Ensure network adequacy in Medicaid managed care

Individuals needing MH/SUD services often face difficulties finding and accessing in-network providers. This can result in long wait times, high out-of-pocket costs associated with out-of-network care, and not receiving critical services. While some states have established their own network adequacy standards for MH/SUD providers, such as timely access and geographic distance standards, these standards vary widely. And even in many states that have standards, they are qualitative, rather than quantitative in nature, significantly impairing beneficiaries’ rights and making the standards difficult to measure or enforce.[1] Studies show that provider network directories overstate provider availability and current network adequacy standards – such as enrollee-to-provider ratios – may not reflect actual access.[2]

The Centers for Medicare and Medicaid Services (CMS) has proposed a new rule on network adequacy standards for Medicaid managed care plans, which includes new national maximum wait time standards for certain appointments and independent secret shopper surveys to validate plan compliance. The proposed maximum wait time standard for routine outpatient MH and SUD appointments is 10 business days.[2] The proposed rule is a significant step forward, and CMS should finalize it without delay.

To further strengthen rules, Congress should establish uniform, quantitative timely access and distance standards for MH/SUD services for all Medicaid managed care plans nationwide. If a plan’s network is unable to provide needed MH/SUD services for a beneficiary within these standards, the plan should be required to arrange out-of-network services with the beneficiary’s cost-sharing limited to what they would have paid had in-network services been available. Several states have implemented such standards, including California, which requires that health plans have medically necessary MH/SUD services available within 10 days.[3]