Kaiser Family Foundation Survey on State Medicaid Managed Care ...

APPENDIX 7: MCO Network Adequacy Requirements by Type of Care, by StateState Primary Care Obstetric Care Specialty Care Hospital Care Dental CareAZ All categories:We require an annual Network and Development Plan, as required in the AHCCCS Contractor Operations Manual (ACOM) Policy 415 [42 CFR 438.207 (b)], Acute Care Contract, Section D, Par 27 & ALTCS Contract, Section D,CA 2000 Beneficiaries to 1 PCP. Sufficient to serve assigned population. Sufficient to serve assigned Par 28. population. Must meet requirements for time and distance - 10 miles and 30 minutes.Not covered in Medi-Cal managed care.CO 1 to 2,000 providers to clients. Same as Primary Care. Same as Primary Care. Same as Primary Care. TBDCarved out.CT 387 adult members per adult PCP and 301children per child PCP; also PCP within 15miles.DC MCO shall have at least 2 PCPs bothgeographically available and able todemonstrate can accept patients whilemaintaining their overall patient load withinprofessional and industry norms andcommunity standards.835 members per woman PCPincluding obstetrics and gynecologyspecialists, nurse midwives, and nursepractitioners of the appropriatespecialty.In addition to a PCP, a female Enrolleemay have a women's health specialist.MCO shall provide female Enrolleeswith direct access to a women's healthspecialist within the network forcovered women's routine andpreventive health care services.Network adequacy evaluations shall use ratiosof Members to specific types of providers andshall not be less than the access ratio based onthe Connecticut Medicaid fee-for-servicedelivery system for a similar population.MCO shall have a network including sufficientnumber and classes to furnish covered specialtyservices. The network shall include medicalsubspecialists and pediatric specialists andsubspecialists. There is a list of specialists, at aminimum the MCO shall include within theirnetwork, but not limited to a list of Specialists asidentified by DHCF.Network adequacy evaluations shall useratios of Members to specific types ofproviders and shall not be less than theaccess ratio based on the ConnecticutMedicaid fee-for-service delivery system fora similar population.Must demonstrate a hospital network in theDistrict capable of furnishing a full range oftertiary services to enrollees. Enrollees shallhave access to at least two general acutecare hospitals located in the District.Additionally, there is a specific healthsystem MCOs shall include within theirnetwork, or shall have hospital(s) providingcomparable services offered by the healthsystem, and at least one hospital thatspecializes in pediatric care.MCOs shall maintain a sufficientnetwork of dental providers, includingdentists, pediatric dentists,orthodontists and oral surgeons to meetthe needs of the enrollees.DE 30 minutes/30 miles. 100 miles.FL 1 full-time PCP per 1500 enrollees (mayincrease by 750 for each ARNP or PA).GA Urban Area: 2 within 8 miles: Rural: 2 within15 miles.HI 1 PCP for every 600 members. Included on each island served. Specialists available on each island served orbring to another island (or out of state) toIL At least one FTE physician for each 1,200enrollees.At least one Women's Health Providerfor each 2,000 female enrolleesbetween ages 19 and 44; at least onephysician specializing in obstetrics foreach 300 pregnant female enrollees.provide.At least one pediatrician for each 2,000enrollees under age 19.1 accredited hospital bed per 275 enrollees.For Obstetrics, Specialty, Hospital and Dental: Urban Area: 1 within 30 miles or 30 minutes; Rural Area: 1 within 45 miles or 45 minutes.Included on each island served. N/AContractor must establish and maintain anetwork of affiliated providers, includinghospitals, that is sufficient to provideadequate access to all services under thecontract.N/AIN Availability within 30 miles of member'sresidence.KSKYMA PCP 1:200 per enrollees and 2 or more withopen panels within 15 miles or 30 minutes ofenrollee's residence.30 miles. Selected specialties must have 2 within 60 milesfor member's residence, some are 1 within 90miles.All categories: Delivery sites that are no more than 30 miles/30 minutes for members in urban areas, or 45 miles/45 minutes for members in rural areas.MD 200:1 ratio; 1 provider in 10 mins/10 milesurban; 1 provider in 30 mins/30 miles rural.no standard. no standard.OB 1:500 female enrollees. Top 5 specialist 1:500 enrollees. Within 20 miles or 40 minutes of enrollee'sresidence.Same as Primary Care. Varies by specialty. Detailed in regulationCOMAR 10.09.66.05-1.None; all MCOs participate with all hospitalsin Maryland.N/A - covered by the state.1 provider in 10 mins/10 miles urban; 1provider in 30 mins/30 miles rural.MI Michigan has a ratio standard of 1 PCP forevery 750 members.Open access to OB services. Must have certain specialties within network ifavailable.Must have hospital contract if possible ormust have the Michigan Hospital Accessagreement available.65