While no single indicator can provide a complete measure of network adequacy, information across indicators provides a robust assessment of the adequacy of mco or dmo provider networks and their performance in meeting contractual obligations. As part of the network adequacy review process, applicants must notify cms of their use of lois to meet network standards in lieu of a signed contract and submit copies upon request and in the form and manner directed by cms. Current federal rules require states to establish and enforce network adequacy standards for medicaid mcos, but states have flexibility to define those standards.
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At a minimum, a state must develop a quantitative network adequacy standard, other than appointment wait times, for the following provider types, if covered under the contract
(i) primary care, adult and pediatric
(iii) mental health and substance use disorder, adult and pediatric. Once an eligible state doi submits to cms an attestation that they consider the area to be prohibitively difficult to establish a network of dental providers, cms will review the attestation to determine if an exception will be granted. Students of medicaid will not be surprised to learn that we found wide variation from state to state in the robustness of the network adequacy standards Interestingly, however, we also found significant variation between the medicaid and marketplace standards within the same state.
This quality strategy is intended to serve as a blueprint for states and their contracted health plans for assessing the quality of care that beneficiaries receive, and setting forth measurable goals and targets for quality improvement and network adequacy.
