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Network Adequacy

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In order to strengthen access to services in a managed care network, the Final Rule requires states to establish network adequacy standards in Medicaid managed care for key types of providers, while leaving states the flexibility to set the actual standards. The Final Rule requires that states:

Develop and implement time and distance standards for primary and specialty care (adult and pediatric), behavioral health (adult and pediatric), OB/GYN, pediatric dental, hospital, and pharmacy providers;
Develop and implement timely access standards for long-term services and support (LTSS) providers who travel to the beneficiary to provide services; and
Assess and certify the adequacy of a managed care plan’s provider network at least annually.

The Final Rule network adequacy requirements are effective in the July 1, 2018 health plan contract year.

The Network Adequacy Standards proposal outlines the approach that DHCS has undertaken to develop the standards and describes monitoring activities for ongoing compliance.

Starting with the 2022 contract year, CMS requested DHCS submit one Annual Network Certification for Medi-Cal Managed Care Health Plans (MCPs), Medi-Cal Dental Managed Care (Dental MC) plans, county Drug Medi-Cal Organized Delivery System (DMC-ODS) plans, and county Mental Health Plans (MHPs).