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Managed Care Final Rule: Network Adequacy Final Rule/Network...Managed Care Final Rule: Network Adequacy Standards and Network Certification California Department of Health Care Services

Jun 11, 2018

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  • Managed Care Final Rule:

    Network Adequacy Standards

    and

    Network Certification California Department of Health Care Services

    Webinar

    February 22, 2018

  • Presentation Outline

    2

    1. Network Adequacy Background and Overview

    2. Standards Time and Distance and Timely Access

    3. Alternative Access Standards

    4. NACT and Supporting Documentation

    5. Submission Requirements

    6. State Network Certification Approach

    7. Non-Compliance

    8. Questions and Open Discussion

  • Network Adequacy

    Announcements

    MHSUDS Information Notice 18-010

    (Issue date: February 13, 2018)

    Enclosure 1 Network Adequacy Certification Tool (contact DHCS for this

    Enclosure)

    Enclosure 2 Network Certification Checklist

    Enclosure 3 Alternative Access Standards Request

    3

  • Network Adequacy

    Background and Overview

    4

  • Background & Overview

    Applicability

    Medi-Cal managed care health plans

    County mental health plans (MHPs)

    Drug Medi-Cal Organized Delivery System (DMC-ODS) health plans

    Dental managed care plans

    Implementation Date

    July 1, 2018 contract year

    5

  • Background & Overview

    Federal network adequacy rules 438.68 Network adequacy

    438.14 Indians and Indian health care providers (IHCPs)

    438.206 Availability of services

    438.207 Assurances of adequate capacity and services

    1 Managed Care Final Rule, Federal Register, Vol. 81, No. 88, 438.68; 438.206; 438.207; 438.14 :

    https://www.gpo.gov/fdsys/pkg/FR-2016-05-06/pdf/2016-09581.pdf 6

    https://www.gpo.gov/fdsys/pkg/FR-2016-05-06/pdf/2016-09581.pdf

  • -

    Network Adequacy

    Requirements

    * Adult and pediatric

    Network Adequacy Standards*

    Psychiatry

    Outpatient Mental Health Services

    Outpatient SUD Services (Non OPD)

    Opioid Treatment Programs (OPD)

    Reporting & Transparency

    Annual Program Assessment Report

    Website posting of network adequacy

    standards and alternative access requests/approvals

    Annual Network

    Certification

    Conduct network certification review

    Submit assurance of compliance to CMS

    7

  • Assembly Bill (AB) 205

    Implemented specific provisions of the Final Rule,

    including the network adequacy standards

    Changed county categorization to be based on

    population density rather than population size

    Authorized alternative access standards process to be

    permitted and use of telehealth to meet standards

    Established a 90-day timeline for reviewing alternative

    access standard requests

    Requires annual demonstration of network adequacy

    compliance

    Sunsets the network adequacy provision in 2022,

    allowing for reevaluation of the standards

    8

  • Network Adequacy Standards

    9

  • Network Adequacy Standards For psychiatry, the standards are as follows:

    10

    Timely Access Within 15 business days from request to appointment

    Time and Distance Up to 15 miles or 30 minutes from the beneficiarys place of residence for the following counties: Alameda, Contra Costa, Los

    Angeles, Orange, Sacramento, San Diego, San Francisco, San

    Mateo, and Santa Clara.

    Up to 30 miles or 60 minutes from the beneficiarys place of residence for the following counties: Marin, Placer, Riverside, San

    Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura.

    Up to 45 miles or 75 minutes from the beneficiarys place of residence for the following counties: Amador, Butte, El Dorado,

    Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa,

    Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter,

    Tulare, Yolo, and Yuba.

    Up to 60 miles or 90 minutes from the beneficiarys place of residence for the following counties: Alpine, Calaveras, Colusa,

    Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa,

    Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra,

    Siskiyou, Tehama, Trinity, and Tuolumne.

  • Network Adequacy Standards The standards for Mental Health Services, Targeted Case Management, Crisis

    Intervention, and Medication Support Services are as follows:

    Timely Access Within 10 business days from request to appointment

    Time and Distance Up to 15 miles or 30 minutes from the beneficiarys place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange,

    Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara.

    Up to 30 miles or 60 minutes from the beneficiarys place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa

    Cruz, Solano, Sonoma, Stanislaus, and Ventura.

    Up to 45 miles or 75 minutes from the beneficiarys place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern,

    Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San

    Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and

    Yuba.

    Up to 60 miles or 90 minutes from the beneficiarys place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn,

    Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono,

    Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and

    Tuolumne.

    11

  • Network Adequacy Standards For outpatient SUD services, other than opioid treatment programs (OTPs), the

    standards are as follows:

    Timely Access Within 10 business days from request to appointment

    Time and Distance Up to 15 miles or 30 minutes from the beneficiarys place of residence for the following counties: Alameda, Contra Costa, Los

    Angeles, Orange, Sacramento, San Diego, San Francisco, San

    Mateo, and Santa Clara.

    Up to 30 miles or 60 minutes from the beneficiarys place of residence for the following counties: Marin, Placer, Riverside, San

    Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura.

    Up to 60 miles or 90 minutes from the beneficiarys place of residence for the following counties: Alpine, Amador, Butte,

    Calaveras, Colusa, Del Norte, El Dorado, Fresno, Glenn, Humboldt,

    Imperial, Inyo, Kern, Kings, Lake, Lassen, Madera, Mariposa,

    Mendocino, Merced, Modoc, Monterey, Mono, Napa, Nevada,

    Plumas, San Benito, San Bernardino, San Luis Obispo, Santa

    Barbara, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tulare,

    Tuolumne, Yolo, and Yuba.

    12

  • Network Adequacy Standards For OTPs, the standards are as follows:

    13

    Timely Access Within 3 business days from request to appointment

    Time and Distance Up to 15 miles or 30 minutes from the beneficiarys place of residence for the following counties: Alameda, Contra Costa, Los

    Angeles, Orange, Sacramento, San Diego, San Francisco, San

    Mateo, and Santa Clara.

    Up to 30 miles or 60 minutes from the beneficiarys place of residence for the following counties: Marin, Placer, Riverside, San

    Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura.

    Up to 45 miles or 75 minutes from the beneficiarys place of residence for the following counties: Amador, Butte, El Dorado,

    Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa,

    Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter,

    Tulare, Yolo, and Yuba.

    Up to 60 miles or 90 minutes from the beneficiarys place of residence for the following counties: Alpine, Calaveras, Colusa, Del

    Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa,

    Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra,

    Siskiyou, Tehama, Trinity, and Tuolumne.

  • Appointment Time Standards

    Urgent care appointment for services that do not

    require prior authorization within 48 hours of a request

    Urgent appointment for services that do require prior

    authorization within 96 hours of a request

    Non-urgent appointment with a non-physician mental

    health care provider within 10 business days of request

    Non-urgent appointment with a psychiatrist within 15 business days of request

    Opioid treatment program within 3 business days of request

    14

  • Appointment Time Exceptions The applicable appointment time standards may be

    extended if the referring or treating provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the beneficiarys record that a longer waiting time will not have a detrimental impact on the health of the beneficiary1

    Periodic office visits to monitor and treat mental health conditions may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed mental health provider acting within the scope of his or her practice1

    1. Cal. Code Regs., tit. 28, 1300.67.2.2(c)(5)(G) 15

  • Alternative Access

    Standards

    16

  • Alternative Access Standards

    Alternative access requests may be

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