Network inadequacy can create a big headache for health plans, so payers should give special attention to any legislative changes (either proposed or finalized) to these policies. One potential change is related to Medicaid and managed care access standards. Since the overwhelming majority (72%) of Medicaid beneficiaries are also managed care members, these standards could have a big impact on how this population receives care.

Legislation Highlights

In 2023, the Biden administration proposed two pieces of legislation to increase health care access for Medicaid recipients who are children. If approved, one of these regulations would require managed care payers to establish national maximum wait time standards for routine medical visits. This same legislation would also require each state to conduct its own secret shopper surveys to ensure all plans adhere to these new standards.

For the integrity of the surveys, states would need to find a third-party agency to assist with this step. States would also need to administer annual experience surveys with all their enrollees and conduct payment analyses to break down costs for certain medical services. Lastly, in an effort to bring all of these action items together, states would also need to submit remediation reports to resolve any areas in need of fixing.

What This Means for Health Plans

  1. Since current legislation allows some flexibility in defining network adequacy standards for managed care, these new regulations require payers to develop uniform standards. Ratios of providers to enrollees must mesh with time and distance standards and average appointment wait times.
  2. If this legislation is passed, CMS and other governing bodies may express more interest in monitoring practice variations across state lines. This may be for the sake of research, but it will also likely lead to cracking down on provider network compliance.
  3. Keep in mind the range of other factors that influence access to care, specifically within your provider network. This includes provider directory accuracy, transportation bottlenecks, reimbursement rates, and provider supply and capacity.

If you need assistance building your provider network or staying on top of provider credentialing, take advantage of our industry-leading platform and years of expertise in the industry. Reach out to TOG Network Solutions to learn more.