Network Adequacy

Network Adequacy A. A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of participating providers to ensure that all covered services to covered persons will be accessible without unreasonable delay. In the case of emergency facility services, covered persons shall have access twenty-four (24) hours per day, seven (7) days per week. B. The sufficiency of health carriers’ networks shall be measured by the network adequacy standards outlined in 45 C.F.R. § 156.230((a)(2)(i) and associated guidance published by the Centers for Medicare and Medicaid Services. C. In any case where the health carrier has an insufficient number or type of participating providers/facilities to provide a covered benefit to a covered person consistent with the geographic access standards set forth in Rule 14.05(B), the health carrier shall ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit were obtained from participating providers/facilities, and additionally, if the covered persons must travel more than one hundred (100) miles one way or more than the distance standard prescribed by this regulation, whichever is greater, to obtain the aforementioned covered benefit, the health carrier shall provide such persons reasonable round trip reimbursement for their food, lodging and travel. Reimbursement for food and lodging shall be at the prevailing federal per diem rates, then in effect, as set by the U.S. General Services Administration. Reimbursement for travel by vehicle shall be reimbursed at the current Internal Revenue Service mileage standard for miles driven for transportation or travel expenses. The health carrier’s regulatory obligation in this Subsection C to provide such reimbursement shall not exceed $10,000.00 per covered person in any applicable policy year. D. The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers/facilities to the locations of covered persons. A health carrier may be deemed to be out of compliance with the geographic access standards in Rule 14.05(B) in the event that the health carrier is not able to meet the applicable time or distance minimum with respect to covered persons’ locations. In determining whether a health carrier has complied with the geographic access standards in Rule 14.05(B), the Commissioner shall give due consideration to the relative availability of health care providers in the geographic area under consideration. The fact that no provider specialist, adult or pediatric, provides a covered service within the minimum geographic access standards shall be taken into consideration when determining whether a health carrier has complied with the geographic access standards in Rule 14.05(B), and the Commissioner may accept the attestation of a health carrier as sufficient even if the health carrier does not comply with Rule 14.05(B) and Rule 14.05(D) if the Commissioner determines the health carrier has made reasonable efforts to secure health care providers in the geographic area at issue, but such providers were not available. The Commissioner’s assessment of the health carrier’s efforts will be performed consistent with the Managed Care Plan Certification Regulation, Title 19, Part 3, Chapter 18. 1. A health carrier shall monitor, on an ongoing basis, the ability, clinical capacity, financial capability, and legal authority of its providers to furnish all contracted benefits to covered persons. 2. If a health carrier does not meet network adequacy standards in a particular geographic area, the Commissioner shall have authority to request and obtain from the health carrier data or information pertaining to the health carrier’s efforts to comply with this section and to obtain contracts with providers/facilities and use this information in his determination under this provision. This authority shall extend to contracts offered to but declined by providers/facilities, and to provider applications that were denied by the health carrier. A health carrier shall maintain records as to all providers/facilities who apply to be a participating provider but were denied such status, along with an explanation of why such status was denied by the health carrier. E. Beginning June 1, 2025, a health carrier shall file with the Commissioner, in addition to the information required to be submitted in this Regulation and the Managed Care Plan Certification Regulation, an access plan meeting the requirements of Rule 14.05 for each of the managed care plans that the carrier offers in this state. The health carrier shall make the access plans, absent proprietary or confidential commercial or financial information, available on its business premises and shall provide them to any interested party upon request. The health carrier shall prepare an access plan before offering a new managed care plan and shall update an existing access plan whenever it makes any material change to an existing managed care plan. The access plan shall describe or contain at least the following: 1. The health carrier’s network; 2. The health carrier’s procedures for making referrals within and outside its network; 3. The health carrier’s process for monitoring and assuring on an ongoing basis the sufficiency of the network to meet the health care needs of populations that enroll in managed care plans; 4. The health carrier’s efforts to address the needs of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with physical and mental disabilities; 5. The health carrier’s methods for assessing the health care needs of covered persons and their satisfaction with services; 6. The health carrier’s method of informing covered persons of the plan’s services and features, including, but not limited to, the plan’s grievance procedures, its process for choosing and changing providers, and its procedures for providing and approving emergency and specialty care; 7. The health carrier’s system for ensuring the coordination and continuity of care for covered persons referred to specialty physicians, for covered persons using ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning; 8. The health carrier’s process for enabling covered persons to change primary care professionals; 9. The health carrier’s proposed plan for providing continuity of care in the event of contract termination between the health carrier and any of its participating providers, or in the event of the health carrier’s insolvency or other inability to continue operations. The description shall explain how covered persons will be notified of the contract termination, or the health carrier’s insolvency or other cessation of operations, and transferred to other providers in a timely manner; and 10. Any other information required by the Commissioner to determine compliance with the provisions of this Regulation.