Health plan network adequacy

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All health plans must have enough hospitals and providers for all members to get all covered services in a timely manner. To make sure that all health plan members have timely access to covered services, all health plans must meet network adequacy time and distance standards.

If a provider or service type is not listed, then there is not a network adequacy standard. In this case, health plans must still provide timely access to all providers for all covered services.

An urban county is a county with at least 250 people per square mile. A rural county is a county with less than 250 people per square mile. Rural counties are usually more spread out than urban counties. They may require a longer driving distance than urban counties. The standards are meant to show that difference.
 

Health plan time and distance standards

Urban county

Rural county

Primary care

At least 2 providers within 30 minutes or 10 miles for at least 95% of members

At least 2 providers within 30 minutes or 30 miles for at least 95% of members

Specialty care

At least 2 providers (per specialty type) within 30 minutes or 15 miles for at least 95% of members

At least 2 providers (per specialty type) within 60 minutes or 60 miles for at least 95% of members

Hospitals

At least 1 hospital within 30 minutes or 15 miles for at least 95% of members

At least 1 hospital within 30 minutes or 30 miles for at least 95% of members

Pharmacies

At least 2 pharmacies within 30 minutes or 10 miles for at least 95% of members

At least 2 pharmacies within 30 minutes or 30 miles for at least 95% of members

Obstetrics

At least 2 providers within 30 minutes or 10 miles for at least 95% of members

At least 2 providers within 30 minutes or 30 miles for at least 95% of members

Occupational, physical or speech therapists

At least 2 providers (per provider type) within 30 minutes or 10 miles for at least 95% of members

At least 2 providers (per provider type) within 30 minutes or 30 miles for at least 95% of members

Outpatient behavioral health services

At least 2 providers (per service) within 30 minutes or 30 miles for at least 95% of members

  • Research-based behavioral health treatment for Autism Spectrum Disorder (ASD): No standard

At least 2 providers (per service) within 45 minutes or 45 miles for at least 95% of members

  • Research-based behavioral health treatment for Autism Spectrum Disorder (ASD): No standard

Location-based services (behavioral health)

At least 2 providers (per service) within 30 minutes or 30 miles for at least 95% of members

At least 2 providers (per service) within 45 minutes or 45 miles for at least 95% of members

Crisis services (behavioral health)

At least 1 provider (per service) within each health plan region

Inpatient behavioral health services

At least 1 provider (per service) within each health plan region

Partial hospitalization (behavioral health)

At least 1 provider of partial hospitalization within 30 minutes or 30 miles for at least 95% of members

At least 1 provider of specialized services partial hospitalization within 60 minutes or 60 miles for at least 95% of members

All state plan LTSS (except nursing facilities)

At least 2 LTSS provider types (home care providers and home health providers, including home health services, private duty nursing services, personal care services, and hospice services), identified by distinct NPI, accepting new patients available to deliver each state plan LTSS in every county

At least 2 providers accepting new patients available to deliver each state plan LTSS in every county; providers do not have to live in the same county where they provide services

Nursing facilities

At least 1 nursing facility accepting new patients in every county

At least 1 nursing facility accepting new patients in every county


All health plans must meet appointment wait time standards. These standards make sure that health plans have enough providers for members to have access to timely care, based on the urgency of the visit.
 

Health plan appointment wait time standards

Description

Standard

Primary care

Preventive care services

Care to prevent illness or injury, such as routine physical exams, immunizations (shots), mammograms and pap smears

Adult, 21 years of age and older:

  • Within 30 days

Child, birth through 20 years of age:

  • Within 14 days for members less than 6 months of age
  • Within 30 days for members 6 months of age or older

Urgent care services

Care for a non-emergent illness or injury that needs immediate care, such as sprains, flu symptoms, minor cuts and wounds, sudden stomach pain, and severe headache

Within 24 hours

Routine check-up without symptoms

Care for a routine health visit

Within 30 days

After-hours access – emergent and urgent

Care after normal office hours

Immediately, available 24 hours a day, 7 days a week, 365 days a year

Prenatal care

Initial appointment

Care for a pregnant member to keep the member and future baby healthy, such as check-ups and prenatal testing

First or second trimester:

  • Within 14 days

High-risk pregnancy or third trimester:

  • Within 5 days

Specialty care

Urgent care services

Care for a non-emergent illness or injury that needs immediate care, such as sprains, flu symptoms, minor cuts and wounds, sudden stomach pain, and severe headache

Within 24 hours

Routine check-up without symptoms

Care for a routine health visit

Within 30 days

After-hours access – emergent and urgent

Care after normal office hours

Immediately, available 24 hours a day, 7 days a week, 365 days a year

Behavioral health care

Mobile crisis management services

Care to treat mental health crises

Within 2 hours

Urgent care services for mental health

Care to treat a condition for a person who could become suicidal or homicidal without immediate help

Within 24 hours

Urgent care services for substance use disorders

Care for a person who has a condition that could become a need for emergent services or care for the use of alcohol or other drugs

Within 24 hours

Routine services for mental health

Care for a person who describes signs and symptoms of impaired behavioral, mental and emotional functioning, affecting the person’s daily life

Within 14 days

Routine services for substance use disorders

Care for a person who describes signs and symptoms related to using alcohol or other drugs

Within 14 days

Emergency services for mental health

Care for a person who is suicidal, homicidal, actively psychotic, showing disorganized thinking, or having hallucinations and delusions

Immediately, available 24 hours a day, 7 days a week, 365 days a year

Emergency services for substance use disorders

Care for a person who is suicidal, homicidal, actively psychotic, showing disorganized thinking, or having hallucinations and delusions related to using alcohol or other drugs

Immediately, available 24 hours a day, 7 days a week, 365 days a year