Health Plan network adequacy | NC Medicaid Managed Care

All health plans must meet network adequacy standards. This means that health plans must have enough hospitals and providers for all members to get all covered services in a timely manner.

Some standards are based on time and distance, such as:

Members must be able to get from home to a provider within a certain amount of time or number of miles
Health plans must have a certain number of providers within a certain area

If a provider or service type is not listed, then there is not a network adequacy standard. In this case, health plans must still provide timely access to all providers for all covered services.

Network adequacy standards apply to Standard Plans and Tailored Plans. If the standard differs for each health plan type, then both standards are listed.

An urban county is a county with at least 250 people per square mile. A rural county is a county with less than 250 people per square mile. Rural counties are usually more spread out than urban counties. They may require a longer driving distance than urban counties. The standards are meant to show that difference.

Health Plan time and distance standards
Urban county	Rural county
Primary care
At least 2 providers within 30 minutes or 10 miles for at least 95% of members	At least 2 providers within 30 minutes or 30 miles for at least 95% of members
Specialty care
At least 2 providers (per specialty type) within 30 minutes or 15 miles for at least 95% of members	At least 2 providers (per specialty type) within 60 minutes or 60 miles for at least 95% of members
Hospitals
At least 1 hospital within 30 minutes or 15 miles for at least 95% of members	At least 1 hospital within 30 minutes or 30 miles for at least 95% of members
Pharmacies
At least 2 pharmacies within 30 minutes or 10 miles for at least 95% of members	At least 2 pharmacies within 30 minutes or 30 miles for at least 95% of members
Obstetrics
At least 2 providers within 30 minutes or 10 miles for at least 95% of members	At least 2 providers within 30 minutes or 30 miles for at least 95% of members
Occupational, physical or speech therapists
At least 2 providers (per provider type) within 30 minutes or 10 miles for at least 95% of members	At least 2 providers (per provider type) within 30 minutes or 30 miles for at least 95% of members
Outpatient behavioral health services
At least 2 providers (per service) within 30 minutes or 30 miles for at least 95% of members Research-based behavioral health treatment for Autism Spectrum Disorder (ASD): No standard	At least 2 providers (per service) within 45 minutes or 45 miles for at least 95% of members Research-based behavioral health treatment for Autism Spectrum Disorder (ASD): No standard
Location-based services (behavioral health)
Standard Plans At least 2 providers (per service) within 30 minutes or 30 miles for at least 95% of members Tailored Plan Psychosocial rehabilitation, Substance Abuse Comprehensive Outpatient Treatment (SACOT), Substance Abuse Intensive Outpatient Program (SAIOP), and Outpatient Opioid Treatment (OTP): At least 2 providers (per service) within 30 minutes or 30 miles for at least 95% of members Child and adolescent day treatment services: No standard	Standard Plans At least 2 providers (per service) within 45 minutes or 45 miles for at least 95% of members Tailored Plans Psychosocial rehabilitation, Substance Abuse Comprehensive Outpatient Treatment (SACOT), Substance Abuse Intensive Outpatient Program (SAIOP), and Outpatient Opioid Treatment (OTP): At least 2 providers (per service) within 45 minutes or 45 miles for at least 95% of members Child and adolescent day treatment services: No standard
Crisis services (behavioral health)
Standard Plans At least 1 provider (per service) within each health plan region Tailored Plans Facility-based services: At least 2 facilities within each health plan service area, or 1 facility within each health plan service area per 450,000 total population Facility-based services for children and adolescents: At least 1 provider within each health plan service area Non-hospital medical detoxification (detox): At least 2 providers within each health plan service area Ambulatory detox, ambulatory withdrawal management with extended on-site monitoring, and clinically managed residential withdrawal: At least 1 provider (per service) within each health plan service area Medically supervised detox or Alcohol Drug Abuse Treatment Center (ADATC) detox crisis stabilization: No standard
Inpatient behavioral health services
At least 1 provider (per service) within each health plan service area
Partial hospitalization (behavioral health)
At least 1 provider of partial hospitalization within 30 minutes or 30 miles for at least 95% of members	At least 1 provider of partial hospitalization within 60 minutes or 60 miles for at least 95% of members
All state plan LTSS (except nursing facilities)
At least 2 LTSS provider types (home care providers and home health providers, including home health services, private duty nursing services, personal care services, and hospice services), identified by distinct NPI, accepting new patients available to deliver each state plan LTSS in every county
Nursing facilities
At least 1 nursing facility accepting new patients in every county

Community/mobile services

Tailored Plans

At least 2 providers within each health plan service area

At least 1 provider accepting new patients in every county within each health plan service area

Residential treatment services

Tailored Plans
Residential Treatment Facility Services:

At least 1 licensed provider within each health plan service area

Substance Abuse Medically Monitored Residential Treatment:

