NYS Contracted Health Plan Network Adequacy Standards
Medicaid managed care plans under Mainstream Managed Care, HIV Special Needs (HIV-SNP), or Health and Recovery (HARP) lines of business are responsible for meeting network adequacy and access requirements. A full list of the requirements can be found in the Mainstream Model Contract including, but not limited to:
Maximum appointment wait time for routine services
- Emergency appointments: Immediately upon presentation
- Sick visits (non-urgent): Within 48-72 hours of request
- Routine, preventative appointments (e.g., primary care, OB/GYN): Within 4 weeks
- Specialist referrals: Within 4-6 weeks
- Outpatient mental health and substance use disorder appointments:
- 10 business days for initial appointments
- 7 calendar days following discharge from hospital or emergency room visit
24-hour access to care
Managed care plans must provide enrollees with access (which may include after hours ‘on-call’ telephone access) to medical services, either directly or through enrollees’ PCPs and OB/GYNs, on a 24-hour-a-day, seven-day-a-week basis
In-network providers
To see if a provider is in a specific MCO’s network, or to inquire about any additional options, contact your plan's member services department.
Network Adequacy Standards Links and Resources
Policies and guidelines
- Other network adequacy contractual requirements for Mainstream Managed Care Plans, HIV Special Needs Plans, or Health and Recovery Plans (HARP) can be found in Section 21 of the Mainstream Model Contract
- Guidelines for MCO Service Delivery Networks
Network adequacy and access standards for behavioral health services
- Part 98 - Managed Care Organizations | New York Codes, Rules and Regulations
- FAQ 10 NYCRR 98-5
- Behavioral Health Network Adequacy Consumer Factsheet
Consumer resources
- Managed Care Organization (MCO) Directory by Plan
- Medicaid Managed Care Member Handbook
- Managed care bill of rights
- Where to file a complaint
Reports
- MCO performance data and reports, including:
- External Quality Review Annual Technical Report (ATR)
- Managed Care Program Annual Report (MCPAR)
- Network Adequacy and Access Assurances Report (NAAAR)1
- Medicaid Managed Care Satisfaction Surveys (composite and plan-specific reports)
Accessibility
