1. CBHDA Small Counties Strategic Planning Meeting Implementing the Medicaid Managed Care Rule: Network Adequacy and Small Counties May 17, 2017

2. Presentation Outline
Review of network adequacy requirements and standards
Overview of Alternate Access Standards
DHCS next steps for network adequacy
Small county discussion
County strategies, resources, and next Steps

3. Network adequacy requirements & standards

4. § Network Adequacy
Requires DHCS to develop and enforce network adequacy standards
Time and distance standards for behavioral health providers (adult and pediatric)
Must include all geographic areas covered by the managed care program or contract
States permitted to have varying standards for the same provider type based on geographic area

5. §438.206 Availability of Services
(a) Basic rule. Each State must ensure that all services covered under the State plan are available and accessible to enrollees of MCOs, PIHPs, and PAHPs in a timely manner. The State must also ensure that MCO, PIHP and PAHP provider networks for services covered under the contract meet the standards developed by the State in accordance with §

6. Adequate Network
Sufficient to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities
Sufficient in number, mix and geographic distribution to meet service area needs
Access and cultural considerations
Accessibility considerations
Offers an appropriate range of services that is adequate for the anticipated number of enrollees in the service area
Provides timely access to care

7. § Assurances
The State must ensure, through its contracts, that each MCO, PIHP, and PAHP gives assurances to the State and provides supporting documentation that demonstrates that it has the capacity to serve the expected enrollment in its service area in accordance with the State’s standards for access to care under this part, including the standards at § and § (c)(1).
Documentation must be submitted annually or whenever there is a significant change in operations

8. Network Certification
(d) After the State reviews the documentation submitted by the MCO, PIHP, or PAHP, the State must submit an assurance of compliance to CMS that the MCO, PIHP, or PAHP meets the State’s requirements for availability of services, as set forth in § and §
The submission to CMS must include documentation of an analysis that supports the assurance of the adequacy of the network for each contracted MCO, PIHP or PAHP related to its provider network.

9. DHCS Methodology
DHCS utilized a methodical approach to determine the proposals.
Nine factors were considered when setting the network adequacy standards (438.68)
A review of other states and lines of business standards were also reviewed.
Considerations for current requirements and structures were made including the efficacy of them.
Utilization, geographic, and provider data were used to identify both service utilization needs and a clear picture of provider availability.

10. MHSUD Methodology
MHSUD reviewed provider data including:
locations/physical addresses of all active organizational providers; and,
service utilization data.
MHSUD also utilized mapping technology to identify standards that a majority of counties could meet without alternate access requests

11. PROPOSED Time and Distance Standards
Standards vary by county size**:
Rural Counties: 60 miles or 90 minutes from the beneficiary’s residence
Small Counties: 45 miles or 75 minutes from the beneficiary’s residence
Medium Counties: 30 miles or 60 minutes from the beneficiary’s residence
Large Counties: 15 miles or 30 minutes from the beneficiary’s residence
Size Category by Population**
Rural <55,000 to 199,999
Small ,000 to 999,999
Medium 1,000,000 to 3,999,999
Large ≥ 4,000,000
**DHCS is considering revising standards and county size categories

12. Standards for Outpatient Mental Health
Table 9. MCP & MHP Mental Health Network Adequacy Standards
Standard
Current Requirement
Proposed Standard
Time and Distance
Reasonable access
Based on county population size as follows:
Rural Counties: 60 miles or 90 minutes from the beneficiary’s residence
Small Counties: 45 miles or 75 minutes from the beneficiary’s residence
Medium Counties: 30 miles or 60 minutes from the beneficiary’s residence
Large Counties: 15 miles or 30 minutes from the beneficiary’s residence
Timely Access
KKA for MCPs: within 10 business days of request
DHCS to MCP contract: within 10 business days
Same as current requirements for both adults and pediatric:
Within 10 business days of request

13. Psychiatry Reasonable access
Table 6. Specialist Network Adequacy Standards (For specialties listed in table 5)
Standard
Current Requirement
Proposed Standard
Time and Distance
Reasonable access
Based on county population size as follows:
 Rural Counties: 60 miles or 90 minutes from the beneficiary’s residence
Small Counties: 45 miles or 75 minutes from the beneficiary’s residence
Medium Counties: 30 miles or 60 minutes from the beneficiary’s residence
Large Counties: 15 miles or 30 minutes from the beneficiary’s residence
Timely Access (Non-Urgent)
KKA: 15 business days to appointment from request
Same as current requirement:
15 business days to appointment from request

14. DMC-ODS: Outpatient Standards
Table 10. Substance Use Disorder Network Adequacy Standards
Standard
Current Requirement
Proposed Standard
Time and Distance: Outpatient Services
None
Based on county population size as follows: Rural Counties: 60 miles or 90 minutes from the beneficiary’s residence
Small Counties: 45 miles or 60 minutes from the beneficiary’s residence
Medium Counties: 30 miles or 45 minutes from the beneficiary’s residence
Large Counties: 30 miles or 45 minutes from the beneficiary’s residence
Timely Access: Outpatient Services
Within 10 business days of request

15. DMC-ODS: OTP Standards
Table 10. Substance Use Disorder Network Adequacy Standards
Standard
Current Requirement
Proposed Standard
Time and Distance:
Opioid Treatment Programs
None
Based on county population size as follows:
Rural to Small Counties: 30 miles or 45 minutes from the beneficiary’s residence
Medium Counties: 15 miles or 30 minutes from the beneficiary’s residence
Large Counties: 15 miles or 30 minutes from the beneficiary’s residence
Timely Access: Opioid Treatment Programs
Within 3 business days of request

