Medicaid MCOs → Delivery → 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 and updated in 2020 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 a quantitative network adequacy standard for certain classes of provider types contracting with MCOs. States can choose which quantitative standard they use (e.g., minimum provider-to-enrollee ratios, maximum travel time or distance to providers, a minimum percentage of contracted providers that are accepting new patients, maximum wait times for an appointment, hours of operation requirements, or a combination of these quantitative measures). While CDC-recognized organizations are not one of the designated classes of providers subject to these standards, MCOs might consider using similar types of quantitative standards when developing their National DPP lifestyle change program networks.
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. To learn more about state MCO contracts and contracts between MCOs and CDC-recognized organizations, visit the Contracting page of the Coverage Toolkit.
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.
To learn about how state agencies can assess the landscape and technical assistance needs of CDC-recognized organizations, expand the capacity of the state network through support of existing and recruitment of new organizations, help organizations develop business acumen skills for successfully engaging with payers, and explore options for providing third-party or collective administrative support, visit the Building Network Capacity and Supporting CDC-Recognized Organizations page of the Coverage Toolkit.
Content Updated: March 2, 2021