The Network Adequacy Crisis
MH/SUD provider networks are consistently smaller and less adequate than medical/surgical networks. Studies show that MH/SUD providers are 3–4x more likely to be out-of-network than medical/surgical providers. This forces members to use out-of-network providers at higher cost — or to forgo care entirely. Inadequate MH/SUD networks are one of the most common MHPAEA violations.
Network Adequacy Metrics
| Metric | Medical/Surgical Standard | MH/SUD Must Be Comparable |
|---|---|---|
| Time-to-appointment | <5 days for urgent; <10 days for routine | MH/SUD wait times must be comparable |
| Distance to provider | <30 miles in urban; <60 miles in rural | MH/SUD distance standards must be comparable |
| Provider-to-member ratio | Varies by specialty | MH/SUD ratios must be comparable |
| Out-of-network utilization | Benchmark varies | MH/SUD OON rate must not be significantly higher |
Network Adequacy Remediation
IQ Insight
Improving MH/SUD network adequacy requires working with your carrier to expand the provider network. Key strategies: increase reimbursement rates to attract more providers, add telemental health providers to expand geographic access, and implement single-case agreements for members who cannot access in-network providers. Document your network adequacy improvement efforts in your MHPAEA comparative analysis.