Medi-Cal Managed Care Time and Distance Standards for Providers

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#5610.01

Medi-Cal managed care plans have to have providers within a certain time and distance from the patients’ home or “time and distance” standards. Managed care is a way to provide and pay for health care. You receive most of your health care from a managed care plan. A managed care plan is an organized network of health care providers that focuses on primary and preventive care. Hospitals, physicians and other health care providers are members of the network. This publication tells you about the “time and distance” standards for providers. It tells you what to do if your plan does not follow its “time and distance” standards.

To ensure that services are accessible and available to recipients in a timely manner, Medi-Cal managed care plans1 will need to maintain a network of providers that are located within a specified time or distance from patients’ homes.2 This publication discusses the time and distance standards for certain types of providers.3

1. What are the time and distance standards for medical care?

For standard medical care, the following standards apply as of January 1, 20184:

  • Primary care providers (pediatric and adult) must be located within ten (10) miles or thirty (30) minutes of your home.
  • Hospitals must be located within fifteen (15) miles or thirty (30) minutes of your home.
  • Dental services covered by Medi-Cal managed care plans must be located within ten (10) miles or thirty (30) minutes of your home.5

Obstetrics and gynecology primary care providers must be located within ten (10) miles or thirty (30) minutes from your home.

2. What are the time and distance standards for specialized medical care?

As of July 1, 2018, Medi-Cal managed care plans must maintain a network of specialists6 (pediatric and adult) with standards dependent on the county you live in.7 If you live in:

  • Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, or Santa Clara counties: Medi-Cal will maintain a network of providers located up to fifteen (15) miles or thirty (30) minutes from your home.
  • Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, or Ventura counties: Medi-Cal will maintain a network of providers located up to thirty miles (30) or sixty (60) minutes from your home.
  • Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, or Yuba counties: Medi-Cal will maintain a network of providers located up to forty-five (45) miles or seventy-five (75) minutes from the your home. 
  • Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, or Tuolumne counties: Medi-Cal will maintain a network of providers located up to sixty miles (60) or ninety (90) minutes from your home.

There are exceptions to these standards. When either the specialist is accessed primarily through a hospital or hospital-associated clinic setting, or when the specialist does not need a face-to-face patient visit to perform the service (e.g. pathology or radiology), a standardized time and distance requirement need not apply.8

In addition, some unique specialties were deliberately excluded from the list, as these types of standards would not reasonably apply.9

3. What are the time and distance standards for pharmacy services?

As of July 1, 2018, for pharmacy services, Medi-Cal managed care plans must maintain a network of providers located up to ten (10) miles or thirty (30) minutes from your home.10

4. What are the time and distance standards for outpatient mental health services?

As of July 1, 2018, Medi-Cal managed care plans must maintain a network of outpatient mental health services for recipients.11 If you live in:

  • Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, or Santa Clara counties: Medi-Cal will maintain a network of providers located up to fifteen (15) miles or thirty (30) minutes from your home.
  • Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, or Ventura counties: Medi-Cal will maintain a network of providers located up to thirty miles (30) or sixty (60) minutes from your home.
  • Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, or Yuba counties: Medi-Cal will maintain a network of providers located up to forty-five (45) miles or seventy-five (75) minutes from the your home. 
  • Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, or Tuolumne counties: Medi-Cal will maintain a network of providers located up to sixty miles (60) or ninety minutes (90) from your home.

5. What are the time and distance standards for outpatient substance abuse treatment and opioid treatment programs?

As of July 1, 2018, standards for outpatient treatment for substance abuse disorders (other than opioid treatment programs) also depend on the county you live in12:

  • Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara counties:  Medi-Cal will maintain a network of providers located up to fifteen (15) miles or thirty (30) minutes from your home.
  • Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura counties: Medi-Cal will maintain a network of providers located up to thirty (30) miles or sixty (60) minutes from your home.
  • Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Madera, Mariposa, Mendocino, Merced, Modoc, Monterey, Mono, Napa, Nevada, Plumas, San Benito, San Bernardino, San Luis Obispo, Santa Barbara, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tulare, Tuolumne, Yolo, and Yuba counties: Medi-Cal will maintain a network of providers located up to sixty (60) miles or ninety (90) minutes from your home.

