§431:26-103 Network adequacy. (a) Network adequacy requirements shall be as follows:
(1) A health carrier providing a network plan shall maintain a network that is sufficient in numbers and appropriate types of providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered benefits will be accessible without unreasonable travel or delay; and
(2) Covered persons shall have access to emergency services twenty-four hours per day, seven days per week.
(b) The commissioner shall determine sufficiency in accordance with the requirements of this section by considering any reasonable criteria, which may include but shall not be limited to:
(1) Provider-to-covered person ratios by specialty;
(2) Primary care professional-to-covered person ratios;
(3) Geographic accessibility of providers;
(4) Geographic variation and population dispersion;
(5) Waiting times for an appointment with participating providers;
(6) Hours of operation;
(7) The ability of the network to meet the needs of covered persons, which may include low-income persons, children and adults with serious, chronic, or complex health conditions or physical or mental disabilities, or persons with limited English proficiency;
(8) Other health care service delivery system options, such as telehealth, mobile clinics, centers of excellence, integrated delivery systems, and other ways of delivering care; and
(9) The volume of technologically advanced and specialty care services available to serve the needs of covered persons requiring technologically advanced or specialty care services.
(c) A health carrier shall have the following process requirements:
(1) A health carrier shall have a process to ensure that a covered person obtains a covered benefit at an in-network level of benefits, including an in-network level of cost-sharing, from a nonparticipating provider, or shall make other arrangements acceptable to the commissioner when:
(A) The health carrier has a sufficient network but does not have a type of participating provider available to provide the covered benefit to the covered person or does not have a participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay; or
(B) The health carrier has an insufficient number or type of participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay;
(2) The health carrier shall specify and inform covered persons of the process a covered person may use to request access to obtain a covered benefit from a nonparticipating provider as provided in paragraph (1) when:
(A) The covered person is diagnosed with a condition or disease that requires specialty care; and
(B) The health carrier:
(i) Does not have a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease; or
(ii) Cannot provide reasonable access to a participating provider with the required specialty and who possesses the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable travel or delay;
(3) The health carrier shall treat the health care services the covered person receives from a nonparticipating provider pursuant to paragraph (2) as if the services were provided by a participating provider, including counting the covered person's cost-sharing for those services toward the maximum out-of-pocket limit applicable to services obtained from participating providers under the health benefit plan;
(4) The process described in paragraphs (1) and (2) shall ensure that requests to obtain a covered benefit from a nonparticipating provider are addressed in a timely fashion appropriate to the covered person's condition;
(5) The health carrier shall establish and maintain a system that documents all requests to obtain a covered benefit from a nonparticipating provider pursuant to this subsection and shall provide this information to the commissioner upon request;
(6) The process established pursuant to this subsection is not intended to be used by health carriers as a substitute for establishing and maintaining a sufficient provider network in accordance with this article nor is it intended to be used by covered persons to circumvent the use of covered benefits available through a health carrier's network delivery system options; and
(7) This section does not prevent a covered person from exercising the rights and remedies available under applicable state or federal law relating to internal and external claims grievance and appeals processes.
(d) The health carrier shall be subject to the following adequate arrangement requirements:
(1) A health carrier shall establish and maintain adequate arrangements to ensure covered persons have reasonable access to participating providers located near their home or business address. In determining whether the health carrier has complied with this paragraph, the commissioner shall give due consideration to the relative availability of health care providers with the requisite expertise and training in the service area under consideration; and
(2) A health carrier shall monitor, on an ongoing basis, the ability, clinical capacity, and legal authority of its participating providers to furnish all contracted covered benefits to covered persons.
(e) [Repeal and reenactment on July 1, 2024. L 2019, c 70, §36(2).] A health carrier shall meet the following access plan requirements:
(1) Beginning on July 1, 2017, a health carrier shall file with the commissioner for approval, prior to or at the time it files a newly offered network plan, in a manner and form defined by rule or order of the commissioner, an access plan that meets the requirements of this article;
(2) The health carrier may request the commissioner to deem sections of the access plan as proprietary, competitive, or trade secret information that shall not be made public. Information is proprietary, competitive, or a trade secret if disclosure of the information would cause the health carrier's competitors to obtain valuable business information. The health carrier shall make the access plans, absent proprietary, competitive, or trade secret information, available online, at the health carrier's business premises, and to any person upon request; and
(3) The health carrier shall prepare an access plan prior to offering a new network plan and shall notify the commissioner of any material change to any existing network plan within fifteen business days after the change occurs. The carrier shall include in the notice to the commissioner a reasonable time frame within which the carrier will submit to the commissioner for approval or file with the commissioner, as appropriate, an update to an existing access plan.
(f) In addition to the requirements of subsection (e), the access plan shall describe or contain at least the following:
(1) The health carrier's network, including how telehealth or other technology may be used to meet network access standards, if applicable;
(2) The health carrier's procedures for making and authorizing referrals within and outside its network, if applicable;
(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 network plans;
(4) The factors the health carrier uses to build its provider network, including a description of the network and the criteria used to select providers;
(5) The health carrier's efforts to address the needs of covered persons, including children and adults, those with limited English proficiency, illiteracy, diverse cultural or ethnic backgrounds, physical or mental disabilities, and serious, chronic, or complex medical conditions. Information required under this paragraph shall include the carrier's efforts, when appropriate, to include various types of essential community providers in the carrier's network. A health carrier that is subject to the Affordable Care Act alternative standard shall demonstrate to the commissioner that the health carrier meets that standard;
(6) The health carrier's methods for assessing the health care needs of covered persons and the covered persons' satisfaction with services;
(7) The health carrier's method of informing covered persons of the plan's covered services and features, including:
(A) The plan's grievance and appeals procedures;
(B) The plan's process for choosing and changing providers;
(C) The plan's process for updating its provider directories for each of its network plans;
(D) A statement of health care services offered, including those services offered through the preventive care benefit, if applicable; and
(E) The plan's procedures for covering and approving emergency, urgent, and specialty care, if applicable;
(8) The health carrier's system for ensuring the coordination and continuity of care:
(A) For covered persons referred to specialists; and
(B) For covered persons using ancillary services, including social services and other community resources, if applicable;
(9) The health carrier's process for enabling covered persons to change primary care professionals, if applicable;
(10) The health carrier's proposed plan for providing continuity of care if a contract termination occurs 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 proposed plan for providing continuity of care shall explain how covered persons will be notified of the contract termination, or the health carrier's insolvency or other cessation of operations, and transitioned to other providers in a timely manner; and
(11) Any other information required by the commissioner to determine compliance with this article. [L 2017, c 191, pt of §1; am L 2019, c 70, §25]