Medicaid AgenciesDelivery → Network Management

 

Network Management

 
Some key issues states may want to consider when establishing a network of National Diabetes Prevention Program (National DPP) CDC-recognized organizations include:

  • Geographic dispersion to ensure adequate access and availability of programs;
  • The data tracking processes and mechanisms to be used by the covered providers;
  • Standards for claims submission processes; etc.

 


 

Medicaid Network Access Rules

While network management rules and regulations typically don’t apply in a fee-for-service environment, states must ensure adequate access to providers (i.e., CDC-recognized organizations).

The “equal access provision” outlined in Title 42 of the Code of Federal Regulations (CFR) requires that state Medicaid reimbursement ensures that program enrollees have the same access to care that is available to the general population (42 CFR 447.204).

Additionally, states must monitor access to care through an access monitoring review plan. “The access monitoring review plan and analysis must, at a minimum, include: The specific measures that the state uses to analyze access to care such as, but not limited to:

  • Time and distance standards,
  • Providers participating in the Medicaid program,
  • Providers with open panels,
  • Providers accepting new Medicaid beneficiaries,
  • Service utilization patterns,
  • Identified beneficiary needs,
  • Data on beneficiary and provider feedback and suggestions for improvement,
  • The availability of telemedicine and telehealth, and
  • Other similar measures…”. (42 CFR 447.203)

 


 

Contracting with CDC-Recognized Organizations

It is important to note that meeting network adequacy standards can be an issue when CDC-recognized organizations are not uniformly available to Medicaid enrollees across the state. Online or distance learning programs may be able to be used to compensate for this.

The state Medicaid agency will outline network expectations for CDC-recognized organizations. It is important to note that even though CDC-recognized organizations have experience with meeting CDC’s Diabetes Prevention Recognition Program (DPRP) standards, many of these organizations will likely be new to the Medicaid program and may not understand Medicaid program standards and MCO contracting procedures. Additional time and/or training may be necessary to assist these organizations.
 


 

Leveraging State Public Health Department

States may also want to consider leveraging their state public health department to help connect them with the CDC-recognized organizations in the state. Many public health organizations and agencies have been involved in initiatives related to scaling and sustaining the National DPP lifestyle change program, including delivering the program themselves in areas that do not have access to CDC-recognized organizations. For more information, see the Additional Initiatives section.

For Medicaid managed care network management issues, see Medicaid MCO Delivery.