Access to Care and Availability Standards
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net's access and availability policies, procedures and guidelines for physicians, other providers and health care facilities providing primary care, specialty care, behavioral health care, and ancillary services are in accordance with applicable federal and state regulations, contractual requirements, and accreditation standards. These access standards are regulated by the California Department of Insurance (CDI) and comply with the National Committee for Quality Assurance (NCQA).
Note: Behavioral health and chemical dependency services are administered by Health Net.
Health Net and its participating physicians and other providers are required to demonstrate that, throughout the geographic regions for Health Net's service area, a comprehensive range of primary, specialty, institutional, and ancillary care services are readily available and accessible at reasonable times to all Health Net members. Additionally, Health Net and its participating physicians and other providers are required to demonstrate that members have access to non-discriminatory and appropriate covered health care services within a reasonable period of time, appropriate for the nature of the member's condition and consistent with good professional practice. This includes, but is not limited to, physician/provider availability, waiting time and appointment access with established time-elapsed standards.
The following information delineates the medical appointment access standards, triage and/or screening access requirements and telephonic access to health care services and the monitoring activities to ensure compliance.
Member Notification
Members are notified annually, via member newsletters or the Evidence of Coverage (EOC), of time-elapsed appointment access standards, the availability of triage or screening services and how to obtain these services.
Primary Care Physician and Specialist Office Hours
As required by applicable federal and state statutes and regulations, primary care physician (PCP) and specialty care practitioner (SCP) office hours must be reasonable, convenient and sufficient to ensure that they do not discriminate against members and members are able to access care within established time-elapsed access standards. PCP and SCP office hours must be posted in the physician's or other provider's office. Health Net requires a PCP practice to be open at least 20 hours per week and an SCP practice to be open at least 16 hours per week for members to schedule appointments within established appointment access standards. During evenings, weekends and holidays, or whenever the office is closed, an answering service or answering machine should be utilized to provide members with clear and simple instruction on after-hours access to medical care.
Behavioral Health Facility Access and Availability
Per their contract with Health Net, network facilities should be available and accessible to members during reasonable hours of operation. Emergency care, where applicable, should also be available and accessible 24 hours a day. Facility information regarding hours of operation is collected every two years via Health Net’s facility application for recredentialing. Facilities must notify Health Net of any changes in their hours of operation or lapses in accessibility or availability as needed.
After-Hours Access Guidelines
As required by applicable statutes, Health Net's participating physicians and other providers must ensure that, when medically necessary, they have medical services available and accessible to members 24 hours a day, seven days a week, and PCPs are required to have an appropriately licensed professional back up for absences. Participating physician groups (PPGs) and PCPs who do not have services available 24 hours a day may use an answering service or answering machine to provide members with clear and simple instruction on after-hours access to medical care (urgent/emergency medical care).
PCPs (or on-call physicians) must return phone calls and pages within 30 minutes and be available 24 hours a day, seven days a week. The PCP or on-call physician designee must provide urgent and emergency care. The member must be transferred to an urgent care center or hospital emergency room, as medically necessary.
Additionally, Health Net provides triage and screening services 24 hours a day, seven days a week through medical/nurse advice lines. Refer to the Triage and Screening Services/Advice Lines section below for further information.
Note: Although Health Net does not delegate triage and screening services, PCPs are still required to comply with these after-hours requirements since medically necessary services are required to be available and accessible 24 hours a day, seven days a week.
After-Hours Sample Scripts
In times of high stress, when members may have an urgent or emergent situation, it is important to provide clear messaging with call-back time frames and directions on how to access urgent and emergency care to prevent potential quality of care issues. Directing members to the appropriate level of care using simple and comprehensive instructions can improve the coordination and continuity of the member's care, health outcomes and satisfaction. Health Net has designed an after-hours script template that PPGs or physicians who have a centralized triage service or other answering service can utilize as a guide for staff answering the phone. For PPGs or physicians who use an automated answering system, this template can be used as a script to advise members on how to access care. Health Net's after-hours scripts provide easy to use messaging examples on how to direct members to emergency care services and who to talk to when they need urgent medical advice.
