HHSC uses appointment availability studies to monitor the length of time a managed care member must wait between scheduling an appointment with a provider and receiving treatment from the provider.
Medicaid and CHIP managed care organizations must ensure that all members have access to all covered services on a timely basis, consistent with medically appropriate guidelines and accepted practices.
HHSC establishes minimum access standards, including time and distance standards, for specific provider types in the Medicaid MCO provider networks. These studies measure whether Medicaid MCOs are following HHSC’s guidelines.
Texas Medicaid Appointment Availability Standards
A client should be able to schedule the following appointment types with Medicaid provider within the time frames listed below:
- Urgent Care: within 24 hours.
- Routine Primary Care: within 14 calendar days.
- Preventive Health Services for New Child Members: no later than 90 calendar days after enrollment.
- Initial Outpatient Behavioral Health Visits: within 14 calendar days
- Preventive Health Services for Adults: within 90 calendar days.
- Prenatal Care: within 14 calendar days.
- High-Risk Prenatal Care: within 5 calendar days.
- Prenatal Care for New Members in the Third Trimester: within 5 calendar days.
- Vision Care (ophthalmology, therapeutic optometry): access without primary care provider referral.
HHSC hires an External Quality Review Organization (EQRO) to evaluate MCO compliance with appointment availability standards. The EQRO uses a mystery shopper method, where they call a random sample of providers to determine how soon an appointment can be scheduled.
The samples of provider offices for the studies are pulled from member-facing, provider directories submitted by the MCOs.
The study is comprised of four reports in the areas of prenatal (previously referred to as OBGYN), primary care (PC or PCP for primary care provider), vision, and behavioral health.
Corrective Action Plans and Liquidated Damages
MCOs who fail to meet the minimum thresholds are assessed for Corrective Action Plans and Liquidated. The LD is the financial penalty for not meeting the minimum threshold, while the CAP is the plan the MCO develops to address the reason the minimum threshold was not met.
MCOs who meet or do better than the minimum threshold based on the EQRO’s analysis are not assessed for CAPs or LDs.
Minimum thresholds are calculated by adding 10 points to the statewide mean. For example, if the average compliance rate across all MCOs in a sub study is 75%, the minimum threshold will be set to 85%.
Study Timelines - State Fiscal Year
- Primary Care—Winter
- Behavioral Health—Summer
Rules and Regulations
- Senate Bill 760, 84th Legislature, Regular Session, 2015 directed HHSC to monitor the length of time a recipient must wait between scheduling an appointment with a provider and receiving treatment from the provider.
- Rules issued by the Centers for Medicare & Medicaid Services in 42 CFR 438.68 - Network Adequacy Standards, require HHSC to establish minimum access standards, including time and distance standards, for MCO provider networks for specific provider types.
- Section 22.214.171.124 of the Texas Uniform Managed Care Contract (PDF) specifies that MCOs must assure that all members have access to all covered services on a timely basis, consistent with medically appropriate guidelines and accepted practice parameters.
For more information on the appointment availability, review our reference guide (PDF).
For questions, email MCD_managed_care_quality@hhsc.state.tx.us.