Access to Provider Networks and Covered Services

Successful ACOs ensure that members have reliable access to a sufficient provider network and that providers can meet members’ needs, as well as ensuring members have access to care across the continuum, including a full range of long-term services and supports, substance use disorders and mental illness services, peer recovery supports and oral health services.

Does your state Medicaid ACO program do the following to ensure members can consistently access their chosen providers?

  • Ensure that members can choose their primary care provider.

  • Create clear policies on how consumers may access providers outside of the ACO network.

  • Provide protections to allow for continuity of care when a provider leaves an ACO network. If this occurs, consumers should be notified in advance of the change and provided with an option to continue seeking treatment from the provider out-of-network.

  • Ensure continuity of care when a consumer joins an ACO. While many Medicaid ACOs allow Consumers to maintain relationships with their existing providers for 60 days, our experience working with complex populations suggests this is not enough time for people who depend on an existing provider to help them manage their complicated health and social needs. We suggest ACOs allow consumers to maintain a relationship with an existing provider for a minimum of 180 days or up to one year, for consumers with complex health and social needs.

Does your state Medicaid ACO program do the following to ensure a sufficient number of easily accessible providers?

  • Implement strategies to encourage safety-net provider participation.

  • Regularly assess patient’s access to needed services as part of a robust quality strategy that includes patient-reported information.

  • Take into account travel time and public transportation access when determining network adequacy, the ability of a health plan to meet its enrollees’ medical needs through in-network health care providers and services. Time and distance standards help guarantee that consumers can access conveniently located health care providers. In an “inadequate” network, consumers must travel long distances or wait for long periods of time before they can receive care from an in-network provider.

    • Communities of color face additional barriers in accessing health care. To meet the needs of these communities, network adequacy standards beyond time and distance should be enacted. These additional standards could include: offering a variety of providers including essential community providers; providers serving the community where members live; operating services during accessible hours; providing culturally sensitive care.

    • People with substance use disorders and/or mental illness also face significant barriers in accessing care. Accessing care quickly can be a matter of life and death, and delayed access can mean a lost opportunity for engagement in treatment. Network adequacy standards must take this into account. For further specific recommendations, see this report from the National Council on Behavioral Healt

    • Distance standards are often not appropriate for long-term services and supports provided in the home. In these cases, time standards may be more important, along with measurement of service gaps.  States should solicit stakeholder input in devising network adequacy standards for long-term services and supports, and ensure those standards support consumer choice of providers and community living.

Does your state Medicaid ACO program do the following to ensure members can access health services that meet their needs

  • Fully integrate services for substance use disorders, mental illness, long-term services and supports, oral health, vision health, and other medical conditions.

  • Ensure provider networks are compliant with the Americans with Disabilities Act (ADA). This means ensuring physical and programmatic accessibility, including appropriate scheduling, communication on medical information, and provider staff training and knowledge. The Disability Competent Care Self-Assessment Tool can be used to determine the accessibility of services. 

    • Partners for Kids, an Ohio ACO serving children with disabilities and complex health needs, has found innovative ways to provide care coordination and health services for this population.


NEXT » Strong Consumer Protections