Health Net makes the script in the following threshold languages:
After-hours scripts are available in additional languages upon request. Contact the Provider Network Management, Access and Availability Team for more information.
Answering Services
Physicians and other providers are responsible for the answering service they use. If a member calls after hours or on a weekend for a possible medical emergency, the physician or other provider is held liable for authorization of, or referral to, emergency care given by the answering service. There must be a message immediately stating, "If this is an emergency, hang up and call 911 or go to the nearest emergency room."
Answering service staff handling member calls cannot provide phone medical advice if they are not a licensed, certified or registered health care professional. Staff members may ask questions on behalf of a licensed professional in order to help ascertain the condition of the member so that the member can be referred to licensed staff; however, they are not permitted, under any circumstance, to use the answers to questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of the member, or to determine when a member needs to be seen by a licensed medical professional. Unlicensed phone staff should have clear instructions on the parameters relating to the use of answers in assisting a licensed physician or other provider.
Additionally, non-licensed, non-certified or non-registered health care staff cannot use a title or designation when speaking to a member that may cause a reasonable person to believe that the staff member is a licensed, certified or registered health care professional.
Health Net encourages answering services follow these steps when receiving a call:
- Inform the member that, if they are experiencing a medical emergency, they should hang up and call 911 or proceed to the nearest emergency medical facility.
- If language assistance is needed, offer the member interpreter services.
- Question the member according to the PCP's or PPG's established instructions (who, what, when, and where) to assess the nature and extent of the problem.
- Contact the on-call physician with the facts as stated by the member.
- After office hours, physicians are required to return phone calls and pages within 30 minutes. If an on-call physician cannot be reached, direct the member to a medical facility where emergency or urgent care treatment can be given. This is considered authorization, which is binding and cannot be retracted.
In the event of a hospitalization, the PPG or hospital must contact Hospital Notification Unit within 24 hours or the next business day of the admission.
The answering service should document all calls. Answering services frequently have a high staff turnover, so physicians and other providers should monitor the answering service to ensure emergency procedures are followed.
Triage and/or Screening Services/Nurse Advice Lines
As defined in 28 CCR 1300.67.2.2(b)(5), Health Net provides 24-hour-a-day, seven-day-a-week triage or screening services by phone. This program is a service offered in conjunction with the PCP and does not replace the PCP's instruction, assessment and advice. According to community access-to-care standards, all PCPs must provide 24-hour phone service for urgent/emergent instructions, medical condition assessment and advice. The Health Net Member Services Department coordinates member access to the service, if necessary.
The program allows registered nurses (RNs) and other applicable licensed health care professionals to assess a member's medical condition and, through conversation with the caller, take further action, and provide instruction on home and care techniques and general health information.
Health Net ensures that phone triage or screening services are provided in a timely manner appropriate for the member's condition, and the triage or screening wait time does not exceed 30 minutes. Health Net provides triage or screening services through a contracted medical/nurse advice line. Health Net members can access these services by contacting the Nurse Advice Line phone number on the back of their ID cards.
Facility Access for the Disabled
Health Net and its participating physicians and other providers do not discriminate against members who have physical disabilities. Participating physicians and other providers are required to provide reasonable access for disabled members in accordance with the Americans with Disabilities Act of 1990 (ADA). Access generally includes ramps, elevators, restroom equipment, designated parking spaces, and drinking fountain design.
Physicians and other providers are to reasonably accommodate members and ensure that programs and services are as accessible (including physical and geographic access) to members with disabilities as they are to members without disabilities. Physicians and other providers must have written policies and procedures to ensure appropriate access, including ensuring physical, communication and programmatic barriers do not inhibit members with disabilities from obtaining all covered services.
Appointment and Referrals
PPO members may seek care through participating physicians and other providers or out-of-network physicians/providers according to their benefit plans.
Missed Appointments
According to Health Net's Medical Records Documentation Standards policies and procedures (KK47-121230), missed appointment follow-up and outreach efforts to reschedule must be documented in the member's record.
Appointment Rescheduling
According to new timely access regulations (28 CCR 1300.67.2.2) and to Health Net's Medical Records Documentation Standards policy and procedure (KK47-121230), when it is necessary for a physician, other provider or a member to reschedule an appointment, the appointment must be rescheduled promptly; in a manner that is appropriate for the member's health care needs. Efforts to reschedule the appointment must ensure continuity of care and be consistent with good professional practice and with the objectives of Health Net's access and availability policies and procedures.
