Provider Network Adequacy

Changes in Medicaid Managed Care Final Rule Leave States with Much to Address

Authors: Hanford Lin, Randal Whiteman, Roshni Arora 

While there are numerous summaries of the Center for Medicare and Medicaid’s (CMS’s) Medicaid and CHIP Managed Care Final Rule, including those provided by CMS, this paper highlights expected and specific changes states will need to make to address requirements of the final rule.


Guidehouse's Government Healthcare Solutions practice reviewed Medicaid managed care contracts for 30 of the 45 states with comprehensive risk-based managed care. The goal was to identify potential changes that the states must make to meet new provider network adequacy requirements. States will need to establish or leverage existing standards and methodologies for determining network requirements, develop enhanced monitoring approaches and document clear processes for monitoring exceptions. 


States should begin to evaluate their current provider network monitoring and oversight practices in light of the new focus on transparency, pediatric access, and documentation requirements. States will likely need to aggregate available provider network data across contractors to gain an understanding of overall enrollee access under Medicaid managed care and to demonstrate value to stakeholders.


Contracts were reviewed to determine:

While other regulatory sources may include network adequacy requirements (e.g., state Medicaid and insurance regulations, policy guidance), Guidehouse reviewed risk-based contracts because they are the primary Medicaid managed care arrangement used to enforce program requirements and hold contractors accountable.

Key Findings


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