States Urged to Enforce Network Adequacy Laws for Medicaid Behavioral Health Access

In recent months, individuals like Aiping, a new mother experiencing panic attacks, have faced significant barriers in accessing mental health care through California’s Medi-Cal program. After being advised to seek treatment, Aiping found several in-network providers were either not accepting new patients or had appointments available only months in the future. This situation highlights broader access issues for Medicaid beneficiaries, with nearly 80% of low-income individuals in Medicaid receiving care through managed care plans by 2026.

Federal regulations stipulate that state Medicaid programs must set network adequacy standards, including appointment wait time standards that begin in 2027. These standards mandate that managed care plans must provide outpatient mental health services within 10 business days of a request. Compliance is gauged through secret shopper surveys, where a plan is deemed compliant if 90% of network providers meet the wait time benchmarks.

In California, the 2017 implementation of federal regulations led to established network adequacy standards for Medi-Cal Managed Care Plans. Despite these regulations and recent strengthening of state law, Medi-Cal enrollees frequently report difficulties in finding timely care, particularly for mental health services, as evidenced by a report indicating that Asian Americans and Pacific Islanders face significant challenges.

Recently, California took enforcement measures against ten county-run Behavioral Health Plans for not adhering to timely access standards. The state found multiple violations concerning both mental health and substance use disorder services. As a consequence, it is withholding a portion of capitation payments while monitoring compliance, with possible further penalties if issues persist.

California’s proactive approach demonstrates a necessary step toward addressing the access challenges in Medicaid managed care. Other states are also undertaking evaluations of their network adequacy compliance. In 2022, nine states utilized financial penalties for network inadequacies, although methods of enforcement and corrective actions vary significantly across states. NHeLP advocates for more rigorous compliance monitoring and enforcement across all states administering Medicaid Managed Care services.