Medicaid Managed Care Final Rule Information
The Centers for Medicare and Medicaid Services (CMS) issued the Medicaid and Children's Health Insurance Program (CHIP) Managed Care Final Rule (Final Rule), which aligns the Medicaid managed care program with other health insurance coverage programs. The Final Rule is effective July 5, 2016 and applies to Medi-Cal Managed Care Plans, County Mental Health Plans (MHPs), Drug Medi-Cal Organized Delivery System (DMC-ODS) Pilot Counties, and Dental Managed Care Plans. County MHPs are considered Prepaid Inpatient Health Plans (PIHPs), and must therefore comply with the Final Rule and Mental Health Parity and Addiction Equity Act (MHPAEA) compliance requirements that are included within the Final Rule.
DHCS is implementing policy changes resulting from the Final Rule requirements and the included MHPAEA compliance requirements. The following links and resources are provided to assist county MHPs and stakeholders with accessing general information regarding the Final Rule, California’s MHPAEA Compliance Plan, and related Information Notices.
Any questions pertaining to the contents of this page, or questions regarding the Final Rule and MHPAEA compliance can be directed to MHSDFinalRule@dhcs.ca.gov.
Network Adequacy
The Medicaid Managed Care Final Rule requires states to develop time and distance standards for adult and pediatric behavioral health (mental health and SUDS) providers. Three parts of the Medicaid Managed Care Final Rule comprise the majority of network adequacy standards set forth in Title 42 of the Code of Federal Regulations:
- Part 438.68, Network adequacy standards, requires states to develop time and distance standards for adult and pediatric behavioral health (mental health and SUD treatment) providers.
- Part 438.206, Availability of services, requires the Plans to meet State standards for timely access to care and services, taking into account the urgency of the need for services.
- Part 438.207, Assurances of adequate capacity and services, requires each Plan to submit documentation to DHCS, in a format specified by DHCS, to demonstrate that it complies with the following requirements:
- Offers an appropriate range of services that is adequate for the anticipated number of beneficiaries for the service area (i.e., county); and,
- Maintains a network of providers, operating within the scope of practice under State law, that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of beneficiaries in the services area (i.e., county).
On February 13, 2018, DHCS issued Mental Health and Substance Use Disorder Services (MHSUDS) Information Notice No. 18-011, Federal Network Adequacy Standards for Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Pilot Counties, which identifies network adequacy standards developed pursuant to Title 42 of the Code of Federal Regulations part 438.68, as specified in Chapter 738, Statutes of 2017 (Assembly Bill 205).
DHCS conducted an analysis of the MHP’s specialty mental health services (SMHS) provider network. DHCS reviewed for compliance in the following areas:
- Time and distance – geographic access mapping;
- Alternative Access Standards;
- Network composition and capacity;
- Language assistance capabilities; and,
- System infrastructure.
The results of DHCS' analysis are detailed in the following reports:
Mental Health Plans Network Certification and Network Adequacy Archive
If you have any questions about the network adequacy requirements, please contact DHCS at MHSDFinalRule@dhcs.ca.gov
Return to Mental Health Plan Information Page