Network Access Evaluations

Federal and state regulations governing Medicaid services require that each Coordinated Care Organization (CCO) maintains a network of appropriate healthcare providers to ensure adequate access to all services covered under the Medicaid contract. Each CCO must submit documentation to the state Medicaid authority demonstrating its capacity to serve the expected enrollment in its service area in accordance with the state’s standards for access to care.

Delivery System Network (DSN) Evaluation

Exhibit G of the CCO contract outlines the reporting requirements of the CCOs related to providers, cooperative agreements, and hospital adequacy. This activity is focused on DSN reports that each CCO is required to submit to the state each contract year. The DSN Evaluation includes three components:

1. The DSN Provider Narrative Report contains information and analysis of CCO operational infrastructure for the oversight and monitoring of network adequacy, processes for monitoring current and future members and membership needs, processes for monitoring and analyzing the capacity of the network to meet member needs, and strategies to address network adequacy challenges identified via monitoring. 
2. The Network Capacity and Adequacy Assessment evaluates CCO compliance with state-established standards to access to different service categories by driving time and distance, delineated by age of population (i.e., adult and child). Calculations and data for this component are provided by OHA. 
3. The Network Availability and Accessibility Assessment contains information and analysis of metrics including but not limited to percent of active providers within each CCO’s network, percent of providers located within a CCO’s service area, and percent of providers accepting new Medicaid patients. Calculations and data for this component are provided by OHA. 

HSAG uses information and data derived from these three components to provide OHA with an annual evaluation of network adequacy within the state in an aggregate report, including results for individual CCOs and recommendations to support ongoing monitoring and improvement activities. 

Network Adequacy Validation (NAV)

The validation of network adequacy evaluates the accuracy of state-defined network adequacy indicators reported by coordinated care organizations (CCOs), and represents one of the mandatory external quality review (EQR) activities that the state Medicaid agencies are required to perform as described in CFR §438.358(b).  During this activity, HSAG performs an Information Systems Capability Assessment (ISCA) to examine the systems, processes, and data sources utilized for calculating network adequacy standards. HSAG conducts interviews with key CCO staff to validate findings from documentation reviews, address outstanding issues, and verify the reliability and validity of source data and processes informing network adequacy reporting.

The following list describes the type of data collected and how HSAG analyzes the data:

• Information systems underlying network adequacy monitoring: CCOs complete and submit an ISCA tool for HSAG’s review and uses the CCOs’ responses to assess the ability of the CCOs’ information systems to collect and report accurate data submitted to OHA to support the calculation of network adequacy indicators. Additionally, OHA completes and submits an ISCA tool allowing HSAG to assess the ability of OHA’s information systems to collect, calculate, and report network adequacy indicators for each CCO. 
• Validate network adequacy logic for calculation of network adequacy indicators: OHA submits documented code, logic, or manual workflows for each indicator in scope of the NAV validation activities. HSAG reviews OHA’s calculation process and methodology to ensure compliance with the defined indicator specifications used to produce network adequacy calculations. As a component of the validation process, HSAG will independently calculate all applicable network adequacy indicators and compare HSAG-calculated results with the OHA-calculated results. The comparison will be used to assess the reasonableness of OHA’s results and confirm the accuracy of methodology, logic, and processes used by OHA. 
• Supporting documentation: HSAG requests documentation that would provide reviewers with additional information to complete the validation process, including policies and procedures, file layouts, system flow diagrams, and data collection process descriptions.

Access and Availability Surveys

OHA contracts with HSAG to perform additional activities to evaluate the quality of provider data and availability of appointments to Medicaid members.  These activities include secret- and revealed-shopper surveys, as well as provider directory validations. While surveys can be used to assess the accuracy of provider directories, provider panel status, and appointment availability, the provider directory validation activity compared network provider data with online provider directories.

The following table highlights the Network Access Evaluations conducted by HSAG:

For questions related to the DSN Evaluation and Access & Availability Survey activities, please contact:

       Ivan Kuletz, MPP
       Project Manager II, State & Corporate Services
       Telephone: 503.583.5497
       Email:  IKuletz@hsag.com