Network Adequacy Oversight Measures and Results
Measures
For the time/distance standards, the Department uses “geo-mapping” software to calculate the distance in travel time and travel miles from a member’s residence to provider locations.
- A health plan’s network must demonstrate that at least 95% of members in a county live within the adequacy standard (by either the miles OR by the travel time) to be compliant in that county for that standard.
- A health plan must request an exception from any network adequacy standard with which they cannot comply.
For the standards based on a minimum number of providers within a geographic boundary, health plans must demonstrate their provider networks have the correct number of providers of the correct type in the specific area to be compliant.
Appointment wait time standards are monitored through secret-shopper analysis, provider surveys and analysis of member complaints.
Results
Standard Plan
The Standard Plan health plans are statewide health plans. A statewide health plan has approximately 5,800 different county/provider/service group/member-age geo-mapping results metrics. NC Medicaid summarizes geo-mapping analysis results to facilitate review and consumption of the information.
During readiness and leading up to managed care launch, NC Medicaid focused on five priority provider/service groups for the Standard Plan health plans and summarized network adequacy analysis results on a regional and county-by-county basis for those five categories of services.
- Primary Care
- Hospitals
- Pharmacy
- OB/GYN
- Outpatient Behavioral Health
The priority categories were chosen due to their potential impact on the member population. NC Medicaid decisions relating to participation in auto-enrollment and for managed care launch were partially based upon the plans’ performance in those priority provider/service groups.
Following Standard Plan launch, the Department decided to include additional provider/service groups in the summary of results.
The expanded summary report includes the five-priority provider/service groups listed above and new metrics for:
- Occupational Therapy
- Physical Therapy
- Speech Therapy
- Specialty Care
- Allergy/Immunology
- Cardiology
- Gastroenterology
- Oncology
- Psychiatry
Network adequacy results based upon network data submitted by the Standard Plans as of April 30, 2024, can be found below.
Medicaid Direct PIHP
The Medicaid Direct PIHP health plans are regional health plans. Of approximately 900 results metrics, each regional health plan has different county/provider/service group/member-age geo-mapping results metrics based on designated catchment areas. NC Medicaid summarizes geo-mapping analysis results to facilitate review and consumption of the information.
During Medicaid Direct PIHP health plan readiness and leading up to launch, NC Medicaid focused on four priority provider/service groups and summarized network adequacy analysis results by catchment area for those four categories of services.
- Outpatient Behavioral Health
- Location Based Services
- Partial Hospitalization
- Substance Abuse Intensive Outpatient Program
Network adequacy results based upon network data submitted by the PIHP Medicaid Direct Plans on April 30, 2024, can be found below.
Network Adequacy and Access Assurances Report (NAAAR)
The Medicaid and CHIP managed care final rule strengthened oversight of managed care programs and created new reporting requirements for states on their managed care programs and operations. To support this reporting, CMS developed a standardized Network Adequacy and Access Assurances reporting template on which states can document an assurance of compliance that the plans are meeting the state’s requirements for availability of services and provider network adequacy.
Recent NAAAR reports documenting compliance of the PHPs and the PIHPs can be found below.
This page was last modified on 07/12/2024