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Deadline for Draft Network Adequacy Requirement Policy Review Due May 31st

The HHSC Vendor Drug Program (VDP) accepts stakeholder comments on the following draft policy. The comment period ends?May 31, 2024. Submit your comments using the?Draft Policy Comment Submission (HHS Form 1342). VDP will consider the comments in the development of the final policy, and will share the final policy and implementation date for Medicaid and CHIP in the future.

Policy Information

HHSC drafted this policy to update the Medicaid and Children?s Health Insurance Program (CHIP) managed care pharmacy network standards. To meet network adequacy standards, MCOs must have at least one network pharmacy within a specified distance or drive times of a percentage of their members? homes. This policy change will increase the distance and drive time.

Current Policy

The MCO must comply with the requirements set forth in Uniform Managed Care Manual Chapter 5, Access to Network Providers Performance Standards and Specifications. Current policy became effective in state fiscal year 2019. The county designation is based on population and density parameters. A map of counties by designation and parameters is available in Attachment B-5 of the Uniform Managed Care Contract. Current network adequacy standards for pharmacy are as follows:

• For counties included in the Medicaid Rural Service Area (MRSA), the following standards apply to STAR:
  • Metro County: 75 percent of Members must have access to a network pharmacy within?2 miles?or?5 minutes?of their residence.
  • Micro County: 55 percent of Members must have access to a network pharmacy within?5 miles?or?10 minutes?of their residence.
  • Rural County: 90 percent of Members must have access to a network pharmacy within?15 miles?or?25 minutes?of their residence.
  • At least 90 percent of Members must have access to a 24-hour pharmacy within?75 miles?or?90 minutes?of their residence.
• For all other counties and programs, the following standards apply:
  • Metro County: 80 percent of Members must have access to a network pharmacy within?2 miles?or?5 minutes?of their residence.
  • Micro County: 75 percent of Members must have access to a network pharmacy within?5 miles?or?10 minutes?of their residence.
  • Rural County: 90 percent of Members must have access to a network pharmacy within?15 miles?or?25 minutes?of their residence.
  • At least 90 percent of Members must have access to a 24-hour pharmacy within?75 miles?or?90 minutes?of the Member?s residence.

Draft Proposed Policy

The draft proposed policy changes would increase the distance and drive times of these requirements. No changes would be made to 24-hour pharmacy requirements or the percentage requirements.

• For counties included in the Medicaid Rural Service Area (MRSA), the following standards apply to STAR:'
  • Metro County: 75 percent of Members must have access to a network pharmacy within?5 miles?or?10 minutes?of their residence.
  • Micro County: 55 percent of Members must have access to a network pharmacy within?15 miles?or?25 minutes?of their residence.
  • Rural County: 90 percent of Members must have access to a network pharmacy within?20 miles?or?30 minutes?of their residence.
  • At least 90 percent of Members must have access to a 24-hour pharmacy within?75 miles?or?90 minutes?of their residence.
• For all other counties and programs, the following standards apply:
  • Metro County: 80 percent of Members must have access to a network pharmacy within?5 miles?or?10 minutes?of their residence.
  • Micro County: 75 percent of Members must have access to a network pharmacy within?15 miles?or?25 minutes?of their residence.
  • Rural County: 90 percent of Members must have access to a network pharmacy within?20 miles?or?30 minutes?of their residence.
  • At least 90 percent of Members must have access to a 24-hour pharmacy within?75 miles?or?90 minutes?of the Member?s residence.

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