Network Adequacy Standards

Provider type
Timely access standard
Time and distance standard by county size1
   

Rural

Small

Medium

Dense

Primary care(adult and pediatric)

Within 10 business days to appt. from request

10 miles and 30 minutes from any member or anticipated member’s residence

Specialty Care2(adult and pediatric)

Within 15 business days to appt. from request3

60 miles and 90 minutes from any member or anticipated member’s residence

45 miles and 75 minutes from any member or anticipated member’s residence

30 miles and 60 minutes from any member or anticipated member’s residence

15 miles and 30 minutes from any member or anticipated member’s residence

Obstetrics/Gynecology(OB/GYN)Primary Care

Within 10 business days to appt. from request

10 miles and 30 minutes from any member or anticipated member’s residence

OB/GYN Specialty Care

Within 15 business days to appt. from request3

60 miles and 90 minutes from any member or anticipated member’s residence

45 miles and 75 minutes from any member or anticipated member’s residence

30 miles and 60 minutes from any member or anticipated member’s residence

15 miles and 30 minutes from any member or anticipated member’s residence

Hospitals

Not Applicable

15 miles and 30 minutes from any member or anticipated member’s residence

Pharmacy

Dispensing of at least a 72hour supply of covered outpatient drug in an emergency situation

10 miles and 30 minutes from any member or anticipated member’s residence

Mental Health(non-psychiatry)Outpatient Services4(adult and pediatric)

Within 10 business days to apt. from request

60 miles and 90 minutes from any member or anticipated member’s residence

45 miles and 75 minutes from any member or anticipated member’s residence

30 miles and 60 minutes from any member or anticipated member’s residence

15 miles and 30 minutes from any member or anticipated member’s residence

Ancillary Services

Within 15 business days to appt. from request.

Not Applicable

Long Term Services and Supports (LTSS)

If applicable5

Time and distance standards are not established for Multipurpose Senior Services Program (MSSP),Skilled Nursing Facilities (SNF), or Intermediate Care Facilities (ICF) providers as these providers either travel to the member to provide services or the member resides at the facility for care.

1 County Size Category by Population defined in Table 1

2 Time and Distance Standards apply to the core specialists outlined in Table 2

3 Timely Access standards apply to all specialists, not only core specialists

4 Non-specialty mental health services for members with mild to moderate impairments

5 LTSS Timely Access Network Standards defined in Table 3

Table 1: County Size Categories by Population

Size Category
Population Density
# of Counties
Counties

Rural

≤50 people per square mile

21

Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa,Mendocino, Modoc, Mono, Plumas, San Benito,Shasta, Sierra, Siskiyou, Tehama, Tuolumne, Trinity

Small

51 to 200 people per square mile

19

Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa, Barbara, Sutter, Tulare, Yolo, Yuba

Medium

201 to 599 people per square mile

9

Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, Ventura

Dense

≥600 people per square mile

9

Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, Santa Clara

Table 2: DHCS Adult and Pediatric Core Specialists

Cardiology/Interventional Cardiology

Nephrology

Dermatology

Neurology

Endocrinology

Oncology

ENT/Otolaryngology

Ophthalmology

Gastroenterology

Orthopedic Surgery

General Surgery

Physical Medicine and Rehabilitation

Hematology

Psychiatry

HIV/AIDS Specialists/Infectious Diseases

Pulmonology

Table 3: LTSS Timely Access Network Standards

Provider type
Time and distance standard by county size1
 

Rural

Small

Medium

Dense

SNF

Within 14 calendar days of request

Within 14 calendar days of request

Within 7 business days of request

Within 5 business days of request

Intermediate Care Facility/Developmentally Disabled (ICF-DD)

Within 14 calendar days of request

Within 14 calendar days of request

Within 7 business days of request

Within 5 business days of request

Community Based Adult Services (CBAS)

Capacity cannot decrease in aggregate statewide below April 2012 level

Table 4: Call Center Wait Time Standards

Medi-Cal Managed Care Health Plan (MCP) Call Center

10 minutes from the time the call is placed.

Approved Alternative Access Standards

Download a .pdf document with the DHCS approved Alternative Access Standards for Blue Shield Promise Health Plan.

San Diego County (PDF, 1 MB)