Shortening or Extending Appointment Waiting Time
The applicable waiting time for a particular appointment may be shortened or extended by the referring or treating licensed health care physician or other provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice. If the applicable licensed health care physician or other provider has determined to extend the appointment wait time, the physician or other provider must document in the member's record that a longer waiting time will not have a detrimental impact on the member's health, as well as the date and time of the appointment offered.
Emergency and Urgent Care Services
Emergency and urgent care services are available and accessible to members within Health Net's service area 24 hours a day, seven days a week.
Providing Emergency and Urgent Care Services in the PCP's Office
The physician, registered nurse (RN) or physician assistant (PA) on duty is responsible for evaluating emergency and urgent care members in the office and making the decision to further evaluate and treat, summon an ambulance for transport to the nearest emergency room, directly admit to the hospital, or refer to a same-day visit with another physician/provider or urgent care facility.
Provider Phone Assessment
Phone assessment of a member's condition, and subsequent follow-up, may only be performed by licensed staff (physicians, RNs and nurse practitioners (NPs)) and only in accordance with established standards of practice.
Telehealth
Telehealth services are subject to the requirements and conditions of the enrollee benefit plan and the contract entered into between Health Net and its participating physicians and other providers. Prior to the delivery of health care via telehealth, the participating physician or other provider at the original site must verbally inform the member that telehealth services may be used and obtain verbal consent from the member. The verbal consent must be documented in the member's medical record. To the extent that telehealth services are provided as described herein and as defined in Section 2290.5(a) of the Business & Professions Code, Section 1374.13 of the Health and Safety Code, and Sections 14132.72 and 14132.725 of the Welfare and Institutions Code, these telehealth services comply with the established appointment access standards.
Interpreter Services
In order to comply with applicable federal and state laws and regulations, Health Net requires physicians and other providers to coordinate interpreter services with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment. If an appointment is rescheduled, it is very important to reschedule the interpreter for the time of the new appointment to ensure the member is provided with these services.
Cultural Considerations
Health Net and its participating physicians and other providers must ensure that services are provided in a culturally competent manner to all members, including those who are limited-English proficient (LEP) or have limited reading skills, and those from diverse cultural and ethnic backgrounds. Refer to Language Assistance and Cultural Competency (Hospitals) for more information.
Minor Consent Services
As defined in 42 CFR 2.14(a) the term "minor" means a person who has not attained the age of majority specified in the applicable state law, or if no age of majority is specified in the applicable state law, age 18 years.
Under California state law, minor consent services are those covered services of a sensitive nature that minors do not need parental consent to access or obtain. The health care practitioner is not permitted to inform a parent or legal guardian without the minor's consent. Minors under age 18 may consent to medical care related to:
- Prevention or treatment of pregnancy (except sterilization) - California Family Code (CFC) § 6925.
- Family planning services, including the right to receive birth control – CFC § 6925.
- Abortion services (without parental consent or court permission) - American Academy of Pediatrics (AAP) v. Lungren, 16 Cal. 4th 307 (1997).
- Sexual assault, including rape diagnosis, treatment and collection of medical evidence; however, the treating physician or other provider must attempt to contact the minor's parent/legal guardian and note in the minor's treatment record the date and time of the attempted contact and whether or not it was successful. This provision does not apply if the treating physician or other provider reasonably believes that the minor's parent or guardian committed the sexual assault on the minor or if the minor is over age 12 and treated for rape - CFC §6927 and CFC §6928.
- HIV testing and counseling (for children ages 12 and older) – CFC § 6926.
- Infectious, contagious, communicable, and sexually transmitted diseases diagnosis and treatment (for children ages 12 and older) – CFC § 6926.
- Drug or alcohol abuse (for children ages 12 and older) treatment and counseling except for replacement narcotic abuse treatment – CFC § 6926(b).
- Outpatient behavioral health treatment or counseling services (for children ages 12 and older) if in the opinion of the attending physician or other provider the minor is mature enough to participate intelligently in the outpatient or residential shelter services – CFC § 6924.
