Policy - Network Adequacy and Timely Access

This replaces BHSD Service Access policy 412-404 and SUTS P&P 2,3, and 4​​​.

To ensure that throughout the geographic regions of Santa Clara County (SCC), the Behavioral Health Services Department (BHSD) will comply with network adequacy standards developed pursuant to Title 42 of the Code of Federal Regulations Part 438.68, as specified in Chapter 738, Statutes of 2017 (Assembly Bill 205), for all beneficiaries. 

This policy covers both in and out of network services. For further information regarding out of network services, please refer to BHSD P&P 2300 “Out of Plan Services.” 

BHSD serves as the mental health plan and the substance use treatment services organized delivery system for Santa Clara County.  BHSD will meet and require its providers to meet Department standards for timely access to care and services, taking into account the urgency of need for services. 

BHSD’s network providers offer hours of operation that are no less than the hours offered to commercial beneficiaries. BHSD and its provider ​network make services available 24 hours a day, 7 days a week, when medically necessary. BHSD will require contracted providers to have hours of operation during which services are provided to Medi-Cal beneficiaries that are no less than the hours of operation during which the provider offers services to non-Medi-Cal beneficiaries. If the provider only serves Medi-Cal beneficiaries, BHSD shall require that hours of operation are comparable to the hours the provider makes available for Medi-Cal services that are not covered by the BHSD.​

BHSD will establish mechanisms to ensure that network providers comply with the timely access requirements, including the assessment of responsiveness of the BHSD’s 24 hour toll-free telephone number, timeliness of scheduling routine appointments, timeliness of services for urgent conditions, and access to after-hours care. BHSD will monitor network providers regularly to determine compliance with timely access requirements.

If BHSD or its network providers fail to comply with the timely access requirements, BHSD must take corrective action.

For Indian enrollees who are eligible to receive services, BHSD must demonstrate that there are sufficient Indian Health Care Providers (IHCPs) participating in the provider network to ensure timely access to services available under the contract with the State from such providers.

BHSD must maintain and monitor a network of appropriate providers that is supported by written agreements for subcontractors. This network of providers must be sufficient to provide adequate access to all services covered under the contract for all beneficiaries, including those with limited English proficiency or physical or mental disabilities. BHSD must ensure that network providers provide physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medi-Cal beneficiaries with physical or mental disabilities.  

BHSD and its network providers must adhere to, in all geographic areas within Santa Clara County, the state standards for time and distance. Based on population density, BHSD must provide behavioral health services within 15 miles or 30 minutes from a beneficiary’s residence, taking into consideration the following:

  •  Anticipated number of Medi-Cal eligible clients;
  • Expected utilization of services;
  • Characteristics and mental health needs of beneficiaries;
  • Expected number and types of providers in terms of training and experience needed to meet expected utilization;
  • Numbers of network providers who are not accepting new beneficiaries;
  • Geographic location of available providers and their accessibility to beneficiaries;
  • Ability of network providers to communicate with limited English proficient beneficiaries in their preferred;
  • Ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medi-Cal beneficiaries with physical or mental disabilities;
  • Availability of screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.

For inpatient services, if BHSD is unable to provide necessary medical services covered under the state contract to a particular beneficiary, BHSD will adequately and timely cover inpatient services out of network for the beneficiary for as long as BHSD is unable to provide them. BHSD will coordinate authorization and payment with out-of-network providers and ensure that the cost to the beneficiary for out-of-network services is no greater that it would be if services were furnished in BHSD’s network.​

BHSD must give assurance and provide supporting documentation to the State in the state’s specified format that demonstrates that it has the capacity to serve the expected enrollment in its service area in accordance with the state’s standards for access and timeliness of care. The documentation must demonstrate that BHSD offers an appropriate range of specialty services that are adequate for the anticipated number of beneficiaries for the service area. BHSD must also maintain a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of beneficiaries in the service area. BHSD will submit this documentation no less frequently than when it enters into contract with the State, on an annual basis, and whenever there is a change in operation that would cause a decrease of 25 percent or more in services or providers available to beneficiaries, change in benefits, geographic service area, composition of or payments to the provider network, or enrollment of a new population in Santa Clara County. BHSD must furnish this information to beneficiaries and potential beneficiaries.

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