Sufficient Network of Providers — Determining Compliance — Timeliness
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Each managed health insurance issuer that offers a plan that limits its enrollees' choice of providers shall maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have access to health care services twenty-four (24) hours per day, seven (7) days per week. Sufficiency shall be determined in accordance with the requirements of this section and may be established by reference to network adequacy standards established by the managed health insurance issuer, specifically:
Primary care provider-covered person ratios; and
Geographic accessibility;
The network adequacy standards description shall be filed with the commissioner and updated annually.
In addition to establishing the standards required pursuant to subsection (a), the managed health insurance issuer's network shall demonstrate the following:
An adequate number of acute care hospital services, within a reasonable distance or travel time;
An adequate number of primary care providers within not more than thirty (30) miles distance or thirty (30) minutes travel time at a reasonable speed;
An adequate number of specialists and subspecialists, within a reasonable distance or travel time;
A comprehensive listing, made available to covered persons and health care providers, of the plan's network participating providers and facilities, and the listing shall be supplemented to show additions and deletions, if any exist, at least annually;
The procedures for making referrals within and outside its network that, at a minimum, shall include the following:
A process for expediting the referral process when indicated by a medical condition; and
A provision that referrals approved by the plan cannot be retrospectively denied except for fraud or abuse, subject to the eligibility and coverage provisions of the contract;
The 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 plans;
The quality assurance standards, adequate to identify, evaluate, and remedy problems relating to access, continuity, and quality of care;
The system for ensuring the coordination of care for covered persons receiving approved care from specialty providers; and
Any other information required by the commissioner to determine compliance with this part.
In any case where the managed health insurance issuer has no participating providers to provide a covered benefit, the managed health insurance issuer shall arrange for a referral to a provider with the necessary expertise and ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit were obtained from a network provider.
In determining whether a managed health insurance issuer has complied with this section, consideration shall be given to the relative availability of health care providers, specialists and subspecialists in the service area under consideration. Relative availability includes the acceptance by the health care providers, specialists or subspecialists of the terms, conditions and fees offered under the contract or plan. A network shall not be deemed inadequate solely because the network does not include a provider, specialist or subspecialist who is the sole provider in the community, if the provider, specialist or subspecialist refuses to contract with the managed health insurance issuer on terms and conditions substantially similar to providers, specialists or subspecialists in contiguous communities.
Health care providers who participate in a managed health insurance issuer's plan shall provide timely appointments to patients and shall see the patients on a timely basis after arrival for an appointment. A managed health insurance issuer may include in its contracts with health care providers provisions that establish the meaning of timeliness.
Providers who do not participate in a managed health insurance issuer's plan but seek reimbursement through the point of service option mandated in § 56-32-128 shall have the obligation to provide appointments on a timely basis and, upon arrival for appointments, the provider shall see the patient on a timely basis; provided, that timeliness shall be consistent with usual and customary standards for the community in which the provider is located. Frequent and repetitive failure to comply with this subsection (f) may be cause for the managed health insurance issuer to withhold reimbursement from the nonparticipating provider.