- Skeletal X-ray - a health care physician or other provider may take skeletal X-rays of a child without the consent of the child's parent/legal guardian, but only for the purposes of diagnosing the case as one of possible child abuse or neglect and determining the extent of it - Cal. Penal Code §11171.
- General medical, psychiatric or dental care if all of the following conditions are satisfied: (1) The minor is age 15 or older, (2) The minor is living separate and apart from their parents or guardian, whether with or without the consent of a parent or guardian and regardless of the duration of the separate residence, (3) The minor is managing their own financial affairs, regardless of the source of the minor's income. If the minor is an emancipated minor they may consent to medical, dental and psychiatric care - CFC § 6922(a) and§ 7050(e).
Minor’s consent for services – Mental health services
Members aged 12 or older may consent to mental health treatment or counseling on an outpatient basis, or to residential shelter services, if the minor, in the opinion of the attending professional, is mature enough to participate intelligently in the outpatient services or residential shelter services.
A professional offering residential shelter services, whether as an individual or as a representative of an entity, shall make their best efforts to notify the parent or guardian of the provision of services.
Mental health treatment or counseling of a minor must include involvement of the minor’s parent or guardian unless the professional treating or counseling the minor, after consulting with the minor, determines that such involvement would be inappropriate. The professional must document in the client record whether and when they attempted to contact the minor’s parent or guardian, and whether the attempt was successful or unsuccessful, or the reason why, in their professional opinion, it would be inappropriate to contact the parent or guardian.
The minor’s parents or guardian are not liable for payment for mental health treatment or counseling services unless they participate in the treatment or counseling, and then only for services rendered with their participation. The minor’s parents or guardian are not liable for payment for any residential shelter services provided under this section unless they consented to the provision of those services.
This section does not authorize a minor to receive convulsive therapy or psychosurgery, as defined in subdivisions (f) and (g) of Section 5325 of the Welfare and Institutions Code, or psychotropic drugs without the consent of the minor’s parent or guardian.
Prior Authorization Processes
Health Net requires prior authorizations to be processed and completed in a manner that assures appointments for covered health care services are provided in a timely manner, appropriate to the member's condition and comply with the requirements of the time-elapsed appointment access standards. If the appointment type requires prior authorization, obtaining authorization must be completed within the time frame for that visit or service to be offered. For example, expedited utilization management review processes and appointment scheduling for urgent care appointments for services that require prior authorization, [28 CCR 1300.67.2.2(c)(5)(B)], more commonly known as urgent pre-service requests, must be conducted concurrently, or the prior authorization turnaround timeline must be shortened to allow sufficient time to communicate the outcome to the member and/or the referring physician or other provider and ensure an appointment is offered to the member within 96 hours of the request. Refer to Prior Authorization for more information.
Quality Assurance
Health Net has a documented system for monitoring and evaluating practitioner/provider availability and accessibility of care. At least annually, Health Net monitors appointment access to care and provider availability standards through member and provider surveys. At least quarterly, Health Net reviews and evaluates the information available to Health Net regarding accessibility, availability and continuity of care, through information obtained from appeals and grievances, triage or screening services, and customer service phone access to measure performance, confirm compliance and ensure the provider network is sufficient to provide appropriate accessibility, availability and continuity of care to Health Net members.
Health Net’s participating providers (including delegated providers) are contractually required to participate in all timely access or accreditation surveys and studies administered by or on behalf of regulatory agencies such as DHCS, DMHC and Centers for the Medicare & Medicaid Services (CMS).
At least on a quarterly basis, Health Net will review reports from the Quality Improvement Department regarding Incidents of non-compliance resulting in substantial harm to an enrollee that are related to access. Health Net will address areas related to network non-compliance with the regional Provider Network Management teams. Corrective actions will be implemented as applicable.
PPGs are responsible for monitoring data provided by Health Net regarding their provider adherence to the following standards, as corrective actions may be required of providers that do not comply. Refer to the Corrective Action section below for further information.
Health Net's performance goals for access-related, time-elapsed provider criteria are available for providers' reference.
