Variation in network adequacy standards in Medicaid managed care

To describe the types and breadth of network adequacy standards used by state Medicaid programs with managed care arrangements.

Document analysis of Medicaid provider network reports, managed care plan contracts, access monitoring review plans, Medicaid services manuals, quality strategy reviews, and state statutes and regulations.

We analyzed 52 primary documents from 2017 to 2020, representing 39 of the 40 states (including the District of Columbia) with Medicaid managed care. We conducted descriptive analyses of network adequacy standards, variation in standards by type of provider, timely access standards, nonquantitative network access standards, and monitoring or enforcement plans.

A majority (89.7%) of states applied time and distance standards for network adequacy, stratified by population size or geography. Time and distance standards ranged from 15 to 90 minutes for a primary care provider (mean, 44.7 minutes in rural areas and 28.9 minutes in urban areas) to 30 to 135 minutes for a cardiologist (mean, 72.1 minutes in rural areas and 40.4 minutes in urban areas). Most states also used timely access or appointment availability standards. Relatively few states applied other quantitative standards, such as provider to enrollee ratios, or provided detailed enforcement plans in cases of poor compliance.

Most states use travel time and distance to account for local contexts and geographies, but there is considerable variation across Medicaid programs. Several states do not publicize their network adequacy regulations, or they rely on qualitative standards despite federal requirements. For network adequacy to be meaningful, states must balance the tension between flexibility and accountability and ensure that regulations are monitored and enforced accordingly.