16. Network Certification Key Steps
Periodic re-assessment of the network standards,
Review and approve alternate access requests from counties,
Provide technical assistance to counties,
Analyze and track provider data,
Review provider directories on a monthly basis,
Use geo-mapping software to validate provider data submissions,
Conduct trends analysis based on network adequacy data received developing strategies for addressing shortages in network adequacy,
Conduct stakeholder meetings,
Validate and certify the network capacity of each MHP on an annual basis;
Submit annual assurances to CMS that the MHPs comply with the established network adequacy standards;
Use the network adequacy data to drive statewide quality improvement strategies; and,
Develop and publish on the DHCS website the locations of behavioral health providers, including the various types of services offered at the various provider locations throughout the state

17. Local Implementation Considerations
Timely access: initial vs. continuation of services
Beneficiary request for services
EHR timeliness tracking challenges
Requests for psychiatric services
Network adequacy for managed care plans
Provider shortages and recruitment challenges
Prescribing providers vs. psychiatrists
Methadone provider issues – availability and zoning
Field-based services
Neighboring county providers
Technological access to services (e.g., text based services)
Consequences for non-compliance

18. Network Adequacy Compliance Next Steps
Finalize standards based upon stakeholder input
Develop alternate access standards
Establish county provider data reporting requirements
Develop network certification processes and criteria
Review provider data and certify networks

19. Alternate access standards

20. Alternate Access Standards – Final Rule
Final rule gives flexibility to states to permit exceptions to any of the provider-specific network standards
§438.68(d) Exceptions process. (1) to the extent the State permits an exception to any of the network standards, the standard by which the exception will be evaluated and approved must be:
(i) specified in the contract
(ii) Based, at a minimum, on the number of providers in that specialty practicing in the Plan’s service area
(2) States that grant an exception must monitor enrollee access on an ongoing basis and include the findings in a report provided to CMS

21. Current MCP Alternate Access Standards Process
DHCS has established an Alternate Access Standards (AAS) Request process for MCPs unable to meet current network adequacy standards
Will be modified and adopted for MHPs
Currently applies to Primary Care Physicians, OB-GYNs, and Hospitals
MCPs apply to the Department for alternate access standards for time & distance, timely access, adequacy of specialists, and physician capacity
Requests are reviewed and approved on a case-by-case basis
MCPs must demonstrate efforts to meet network adequacy standards before applying for alternate access
DHCS monitors approved requests to ensure MCP taking all necessary steps to comply with the standards

22. Current MCP AAS Review Criteria – PCP T&D
Address of 10 nearest in-network PCPs
List of nearest providers using DHCS’ provider file data.
Driving times to 10 nearest in-network PCPs accepting new enrollees
Using DMHC’s Timely Access Database list 10 nearest in-network PCPs in specified zip code.
Distance to 10 nearest in-network PCPs accepting new enrollees
MCP Proposed Standards
The alternative standard the MCP requested
Is proposed standard reasonable request based on Google Maps data
Using the information included in the timely Access Database, is the requested alternative standard reasonable. DHCS will consider the geographic region, size, and total members affected when reviewing the request. If the standard is within 5 miles of the nearest PCP, the request does not need additional substantiation.
Request approved/denied
List the approved standard or deny the request. If denied, provide additional comments on reason for the denial.
Comments
Additional comments

23. Current MCP AAS Review Criteria – Timely Access
Requested alternative standard
The alternative standard the MCP requested
Barrier to meeting timely access to appointment standards
Information provided by the MCP that documents and substantiates the request
Request feasible
Is the requested alternative standard reasonable? Based on additional review and analysis, is the information provided by the MCP substantiated and reasonable? Examples of a reasonable request for an alternative timely access standard would be provider shortage due to closing of clinics, lack of specialists, geographic location, etc.
Request approved/denied
List the approved standard or deny the request. If denied, provide additional comments on reason for the denial.
Comments
Additional comments

24. Future AAS Considerations
Alternate Access Requests considerations may include:
Availability of tele-health services
Provider travels to beneficiary to deliver services
Population density within a county
Seasonal considerations

25. Network Adequacy: CBHDA Input

26. CBHDA Input on Proposed Standards
DHCS Network Adequacy Policy Proposal (dated 2/2/17):
CBHDA Comments on DHCS Proposal:

27. Small county Discussion

28. Discussion Questions How are counties reviewing networks?
What staff within your department are critical partners?
What should counties be doing?

29. Discussion Questions
What are areas of concern related to network adequacy (e.g. specific provider type, timeliness requirement, time/distance standard)?
How can these concerns be addressed/mitigated?

30. Discussion Questions – Alternate Access
What are key considerations for the process that may look different for counties than for managed care plans?
What recommendations should small counties make regarding Alternate Access Standard request process?

31. County Strategies, Resources, & next steps

32. Strategies & Resources
Federal and State designations for rural areas
How designation status may increase resources available to counties
Collaborative efforts for recruiting psychiatrists
Are counties currently recruiting for psychiatrists across county lines?
What are the opportunities for further collaboration?
What are opportunities for collaborating with managed care?

33. Conclusion
Final reflections and questions
Next steps

34. Contact Information
CBHDA Contact:
Linnea Koopmans, Senior Policy Analyst
x6018
DHCS Contact:
Autumn Boylan, Section Chief