Monitoring and Reporting
Health Net collects and analyzes all data to identify opportunities for improvement, which is communicated to the appropriate quality committee or department to review for recommendations. Health Net implements plan-wide corrective actions based on its assessment as indicated. Plan-level results and applicable actions for improvement are communicated to practitioners, providers and PPGs through the Quality Improvement Committee.
At least annually, Health Net conducts provider surveys to measure and evaluate member access. Listed below are Health Net's performance goals for access-related, time-elapsed provider criteria:
Health Net PPO Plans Medical Appointment Access Standards
ACCESS MEASURE | STANDARD | PERFORMANCE GOAL |
|---|---|---|
Non-urgent appointments for primary care - regular and routine care (PCP) | Appointment within 10 business days of request | 70% |
Urgent care (PCP) services that do not require prior authorization | Appointment within 48 hours of request | 70% |
Non-urgent appointments with specialist (SCP) | Appointment within 15 business days of request | 70% |
Urgent care services (SCP and other) that require prior authorization | Appointment within 96 hours of request | 70% |
After-hours care (PCP) | Ability to contact on-call physician after hours within 30 minutes for urgent issues. Appropriate after hours emergency instructions | 90% |
Non-urgent ancillary services for MRI/mammogram/physical therapy | Appointment within 15 business days of request | 70% |
In-office wait time for scheduled appointments (PCP and SCP) | Not to exceed 30 minutes | 70% |
Compliance is measured by results from the Provider Appointment Availability Survey (PAAS) and Provider After-Hours Availability Survey (PAHAS) conducted via phone by Health Net and the Consumer Assessment of Health Care Providers & Systems (CAHPS®1) survey.
1CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Health Net Commercial (HMO, POS, PPO) Plans Appointment Access Standards – Behavioral Health
ACCESS MEASURE | STANDARD | PERFORMANCE GOAL |
|---|---|---|
Urgent care1 | Within 48 hours | 90% or more of members with a clinical risk rating of urgent have access to urgent appointments within 48 hours |
Non-life threatening emergency (NLTE)1 | Within 6 hours | 90% or more of members with a clinical risk rating of NLTE have access to an appointment within 6 hours |
Access to care for life-threatening emergency1 | Immediately | 100% compliance with immediate referral to care |
Rescheduled Appointments2 | Appointment was scheduled to member's satisfaction | 85% or more of members report their appointment was rescheduled to their satisfaction |
Non-urgent appointments with behavioral health care physician (psychiatrist) for routine care3 | Appointment within 15 business days of request | 70% |
Non-urgent appointment with non-physician behavioral health care provider for routine care3 | Appointment within 10 business days of request | 70% |
Urgent care appointment with non-physician behavioral health care provider or behavioral health care physician (psychiatrist) that does not require prior authorization3 | Appointment within 48 hours of request | 70% |
Urgent care appointment with non-physician behavioral health care provider or behavioral health care physician (psychiatrist) that requires prior authorization3 | Appointment within 96 hours of request | 70% |
Non-urgent follow-up appointment with non-physician behavioral health care provider3 | Within 10 business days of request | 80% |
1Assessed through care management software.
2Assessed through annual BH member experience survey (ECHO).
3Assessed through annual Provider Appointment Availability Survey (PAAS).
Corrective Action
Health Net investigates and implements corrective action when timely access to care standards, as required by Health Net's Appointment Accessibility for all lines of business appointment access policy and procedure (CA.NM.05), is not met.
Health Net uses the following criteria to identify PPGs with patterns of noncompliance and will issue a corrective action plan (CAP) when one or more metrics are noted as being noncompliant:
- Appointment access - PPGs that do not meet Health Net's 70% rate of compliance/performance goal in one or more of the appointment access metrics.
- After-hours access - PPGs that do not meet Health Net's 90% rate of compliance/performance goal in one or more of the after-hours metrics.
PPG Notification of CAP
Health Net provides the following:
- PPGs receive a description of the identified deficiencies, the rationale for the corrective action and the contact information of the person authorized to respond to provider concerns regarding the corrective action.
- Feedback to the PPGs regarding the accessibility of primary care, specialty care and phone services, as necessary.
