Network adequacy measures the ability of each NC Medicaid Managed Care health plan to deliver benefits by providing adequate access for members to all covered health care services through a network of contracted health care providers.
Federal regulations require NC Medicaid to verify health plans maintain a network of appropriate providers that is “sufficient to provide adequate access” to all services covered under the contract for all members. Network adequacy and accessibility standards help verify members have access to providers and offer an important tool for NC Medicaid to monitor and measure that access.
In NC Medicaid, network adequacy standards are established as either:
- A maximum travel time or distance from a member’s residence to one or more providers of a certain type
- A minimum number of providers of a certain type within a geographic boundary (county or region)
Network accessibility standards are different than network adequacy standards and establish the maximum amount of time a member should have to wait to obtain an appointment with a participating provider based on the type and urgency of the service requested. Additional details on Network Adequacy Time or Distance Standards can be found here.