Skip to content

Menu

LexBlog, Inc. logo
NetworkSub-MenuBrowse by SubjectBrowse by PublisherBrowse by ChannelAbout the NetworkJoin the NetworkProductsSub-MenuProducts OverviewBlog ProBlog PlusBlog PremierMicrositeSyndication PortalsAbout UsContactSubscribeSupport
Book a Demo
Search
Close

Network Adequacy for Medicaid Managed Care: New Standards under the Final Rule

By Marisa E. Adelson on May 18, 2016
Email this postTweet this postLike this postShare this post on LinkedIn

The Medicaid Managed Care Final Rule addresses managed care plan network issues while preserving significant flexibility for the states in designing the standards.  The Rule adds a new regulation (42 C.F.R. § 438.68) on network adequacy standards for medical care and Long-Term Services and Supports (LTSS) as well as one related to availability of services (42 C.F.R. § 438.206).  Although states already regulate network adequacy, the Rule provides a new minimum level of compliance and aligns standards for Medicaid managed care plans around the country while deferring to states to actually develop the standards.  States must set time and distance standards for a variety of provider types, including, primary care (adult and pediatric), OB/GYN, behavioral health, specialist (adult and pediatric), hospital, pharmacy, pediatric dental, LTSS providers, and additional provider types that promote the objectives of the Medicaid program.  These standards must include CMS-mandated elements such as anticipated enrollment, expected utilization, the numbers and types of providers required to provide contracted services, the ability of providers to communicate with limited English proficient beneficiaries in their preferred language, and the availability of telemedicine and other “evolving and innovative technological solutions.”  42 C.F.R.§ 438.68 (c).  In the Preamble, CMS explains that time and distance standards are a more accurate measure of timely access than provider-to-enrollee ratios, which some states previously used.  States must publish these standards online and make them available, at no cost, in alternative formats for individuals with disabilities.  42 C.F.R.§ 438.68 (e).

Additionally, states must ensure that covered services are available and accessible in a timely manner, as explained in 42 C.F.R. § 438.206. The Rule requires states to enforce network maintenance and monitoring requirements for managed care plans, including direct access to women’s health specialists for female beneficiaries, appropriate access to second opinions, coordination with out of network providers for payment, and provision of sufficient family planning providers.  States also must ensure compliance with timely access requirements, including the specific requirement that network provider hours of operation are no less than the hours offered to commercial enrollees.  42 C.F.R. § 438.206(c)(1)(i).  And service delivery must be provided in a culturally competent manner and accessible to those with physical or mental disabilities.  In the Rule’s Preamble, CMS remarked that the disability access was especially critical for LTSS recipients, who have a higher rate of disability than other beneficiary groups.

For additional coverage of the Medicaid Managed Care Final Rule, click here.

Photo of Marisa E. Adelson Marisa E. Adelson

Marisa Adelson is an associate in Crowell & Moring’s San Francisco office, where she practices in the Health Care and Antitrust groups. In her health care practice, Marisa represents managed care payors and provides counseling on regulatory compliance. Marisa’s antitrust practice primarily involves…

Marisa Adelson is an associate in Crowell & Moring’s San Francisco office, where she practices in the Health Care and Antitrust groups. In her health care practice, Marisa represents managed care payors and provides counseling on regulatory compliance. Marisa’s antitrust practice primarily involves complex antitrust recovery litigation. Marisa has an active pro bono practice and currently represents a client from South Asia seeking asylum in the United States.

Read more about Marisa E. AdelsonEmail
Show more Show less
  • Posted in:
    Health Care
  • Blog:
    Health Law
  • Organization:
    Crowell & Moring LLP
  • Article: View Original Source

LexBlog, Inc. logo
Facebook LinkedIn Twitter RSS
Real Lawyers
99 Park Row
  • About LexBlog
  • Careers
  • Press
  • Contact LexBlog
  • Privacy Policy
  • Editorial Policy
  • Disclaimer
  • Terms of Service
  • RSS Terms of Service
  • Products
  • Blog Pro
  • Blog Plus
  • Blog Premier
  • Microsite
  • Syndication Portals
  • LexBlog Community
  • Resource Center
  • 1-800-913-0988
  • Submit a Request
  • Support Center
  • System Status
  • Resource Center
  • Blogging 101

New to the Network

  • Tennessee Insurance Litigation Blog
  • Claims & Sustains
  • New Jersey Restraining Order Lawyers
  • New Jersey Gun Lawyers
  • Blog of Reason
Copyright © 2025, LexBlog, Inc. All Rights Reserved.
Law blog design & platform by LexBlog LexBlog Logo