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Medi-Cal Managed Care: An Overview and Key Issues

Appendix Table 1: Network Adequacy Standards in Medi-Cal Managed Care
Knox-Keene Act Standardsa Medi-Cal Two-Plan and GMC Contract Standardsb COHS Contract Standardsb
General Requirements
Comprehensive range of primary, specialty, institutional, and ancillary services readily available at reasonable times to all enrollees. Maintain network adequate to serve 60% of all eligible beneficiaries within the service area and provide full scope benefits.

Ensure appropriate provider network, including PCPs, specialists, and other personnel and an adequate number of inpatient facilities within the service area.

Submit a complete provider network adequate to provide covered services to eligible beneficiaries within the service area.

Increase capacity of the network to accommodate growth.

Time and Distance Standards
Primary care and hospital services must be available within 30 minutes or 15 miles of enrollee’s residence or workplace.

Laboratory, pharmacy, and similar services available at locations within a reasonable distance from PCP.

Maintain a network of PCPs located within 30 minutes or 10 miles of a member’s residence unless MCO has an approved alternative standard. Maintain a network of PCPs located within 30 minutes or 10 miles of a member’s residence unless MCO has an approved alternative standard.
Provider-to-Enrollee Ratios and Other Access Standards
·  PCPs: 1: 2,000

·  Total physicians: 1: 1,200

·  Complete network of PCPs and specialists with admitting staff privileges at least one contracting hospital equipped to provide range of basic health care services

·  Emergency 24/7

·  Access to medically required specialists

·  PCPs: 1: 2,000

·  Total physicians: 1: 1,200

·  Non-physicians not to exceed provider/patient caseload of 1: 1,000

·  Emergency services 24/7

·  Adequate number and type of specialists

·  PCPs: 1: 2,000

·  Total physicians: 1: 1,200

·  Non-physicians not to exceed provider/patient caseload of 1: 1,000

·  Emergency services 24/7

·  Adequate number and type of specialists

 

a Title 28, California Code of Regulations, §1300.51.H and §1300.67.2.
b COHS Boilerplate Contract and Two Plan Boilerplate Contract, available at http://www.dhcs.ca.gov/provgovpart/Pages/MMCDBoilerplateContracts.aspx
Appendix Table 2: Timeliness Standards for Appointments in Medi-Cal Managed Care
Type of Appointment Standard for Timeliness
Urgent care, no prior authorization 48 hours*
Urgent care, prior authorization 96 hours
Non-urgent primary care 10 business days of request
Specialist care 15 business days of request
Non-urgent ancillary services for diagnosis or treatment of injury, illness, or other health condition 15 business days of request
First prenatal visit 10 business days
Urgent dental care 72 hours
Non-urgent dental care 36 business days
Preventive dental care 40 business days
* The COHS contract has a more stringent urgent care provision that requires that a member needing urgent care be seen within 24 hours.
Issue Brief

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