Alternative Access Standards and Network Adequacy Standards

Network Adequacy Standards

Provider Type Timely Access Standard Time and Distance Standard by County Size1
Rural Small Medium Dense
Primary care (adult and pediatric) Within 10 business days to appt. from request 10 miles and 30 minutes from any member or anticipated member’s residence
Specialty Care2 (adult and pediatric) Within 15 business days to appt. from request3 60 miles and 90 minutes from any member or anticipated member’s residence 45 miles and 75 minutes from any member or anticipated member’s residence 30 miles and 60 minutes from any member or anticipated member’s residence 15 miles and 30 minutes from any member or anticipated member’s residence
Obstetrics / Gynecology (OB/GYN) Primary Care Within 10 business days to appt. from request 10 miles and 30 minutes from any member or anticipated member’s residence
OB/GYN Specialty Care Within 15 business days to appt. from request3 60 miles and 90 minutes from any member or anticipated member’s residence 45 miles and 75 minutes from any member or anticipated member’s residence 30 miles and 60 minutes from any member or anticipated member’s residence 15 miles and 30 minutes from any member or anticipated member’s residence
Hospitals Not Applicable 15 miles and 30 minutes from any member or anticipated member’s residence
Pharmacy Dispensing of at least a 72hour supply of covered outpatient drug in an emergency situation 10 miles and 30 minutes from any member or anticipated member’s residence
Mental Health (non-psychiatry) Outpatient Services4 (adult and pediatric) Within 10 business days to apt. from request 60 miles and 90 minutes from any member or anticipated member’s residence 45 miles and 75 minutes from any member or anticipated member’s residence 30 miles and 60 minutes from any member or anticipated member’s residence 15 miles and 30 minutes from any member or anticipated member’s residence
Ancillary Services Within 15 business days to appt. from request Not Applicable
Long Term Services and Supports (LTSS) If applicable5 Time and distance standards are not established for Multipurpose Senior Services Program (MSSP),Skilled Nursing Facilities (SNF), or Intermediate Care Facilities (ICF) providers as these providers either travel to the member to provide services or the member resides at the facility for care.

1 County Size Category by Population defined in Table 1
2 Time and Distance Standards apply to the core specialists outlined in Table 2
3 Timely Access standards apply to all specialists, not only core specialists
4 Non-specialty mental health services for members with mild to moderate impairments
5 LTSS Timely Access Network Standards defined in Table 3

Table 1: County Size Categories by Population

Size Category Population Density # of counties Counties
Rural ≤50 people per square mile 21 Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa,Mendocino, Modoc, Mono, Plumas, San Benito,Shasta, Sierra, Siskiyou, Tehama, Tuolumne, Trinity
Small 51 to 200 people per square mile 19 Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa, Barbara, Sutter, Tulare, Yolo, Yuba
Medium 201 to 599 people per square mile 9 Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, Ventura
Dense ≥600 people per square mile 9 Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, Santa Clara

Table 2: DHCS Adult and Pediatric Core Specialists

Cardiology/Interventional Cardiology Nephrology
Dermatology Neurology
Endocrinology Oncology
ENT/Otolaryngology Ophthalmology
Gastroenterology Orthopedic Surgery
General Surgery Physical Medicine and Rehabilitation
Hematology Psychiatry
HIV/AIDS Specialists/Infectious Diseases Pulmonology

Table 3: LTSS Timely Access Network Standards

Provider Type Time and Distance Standard by County Size1
Rural Small Medium Dense
SNF Within 14 calendar days of request Within 14 calendar days of request Within 7 business days of request Within 5 business days of request
Intermediate Care Facility/Developmentally Disabled (ICF-DD) Within 14 calendar days of request Within 14 calendar days of request Within 7 business days of request Within 5 business days of request
Community Based Adult Services (CBAS) Capacity cannot decrease in aggregate statewide below April 2012 level

Table 4: Call Center Wait Time Standards

Medi-Cal Managed Care Health Plan (MCP) Call Center 10 minutes from the time the call is placed

Approved Alternative Access Standards

Download a .pdf document with the DHCS approved Alternative Access Standards for Blue Shield Promise Health Plan.

San Diego County (PDF, 1 MB)

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