Medicaid MCOsDelivery → Network Management


Network Management


Medicaid managed care organizations (MCOs) will need to consider network adequacy standards when covering the National Diabetes Prevention Program (National DPP) lifestyle change program.


Medicaid Managed Care Network Management Rules

The Medicaid managed care rule finalized in April 2016 includes several provisions related to network management that will need to be followed when contracting with CDC-recognized organizations.

First, all MCO contracted providers (i.e., CDC-recognized organizations) are required to enroll with the state as Medicaid providers, even if they do not deliver services to Medicaid fee-for-service beneficiaries. As Medicaid enrolled providers, these organizations will need to comply with Medicaid program integrity rules such as confidentiality, screening, and disclosure standards.

Second, states must set network adequacy standards that are defined by time and distance for certain classes of providers starting in July 2018. While CDC-recognized organizations are not one of the designated classes, the rule does provide CMS discretion when determining which provider types are subject to the new rule.

Beyond state and federal rules, some key issues MCOs may want to consider when establishing a network of CDC-recognized organizations for the National DPP lifestyle change program 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.



Contracting with CDC-Recognized Organizations

Contracts between the state and the MCO will outline network expectations for CDC-recognized organizations. These expectations will then be reflected in the contracts between MCOs and CDC-recognized organizations.

It is also 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 Departments

MCOs could also 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.