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)