CAP Minimum Requirements
- Each PPG is required to send in a written improvement plan to include what interventions will be implemented for each deficiency to improve access availability. The improvement plan must include:
- Date of implementation of the improvement plan.
- Department/person responsible for the implementation and follow-up of the improvement plan.
- Anticipated date that the improvement plan is expected to produce outcomes that result in correcting the deficiency.
- The PPG is to return the improvement plan within 30 calendar days.
- The PPG is to return the signed Provider Notification of Timely Access Results Attestation that attests that the PPG has notified their providers of their individual results and of their responsibilities of compliance related to timely access.
- Providers and PPGs deemed non-compliant will be encouraged to attend a Timely Access Provider Training session as part of the CAP process. Health Net will notify all non-compliant providers/PPGs of the training schedule and will suggest that the provider/PPG sign up for one session. Attendance at the training will be documented. A "Timely Access Provider Training" certificate must be completed after attending the training.
CAP Follow-Up Process
- If the PPG fails to return a completed improvement plan within the prescribed time frame, the Provider Network Management Department is asked to intercede.
- PPGs demonstrating a pattern of noncompliance with access regulations and standards are subject to an in-office audit and may be referred to Provider Network Management and the Contracting departments for further action.
Availability Corrective Action
Health Net collects and analyzes all data to identify opportunities for improvement, which is communicated to the appropriate quality committee or department to review for recommendations. Health Net implements plan-wide corrective actions based on its assessment. These results and applicable actions for improvement are communicated to practitioners, providers and PPGs through the Quality Improvement Committee or through the activities of Provider Network Management.
Availability Standards
Health Net provides established availability standards and performance goals for providers. At least annually, Health Net measures, evaluates and reports geo-access and provider availability. Listed as follows are Health Net's performance goals for geo-access and provider availability-related criteria:
Health Net PPO and Ambetter PPO Geo-Access Standards
Provider Type | DMHC |
|---|---|
PCP | 15 miles/30 minutes* |
Hospital | 15 miles/30 minutes* |
Ancillary | reasonable distance from PCP |
*Time or distance standards are from the members’ residence.
There are no DMHC regulatory standards for Ancillary, other than reasonable distance. Health Net has set the following standards for Ancillary to be reviewed at 90 percent within 15 miles or 30 minutes from the PCP locations.
DMHC County Size Categories by Population | ||||
|---|---|---|---|---|
COUNTY | DESIGNATION | COUNTY | DESIGNATION | |
Alameda | Large Metro | Orange | Large Metro | |
Alpine | CEAC | Placer | Metro | |
Amador | Micro | Plumas | CEAC | |
Butte | Metro | Riverside | Metro | |
Calaveras | Rural | Sacramento | Large Metro | |
Colusa | Rural | San Benito | Micro | |
Contra Costa | Large Metro | San Bernardino | Metro | |
Del Norte | Rural | San Diego | Metro | |
El Dorado | Metro | San Francisco | Large Metro | |
Fresno | Metro | San Joaquin | Metro | |
Glenn | Rural | San Luis Obispo | Metro | |
Humboldt | Micro | San Mateo | Large Metro | |
Imperial | Micro | Santa Barbara | Metro | |
Inyo | CEAC | Santa Clara | Large Metro | |
Kern | Metro | Santa Cruz | Metro | |
Kings | Metro | Shasta | Micro | |
Lake | Micro | Sierra | CEAC | |
Lassen | CEAC | Siskiyou | CEAC | |
Los Angeles | Large Metro | Solano | Metro | |
Madera | Micro | Sonoma | Metro | |
Marin | Metro | Stanislaus | Metro | |
Mariposa | Rural | Sutter | Metro | |
Mendocino | Micro | Tehama | Micro | |
Merced | Metro | Trinity | CEAC | |
Modoc | CEAC | Tulare | Metro | |
Mono | CEAC | Tuolumne | Micro | |
Monterey | Metro | Ventura | Metro | |
Napa | Metro | Yolo | Metro | |
Nevada | Metro | Yuba | Metro | |
Specialist 90% Threshold
Standard in Miles
County Designation | Specialist Group 1 | Specialist Group 2 |
|---|---|---|
Large Metro | 15^ | 15^^ |
Metro | 20* | 25* |
Micro | 55 | 65 |
Rural | 55 | 65 |
CEAC | 100 | 125 |
Specialist Group 1: cardiovascular disease, dermatology, gastroenterology, neurology, obstetrics/gynecology, oncology, ophthalmology, podiatry, pulmonology, surgery-general, and surgery-orthopedic.
