Beginning July 1, 2018, all Medi-Cal managed care plans (MCPs) will be required to submit annual network certifications in addition to continuing requirements for reporting significant changes to their networks.
MCPs must confirm that their networks will meet the anticipated needs of their service areas. This means that plans must maintain a provider network adequate to serve their service areas. DHCS requires network capacity adequate to serve 60% of all eligible beneficiaries in the service areas of county/two-plan model plans, 60% of geographic managed care plans, and 100% of county-organized health system plans. MCPs must also meet FTE provider-to-beneficiary ratios of 1 FTE PCP to every 2000 beneficiaries, and 1 FTE network physician to every 1200 beneficiaries.
MCP provider networks must include FTE adult and pediatric PCPs, FTE adult and pediatric core specialists, mental health providers, hospitals, pharmacies, and ancillary services. MCPs must also include at least one FQHC, one rural health clinic, and one freestanding birth center, where available in the contracted service area. Plans must also meet requirements regarding midwifery, Indian Health Facilities, and Behavioral Health Treatment.
Effective July 1, 2018, DHCS has also established time and distance standards based on county population density. These standards apply to primary and specialty care for adults and children, OB/GYN services, hospitals, pharmacy, and mental health services. Primary care and mental health outpatient services should be offered within 10 business days of request, while specialty care appointments should be offered within 15 business days of request. Primary care, hospital, and pharmacy sites must be located within 10 miles or 30 minutes of a beneficiary’s residence regardless of county; time and distance standards vary by county density designation.
Plans may use telehealth and mail order pharmacies to meet network adequacy requirements, but plans may not require use of either in place of in-person services. Plans may also subcontract, but subcontractors must have an adequate provider network.
Dental managed care plans also must meet DHCS-required network adequacy standards. Primary care dental appointments must be located 10 miles or 30 minutes from a beneficiary’s residence. Routine appointments must be provided within 4 weeks of request, while specialty dental services must be scheduled within 30 business days of request for adults and 30 calendar days of request for children. Emergency appointments must be available within 24 hours from the request for appointment.
DHCS APL 18-005 (February 16, 2018)
DHCS Dental APL 18-003 (January 9, 2018)
DHCS Dental APL 17-008 (November 8, 2017)