C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 438—MANAGED CARE › Subpart D—MCO, PIHP and PAHP Standards

42 C.F.R. § 438.206

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(a) Basic rule. Each State must ensure that all services covered under the State plan are available and accessible to enrollees of MCOs, PIHPs, and PAHPs in a timely manner. The State must also ensure that MCO, PIHP and PAHP provider networks for services covered under the contract meet the standards developed by the State in accordance with § 438.68.

(b) Delivery network. The State must ensure, through its contracts, that each MCO, PIHP and PAHP, consistent with the scope of its contracted services, meets the following requirements:

(1) Maintains and monitors a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities.

(2) Provides female enrollees with direct access to a women's health specialist within the provider network for covered care necessary to provide women's routine and preventive health care services. This is in addition to the enrollee's designated source of primary care if that source is not a women's health specialist.

(3) Provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost to the enrollee.

(4) If the provider network is unable to provide necessary services, covered under the contract, to a particular enrollee, the MCO, PIHP, or PAHP must adequately and timely cover these services out of network for the enrollee, for as long as the MCO, PIHP, or PAHP's provider network is unable to provide them.

(5) Requires out-of-network providers to coordinate with the MCO, PIHP, or PAHP for payment and ensures the cost to the enrollee is no greater than it would be if the services were furnished within the network.

(6) Demonstrates that its network providers are credentialed as required by § 438.214.

(7) Demonstrates that its network includes sufficient family planning providers to ensure timely access to covered services.

(c) Furnishing of services. The State must ensure that each contract with a MCO, PIHP, and PAHP complies with the following requirements.

(1) Timely access. Each MCO, PIHP, and PAHP must do the following:

(i) Meet and require its network providers to meet State standards for timely access to care and services taking into account the urgency of the need for services, as well as appointment wait times specified in § 438.68(e).

(ii) Ensure that the network providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid FFS, if the provider serves only Medicaid enrollees.

(iii) Make services included in the contract available 24 hours a day, 7 days a week, when medically necessary.

(iv) Establish mechanisms to ensure compliance by network providers.

(v) Monitor network providers regularly to determine compliance.

(vi) Take corrective action if there is a failure to comply by a network provider.

(2) Access and cultural considerations. Each MCO, PIHP, and PAHP participates in the State's efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of sex which includes sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity and sex stereotypes.

(3) Accessibility considerations. Each MCO, PIHP, and PAHP must ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities.

(d) Applicability date. States will not be held out of compliance with the requirements of paragraphs (c)(1)(i) of this section prior to the first rating period that begins on or after 3 years after July 9, 2024, so long as they comply with the corresponding standard(s) codified in 42 CFR 438.206(c)(1)(i) (effective as of October 1, 2023).

[81 FR 27853, May 6, 2016, as amended at 85 FR 37243, June 19, 2020; 89 FR 37691, May 6, 2024; 89 FR 41276, May 10, 2024]
Notes of Decisions
Cited in 12 cases (2 in the last 5 years), 2002–2025 · leading case: Arizona Ass'n of Providers for Persons with Disabilities v. State, 219 P.3d 216 (Ariz. Ct. App. 2009).
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Arizona Ass'n of Providers for Persons with Disabilities v. State, 219 P.3d 216 (Ariz. Ct. App. 2009). · cites it 4× “” 42 C.F.R. § 438.206 (b)(1) (2009). Significantly, the regulation also requires that “[i]f the network is unable to provide necessary services .”
G. v. Hawaii, Dept. of Human Servs., 703 F. Supp. 2d 1112 (D. Haw. 2010). · cites it 7× “Meyers’ Preliminary Report begins by referencing the factors set forth in 42 C.F.R. § 438.206 (b). Preliminary Report at 2.”
Appalachian Reg'l Healthcare, Inc. v. Coventry Health & Life Ins., 714 F.3d 424 (6th Cir. 2013). “, 42 C.F.R. § 438.206 (b)(1)(v); 907 Ky. Admin.”
Appalachian Reg'l Healthcare, Inc. v. Coventry Health & Life Ins. Co., 214 F. Supp. 3d 606 (E.D. Ky. 2016). · cites it 5× “§ 1396u2(c)(l)(A)(i)) and a federal regulation ( 42 C.F.R. § 438.206 (a), (b)). (DE 279-1, Mem.”
M.G. v. Armijo, 117 F.4th 1230 (10th Cir. 2024). “But see 42 C.F.R. § 438.206 (b) (requiring states to ensure through its contracts, that the MCOs monitor their networks to assure the networks are sufficient to provide all covered services and, if the network is not sufficient, to timely and adequately cover those services out…”
Midwest Emergency Assocs.-Elgin, Ltd. v. Harmony Health Plan of Illinois, Inc., 888 N.E.2d 694 (Ill. App. Ct. 2008). “See 42 C.F.R. §438.206 (b)(1) (2007). Providers and MCOs negotiate rates of reimbursement for services that may differ from the rates paid by the state in a fee-for-service arrangement.”
Solter v. Health Partners of Philadelphia, Inc., 215 F. Supp. 2d 533 (E.D. Pa. 2002). “” 42 C.F.R. § 438.206 . 3 .Under the Medicaid contract between Health Partners and the Commonwealth, "medically necessary” is defined as follows: [a] service or benefit is medically necessary if it is compensable under the Medical Assistance Program and if it meets any one of…”
G. v. Hawaii, Dept. of Human Servs., 703 F. Supp. 2d 1078 (D. Haw. 2010). · cites it 12× “42 C.F.R. § 438.206 states in relevant part: (b) Delivery network.”
Arizona Ass'n of Providers v. State, 219 P.3d 216 (Ariz. Ct. App. 2009). · cites it 4× “" 42 C.F.R. § 438.206 (b)(1) (2009). Significantly, the regulation also requires that "[i]f the network is unable to provide necessary services .”
Doxzon v. Dep't of Human Servs. of the Commonwealth of Pennsylvania (M.D. Penn. 2020). “” 42 C.F.R. § 438.206 (a) and § 438.206(b)(1).”
Nielsen (D. Haw. 2025). “The Complaint The Complaint alleges three claims: (1) ADA discrimination “on the basis of disability”, (2) Rehabilitation Act discrimination “on the basis of disability”, and (3) Section 1983 constitutional violations for abridging legal rights under the “ADA, Section 504 [of…”
Midwest Emergency Assocs.-Elgin Ltd. (Ill. App. Ct. 2008). “See 42 C.F.R. §438.206 (b)(1) (2007). Providers and MCOs negotiate rates of reimbursement for services that may differ from the rates paid by the state in a fee-for-service arrangement.”
— 42 C.F.R. § 438.206(b)(1)(i) — 1 case
G. v. Hawaii, Dept. of Human Servs., 703 F. Supp. 2d 1078 (D. Haw. 2010). “42 C.F.R. § 438.206 states in relevant part: (b) Delivery network.”
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