro-Enabled Workbook (.xlsm). Macros must be enabled for editing."]
["2.","Enter the Carrier, Network Name, and Network ID where prompted. These identifiers must match those entered in SERFF."]
["3.","Enter the name of the primary contact/form submitter under “Name”."]
["4.","Enter the title of the primary contact/form submitter under “Title”."]
["5.","Enter the date of form submission, in MM/DD/YYYY format, under “Date”."]
["6.","Select a provider type using the drop-down menu. Only one provider type may be selected per line. "]
["7.","Select counties using the drop-down menu. To remove a county, select it twice. Do not delete. Multiple counties may be selected for most provider types."]
[null,"EXCEPTION: for Primacy Care, Pediatric Services (Primary Care), General Hospital, and Mental Health provider types, only one county may be selected per line."]
["8.","Select a reason code using the drop-down menu. Only one reason code may be selected per line."]
["9.","For additional rows, please see the tab labeled “Additional” at the bottom of the Request for Waiver form. DO NOT add rows to the “RequestForWaiver” sheet."]
["10.","Once ready to submit, save the final version of the document as an Excel Workbook, macros disabled (.xlsx). Macros must be disabled for uploading."]
["11.","Upload the document to"]

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["Provider Type",null,null,null,null,null,null,null,"County",null,null,"Reason Code",null,"Notes",null,null,null,null,null,null,null,null,null,null,null,"Affected Enrollees*",null,null,"Percent Total Enrollees Affected",null,null,"Percent Not Covered*",null,null,"Percent Available Providers Included in Network"]
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