Network Adequacy Questions and Answers
Why do some health plans show less than 100% of members with access in some regions for some categories?
This means that some members in the region do not reside within the applicable time/distance standard of the appropriate number of providers for the applicable provider/service category. Generally, the network adequacy time/distance standards require that 95% of members live within the time/distance standard. If the health plan does not meet the standard, then the health plan must submit a request for approval of an exception from the standard for the county(ies) for which the standard is not met.
Why does the data only include certain categories of services?
Because a regional PIHP could have around 900 different provider/service group geo-mapping results, and a statewide health plan has around 5,800 different results, NC Medicaid focused on a few priority provider/service groups and summarized network adequacy analysis results on a regional and county-by-county basis for those categories of services. The categories were chosen due to their impact or potential upon the member population.
For PIHP Medicaid Direct, the priority categories of service are: Outpatient Behavioral Health, Location Based Services, Partial Hospitalization, Substance Abuse Intensive Outpatient Program.
For Standard Plan, the priority categories of services are: Primary Care, Hospitals, Pharmacy, OB/GYN and Outpatient Behavioral Health.
What are the other categories of services the Department measures adequacy against?
The other categories include, but are not limited to, the following Standard Plan provider/service groups; Specialty Care, Occupational/Physical/Speech Therapies, Long-term Services and Support, Skilled Nursing Facilities, Inpatient Behavioral Health, Location-based Services (BH), Partial Hospitalization (BH) and Crisis Services (BH).
What does the data represent?
The percentage of members in a region whose residential address is within the specific time or distance of the appropriate number of providers for the specified service type.
What are the standards utilized by the Department to measure the adequacy of the plans’ networks?
Refer to the Network Adequacy Standards found on the Network Adequacy Time and Distance Standards webpage.
How does the Department measure accessibility?
Accessibility involves the proximity of providers to Members, based on geographic time and distance. At the point of care, accessibility is determined by physical access, such as ramps, and providers’ ability to communicate in non-English languages or sign language. Additionally, to what extent is a provider’s operating hours, appointment policies, language and cultural competence, awareness, and communication meeting Members’ constraints and preferences.
Lastly, while numeric standards may help evaluate a network “on paper,” evaluating realized access, which addresses Members’ actual use of service, is the goal of network adequacy oversight. For monitoring purposes, it is most important to measure the use of clinically recommended care, such as preventive screenings and immunizations, as well as services that could be markers of potential access problems, such as hospital admissions for chronic conditions that can be avoided through regular outpatient care.
How often does NC Medicaid analyze the health plans’ networks?
In addition to an annual assessment of the health plan’s networks and review of health plan’s exception requests, NC Medicaid monitors health plan’s networks on an ongoing basis throughout the contract year and, at a minimum, receives quarterly network submissions.
What happens if a health plan does not meet the standard?
If a health plan does not meet a network adequacy standard, NC Medicaid may request a corrective action plan and/or assess the plan liquidated damages.