Specialist Group 2: allergy/immunology, endocrinology, hematology, nephrology, otolaryngology, pain medicine, physical medicine and rehabilitation, radiation oncology, rheumatology, and urology.
DMHC has options for Alternative Low Density Zip Standard – when applicable:
- Large Metro County – ^20 and ^^35 miles
- Metro County – *35 and **45 miles
Mental Health 90% Threshold
Standard in Miles
County Designation | Psychiatrist | MHP | MHF |
|---|---|---|---|
Large Metro | 15* | 15 | 15^ |
Metro | 20* | 15~ | 45^^ |
Micro | 55 | 35 | 90 |
Rural | 55 | 35 | 90 |
CEAC | 100 | 65 | 120 |
Psychiatrist means a physician reported as one of the following specialist physician types: psychiatry, child and adolescent psychiatry, consultation-liaison psychiatry, geriatric psychiatry or addiction psychiatry.
MHP (Mental Health Professionals) means a Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Licensed Professional Clinical Counselor, or Psychologist.
MHF (Mental Health Facility) means a facility identified as one of the following categories: acute psychiatric hospital, psychiatric health facility, chemical dependency recovery hospital, intensive outpatient, partial hospitalization, residential treatment, residential detoxification, and/or alcohol or other drug facility (outpatient). Also includes those facilities categorized as a general acute care hospital, where such hospital maintains an inpatient psychiatric unit.
DMHC has options for Alternative Low Density Zip Standard – when applicable
- * for Large Metro Psychiatry – 20 miles
- ** for Metro Psychiatry – 35 miles
- ~ for Metro MHPs- 20 miles
- ^ for Large Metro MHFs - 30 miles
- ^^ for Metro MHFs - 75 miles
Physician/Practitioner to Enrollee Ratios
CA DMHC: COMMERCIAL/HEALTH BENEFIT EXCHANGE: | |
PCP | PHYSICIAN |
1 FTE PCP/ 2,000 enrollees | 1 FTE physician/ 1,200 enrollees |
Open Practice Ratios
Percent of Open PCP Practices Accepting New Patients | DMHC Standard | 60% of PCPs in the network are accepting new patients or at least 75% of PCP locations in the network are a PCP location accepting new patients |
|---|---|---|
Percent of Open Specialist Practices Accepting Referrals | Internal Standard | 85% |
Additional Ratios
NCQA Ratios, internal standards, not a regulatory standard | Rate of Compliance | Standard |
Full Time Equivalent (FTE) PCP ratio for each type of PCP to Enrollee: | 100% of PCPs | 1 : 2,500 |
·Family | ||
·General Practice | ||
· Internal Medicine | ||
· Pediatrics | ||
High volume SCP (Obstetrics/Gynecology) | 100% of SCPs | 1 : 3,000 |
High impact SCP (Hematology/Oncology) | 1 : 8,000 | |
Behavior Health | 100% | |
·MD’s/DO (Psychiatrists) | 1 : 5,000 | |
·Psychologist | 1 : 2,300 | |
·Masters Level practitioner | 1 : 1,150 | |
Autism | 100% | |
·Qualified Autism Service Provider (BCBA) | 1 : 5,000 | |
·Qualified Autism Service Professionals (BCaBA) or Paraprofessionals | 1 : 5,000 |
Behavioral Health Access Measurement
Health Net's access and availability policies, procedures and guidelines for providers and health care facilities providing behavioral health care are in accordance with applicable federal and state regulations, contractual requirements, and accreditation standards. These access standards are based on and monitored/regulated by the NCQA and the CDI.
Health Net has a documented system for monitoring and evaluating provider availability and accessibility of care. At least annually, Health Net monitors access to care guidelines to measure behavioral health access performance and confirm compliance. PPGs are also responsible for monitoring data regarding their adherence to the following performance goals. Listed below are the appointment access provider criteria and performance goals for: