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Rebecca Farley David

Vice President, Policy & Advocacy

National Council Urges CMS to Strengthen Network Adequacy Standards for Medicaid Managed Care

January 17, 2019 | Medicaid | Comments
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State Medicaid programs should work with managed care organizations to ensure beneficiaries have timely access to robust provider networks, the National Council urged the Centers for Medicare and Medicaid Services in comments submitted Monday. Our comments were submitted in response to a Notice of Proposed Rulemaking issued by CMS in November that proposed to roll back prior regulations on Medicaid and CHIP managed care. While CMS indicated the new proposed rules are intended to “increase state flexibility,” the National Council is concerned they would result in loss of access to mental health and addiction treatment providers.


 The proposed rule would replace the current “time and distance” standard for determining managed care network adequacy with a new “quantitative” standard that could incorporate other measures of adequacy and access at state discretion. This quantitative minimum access standard would apply to a number of provider types, including behavioral health providers, and states would be able to elect what standard(s) they will use. The rule includes a non-exhaustive list of the types of standards states may want to consider, including minimum provider-to-enrollee ratios; a minimum percentage of contracted providers that are accepting new patients and maximum wait times for an appointment. States would be free to use different standards in combination and are encouraged, but not required, to do so.

In our comments, the National Council applauded CMS’ attention to important barriers to treatment access posed by networks that do not include sufficient numbers of providers per enrollee, networks comprised of clinicians that are not accepting new patients, and lengthy wait times to access care. Incorporating these standards into the assessment of a network’s “adequacy” should enable more meaningful oversight and evaluation by states and CMS of actual patient access to managed care plan networks.

However, we also have serious reservations about the proposed changes: a) not all quantitative standards are equivalent in what they measure or potentially indicate about the adequacy of a network, and CMS does not require a particular degree of rigor for the network adequacy analysis; b) states are afforded significant discretion to choose which standard(s) they will use and whether to use several standards in combination, meaning that access may vary substantially across states and may be weaker in some areas than others; and c) there is not a clear indication of the relationship of these standards to the requirements of federal mental health and addiction parity law.


The National Council recommends that CMS:

  1. Establish two categories of network adequacy which distinguish between those that are static (e.g. time and distance, provider-to-enrollee ratios) and those that permit real-time assessment of actual network performance (e.g. length of wait time to appointment, percentage of providers accepting new patients, etc.).
  2. Require, rather than encourage, states to implement a combination of standards that includes one or more standards from the second category, measuring network performance.
  3. Cross-reference the network adequacy standards codified in the parity regulations, and stipulate that both regulations be satisfied.

To read our full comments, click here.