Aiping recently gave birth to her first child. Since then, she has been experiencing sudden and intense symptoms, including chest pain, shortness of breath, and heart palpitations. After the third time this happened, Aiping went to the emergency room. The doctor there told Aiping that she was experiencing a panic attack, not a cardiac event. He advised her to consider seeking mental health treatment, noting that she might be experiencing a postpregnancy mental health condition. Luckily, Aiping has Medi-Cal, California’s Medicaid program. She called her Medi-Cal plan to get a referral to an in-network mental health provider for her treatment. However, the first three providers she called told her they were not accepting new patients, the next provider’s first appointment was in four months, and the final provider had no availability for more than six months. Aiping made the first appointment she could, four months out. In the meantime, she has continued to experience panic attacks. She is not sure she’ll be able to manage her symptoms while she waits to get care, especially while she cares for her newborn.
In 2026, nearly 80% of low-income people in Medicaid receive their health care through a Medicaid Managed Care plan. Yet too often, people like Aiping who are enrolled in Medicaid Managed Care plans struggle to find health care providers who can deliver the care they need in a timely and accessible manner. States set standards, following federal regulations, to make sure that managed care plans provider networks are broad enough to offer timely and accessible care to all enrollees. Unfortunately, just setting standards is not enough. Rather, states must set robust standards and then actively monitor compliance and take corrective action when plans fall short.
Federal regulations require state Medicaid programs to set network adequacy standards for Medicaid Managed Care plans in their state, including, starting in 2027, “appointment wait time” standards. Appointment wait time standards, also known as timely access standards, require managed care plans to provide health appointments within a particular time period. For example, the federal regulations require Medicaid Managed Care plans to make outpatient mental health and substance use disorder services available within 10 business days of a request for care (states can set more stringent standards for plans in their state if they choose). Under the regulation, plans are considered compliant if the results of a secret shopper survey show that 90% of network providers meet the applicable wait time standard.
By example, in California, the legislature in 2017 implemented the federal regulations by establishing network adequacy standards for Medi-Cal Managed Care Plans. Those standards, encoded in state law, include time and distance standards for Medi-Cal enrollees to obtain primary care, certain specialty, mental health, dental, and pharmacy services, as well as appointment wait time standards. The state re-affirmed and strengthened those statutory standards last year. Despite the strong standards in state law, Medi-Cal managed care enrollees like Aiping frequently report difficulty finding a provider. A recent report found that many people in Medi-Cal faced barriers to accessing covered mental health services, and that Asian Americans and Pacific Islanders had a particularly difficult time finding providers to deliver covered mental health care.
Last month, California took action to address persistent network adequacy violations in Medi-Cal plans. The state announced that it was taking enforcement actions against ten county-run Behavioral Health Plans for failing to comply with the state’s timely access standards. In California, county Behavioral Health Plans are responsible for providing certain specialty mental health and substance use disorder services to people in Medi-Cal. The state found that six plans failed to provide timely access to covered mental health services, three plans failed to provide timely access to covered substance use disorder services, and one plan failed to provide timely access to both covered mental health and substance use disorder services. In all cases, the state had previously cited the plan for failing to provide timely access, but the plan failed to resolve the issue. The state will temporarily withhold a portion of its capitation payments to the ten plans while the state engages in a period of enhanced monitoring; the payments can be returned to the plans if they are able to come into compliance. If the plans remain out of compliance, the funds may be permanently withheld, and the state may impose additional penalties, including monetary sanctions.
California’s actions are an important step to address real access problems faced by Medicaid managed care enrollees, whether the plans are specific behavioral health plans or plans that are responsible for all physical and behavioral health needs. And the state is not alone. At least 24 states have already implemented secret shopper surveys in anticipation of the rollout of federally required wait time standards. The results from these “secret shopper” surveys consistently fall far short of the new standards. A 2023 report by the Kaiser Family Foundation found that 9 states had used financial penalties to address network adequacy failures in 2022. However, the Medicaid and CHIP Access and Payment Commission (MACPAC) has found that state strategies to determine compliance with network adequacy standards vary widely, as do their approaches to corrective action and enforcement. Often, monetary sanctions are low and may do little to effect improvements at the plan level. NHeLP encourages all states that deliver services through Medicaid Managed Care to closely monitor plans’ compliance with network adequacy standards, and to take enforcement actions when plans fail to comply with those standards.
