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 will be monitored through secret-shopper analysis, provider surveys and analysis of member complaints following managed care launch.

Results

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 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. 

With the update of network results using data from the May 2022 Standard Plan networks, the Department decided to include additional provider/service groups in the summary of results.

The new 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 on July 12, 2021, Sept. 20, 2021, and on May 31, 2022, can be found below. Please note that PHP Standard Plan Exception Requests for Contract Year 1 (July 1, 2021 – June 31, 2022) have been received from the health plans and NC Medicaid has reviewed these requests as part of the final assessment of each plan’s network for Contract Year 1.

• Standard Plan Network Adequacy Results as of August 2021
• Standard Plan Network Adequacy Results as of Sept. 20, 2021
• Standard Plan Network Adequacy Results as of May 31, 2022