As of July 1, 2018, opioid treatment program standards also depend on the county you live in13:

  • Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara counties:  Medi-Cal will maintain a network of providers located up to fifteen (15) miles or thirty (30) minutes from your home.
  • Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura counties: Medi-Cal will maintain a network of providers located up to thirty (30) miles or sixty (60) minutes from your home.
  • Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba counties:  Medi-Cal will maintain a network of providers located up to forty-five (45) miles or seventy-five (75) minutes from your home.
  • Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne counties: Medi-Cal will maintain a network of providers located up to sixty (60) miles or ninety (90) minutes from your home.

A county Drug Medi-Cal organized delivery system shall provide an appointment within three business days to an opioid treatment program.14

6. What are the time and distance standards for nursing or intermediate care facility services? 

Skilled nursing or intermediate care facility services standards are also based on residence location:

For Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara counties:  the managed care plan must make this service available within five (5) business days of your request.15

For Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura counties: the managed care plan must make this service available within seven (7) business days of your request.16

For Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba counties: the managed care plan must make this service available within fourteen (14) business days of your request.17

For Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne counties: the managed care plan must make this service available within fourteen (14) business days of your request.18

7. Are there any exceptions to these standards?

If a Medi-Cal managed care plan cannot meet the time and distance standards, it can request different standards from the Department of Health Care Services (DHCS), the single state agency that oversees the Medi-Cal program (including Medi-Cal managed care plans) in California. The Medi-Cal managed care plan will need to show that it has exhausted all reasonable options to get providers.19 It will also need to show why different standards are necessary. If DHCS approves different standards, these standards must be posted on the department’s website.20

Also, DHCS will consider other time and distance standards when the provider travels to the Medi-Cal recipient and/or a community-based setting to provide services.21

If you are receiving services from your Medi-Cal managed care plan through an out-of-network provider, the same timely access requirements for in-network providers apply.22

8. Can a managed care plan use telehealth, other telecommunications technology, or pharmacy mail order to provide care?

Yes, the DHCS may allow for the use of clinically appropriate telecommunications technology as a method of complying with time and distance standards.23

What can I do if my Medi-Cal managed care plan does not comply with these standards?

You can file a grievance with your Medi-Cal managed care plan24, and/or with the Medi-Cal Managed Care Office of the Ombudsman25.

Additional resource

See, CA Dept. of Health Care Services, Medicaid Managed Care Final Rule: Network Adequacy Standards (2017).

 

 

1 For information on Medi-Cal managed care plans, see our publication Medi-Cal Managed Care Health Plans: What are they? What do I need to know about them?(Return to main document)

2 See California Welfare & Institutions Code Section §14197. – (Return to main document)

3 For more information about appointment standards for certain services,  see our publication, Timely Access to Medical Care, – (Return to main document)

4 W&IC §14197(b) – (Return to main document)

5 For more information see All Medi-Cal Dental Managed Care Plans. – (Return to main document)

6 “Specialist” means a professional who practices any of the following: Cardiology/interventional cardiology, Nephrology, Dermatology,Neurology, Endocrinology, Ophthalmology,Ear, nose, and throat/otolaryngology, Orthopedic surgery,Gastroenterology, Physical medicine and rehabilitation, General surgery, Psychiatry, Hematology Oncology,Pulmonology, HIV/AIDS/infectious diseases. – (Return to main document)

7 WIC 14197(c) – (Return to main document)

8 CA Dept. of Health Care Services, Medicaid Managed Care Final Rule: Network Adequacy Standards, p. 15 (2017). – (Return to main document)

9 Id. – (Return to main document)

10 WIC §14197(c)(2) – (Return to main document)

11 WIC §14197(c)(3) – (Return to main document)

12 WIC §14197(c)(4)(A) – (Return to main document)

13 WIC §14197(c)(4)(B) – (Return to main document)

14 Medicaid Managed Care Final Rule, p. 7 – (Return to main document)

15 WIC §14197(d)(2)(A) – (Return to main document)

16 WIC §14197(d)(2)(B) – (Return to main document)

17 WIC §14197(d)(2)(C) – (Return to main document)

18 WIC §14197(d)(2)(D) – (Return to main document)

19 WIC §14197(e)(1) – (Return to main document)

20 WIC §14197(e)(3) – (Return to main document)

21 Medicaid Managed Care Final Rule, p. 24 – (Return to main document)

22 Id. at  p. 16 – (Return to main document)

23 WIC §14197(e)(4) – (Return to main document)

24 See our publication, Medi-Cal Managed Care: Appeals and Grievances. – (Return to main document)

25 See MMCD Office of the Ombudsman – (Return to main document)