At least 1 licensed provider within each health plan service area

Substance Abuse Non-Medical Community Residential Treatment:

Adults: At least 1 licensed provider within each health plan service area
Adolescents: Contract with all Cross Area Service Programs (CASPs) within the health plan service area
Women and children: Contract with all CASPs within the health plan service area

Substance Abuse Halfway House:

Adults: Access to at least 1 male and 1 female program per health plan service area, and access to services for gender non-conforming adults
Adolescents: Access to at least 1 program per health plan service area

Psychiatric Residential Treatment Facilities (PRTFs) and Intermediate Care Facilities for Individuals with Intellectual Disabilities ICF-IID:

No standard

1915(c) HCBS Waiver Services: NC Innovations

Tailored Plans
Community Living and Support, Community Navigator, Community Networking, Residential Supports, Respite, Supported Employment, and Supported Living services:

At least 2 providers (per service) within each health plan service area

Crisis Intervention and Stabilization Support, Day Support, and Financial Support services:

At least 1 provider (per service) within each health plan service area

Assistive Technology Equipment and Supplies, Community Transition, Home Modifications, Individual Directed Goods and Services, Natural Supports Education, Specialized Consultation, and Vehicle Modification services:

No standard

1915(c) HCBS Waiver Services: NC TBI Waiver (TBI Waiver counties only)

Tailored Plans
Community Networking, Life Skills Training, Residential Supports, Resource Facilitation, In-Home Respite, and Supported Employment services:

At least 2 providers (per service) within each health plan service area

Day Support, Cognitive Rehabilitation, and Crisis Intervention and Stabilization Support services:

At least 1 provider (per service) within each health plan service area

Adult Day Health, Assistive Technology Equipment and Supplies, Community Transition, Home Modifications, Natural Supports Education, Occupational Therapy, Physical Therapy, Speech and Language Therapy, and Vehicle Modification services:

No standard

All health plans must meet appointment wait time standards. These standards make sure that health plans have enough providers for members to have access to timely care, based on the urgency of the visit.

Health Plan appointment wait time standards
Description	Standard
Primary care
Preventive care services
Care to prevent illness or injury, such as routine physical exams, immunizations (shots), mammograms and pap smears	Adult, 21 years of age and older: Within 30 days Child, birth through 20 years of age: Within 14 days for members less than 6 months of age Within 30 days for members 6 months of age or older
Urgent care services
Care for a non-emergent illness or injury that needs immediate care, such as sprains, flu symptoms, minor cuts and wounds, sudden stomach pain, and severe headache	Within 24 hours
Routine check-up without symptoms
Care for a routine health visit	Within 30 days
After-hours access – emergent and urgent
Care after normal office hours	Immediately, available 24 hours a day, 7 days a week, 365 days a year
Prenatal care
Initial appointment
Care for a pregnant member to keep the member and future baby healthy, such as check-ups and prenatal testing	First or second trimester: Within 14 days High-risk pregnancy or third trimester: Within 5 days
Specialty care
Urgent care services
Care for a non-emergent illness or injury that needs immediate care, such as sprains, flu symptoms, minor cuts and wounds, sudden stomach pain, and severe headache	Within 24 hours
Routine check-up without symptoms
Care for a routine health visit	Within 30 days
After-hours access – emergent and urgent
Care after normal office hours	Immediately, available 24 hours a day, 7 days a week, 365 days a year
Behavioral health care
Mobile crisis management services
Care to treat mental health crises	Within 2 hours
Facility-based crisis management services
Tailored Plans Care to treat mental health crises for children, adolescents, adults and non-hospital medical detox	Tailored Plans Emergency services available immediately, available 24 hours a day, 7 days a week, 365 days a year
Urgent care services for mental health
Care to treat mental health crises	Within 2 hours
Urgent care services for mental health
Care to treat a condition for a person who could become suicidal or homicidal without immediate help	Within 24 hours
Urgent care services for substance use disorders
Care for a person who has a condition that could become a need for emergent services or care for the use of alcohol or other drugs	Within 24 hours
Routine services for mental health
Care for a person who describes signs and symptoms of impaired behavioral, mental and emotional functioning, affecting the person’s daily life	Standard Plans: Within 14 days Tailored Plans: Within 48 hours
Routine services for substance use disorders
Care for a person who describes signs and symptoms related to using alcohol or other drugs	Within 14 days
Emergency services for mental health
Care for a person who is suicidal, homicidal, actively psychotic, showing disorganized thinking, or having hallucinations and delusions	Immediately, available 24 hours a day, 7 days a week, 365 days a year
Emergency services for substance use disorders
Care for a person who is suicidal, homicidal, actively psychotic, showing disorganized thinking, or having hallucinations and delusions related to using alcohol or other drugs	Immediately, available 24 hours a day, 7 days a week, 365 days a year