All Standard Plans must have enough hospitals and providers for all members to get all covered services in a timely manner. To make sure that all Standard Plan members have timely access to covered services, all Standard 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, Standard 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.
Urban county |
Rural county |
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Primary care |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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At least 2 providers (per service) within 30 minutes or 30 miles for at least 95% of members
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At least 2 providers (per service) within 45 minutes or 45 miles for at least 95% of members
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Location-based services (behavioral health) |
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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) |
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At least 1 provider (per service) within each health plan region |
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Inpatient behavioral health services |
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At least 1 provider (per service) within each health plan region |
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Partial hospitalization (behavioral health) |
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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) |
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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 |
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At least 1 nursing facility accepting new patients in every county |
At least 1 nursing facility accepting new patients in every county |
All Standard Plans must meet appointment wait time standards. These standards make sure that Standard Plans have enough providers for members to have access to timely care, based on the urgency of the visit.
Description |
Standard |
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Primary care |
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Preventive care services |
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Care to prevent illness or injury, such as routine physical exams, immunizations (shots), mammograms and pap smears |
Adult, 21 years of age and older:
Child, birth through 20 years of age:
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Urgent care services |
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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 |
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Care for a routine health visit |
Within 30 days |
After-hours access – emergent and urgent |
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Care after normal office hours |
Immediately, available 24 hours a day, 7 days a week, 365 days a year |
Prenatal care |
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Initial appointment |
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Care for a pregnant member to keep the member and future baby healthy, such as check-ups and prenatal testing |
First or second trimester:
High-risk pregnancy or third trimester:
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Specialty care |
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Urgent care services |
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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 |
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Care after normal office hours |
Immediately, available 24 hours a day, 7 days a week, 365 days a year |
Behavioral health care |
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Mobile crisis management services |
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Care to treat mental health crises |
Within 2 hours |
Urgent care services for mental health |
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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 |
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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 |
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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 |
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Care for a person who describes signs and symptoms related to using alcohol or other drugs |
Within 14 days |
Emergency services for mental health |
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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 |
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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 |