Section 031-850-7 - Access to Services In addition to the requirements of Title 24-A, Chapter 56 or otherwise required by rule a carrier offering a managed care plan is subject to the requirements of this section.
A.Access Plan In addition to the requirements of 24-A M.R.S.A. §4203(3) or requirements otherwise provided by rule, a carrier's application for approval of a managed care plan, application for an HMO certificate of authority, or application for a Preferred Provider Arrangement registration shall include an Access Plan. Carriers shall, consistent with the requirements of section 11 of this rule, file annual Access Plan information updates reflecting any changes to previously filed information, except that consistent with the requirements of Title 24-A M.R.S.A. §4204(8), the net loss of 5 or more primary care physicians in any county in any 30-day period must be reported within 10 days. Access Plans must include a description of the provider network, including:
1) A current list of all providers and facilities;2) The projected ratio of primary care providers to enrollees by county;3) Written standards for providing a network that is sufficient in numbers and types of providers to assure that all services to covered persons will be reasonably accessible without unreasonable delay. Standards must be realistic for the community, the delivery system, and clinical safety. In establishing these standards, the carrier may incorporate standards published by independent standard-setting organizations and approved by the Superintendent.4) A description of the carrier's plan for providing services for rural and underserved populations and for developing relationships with essential community providers.5) A description of the carrier's plan for addressing the needs of patients needing coordinated care, frequent services, or other needs that might impede access to care. B.Access to Health Care Providers1)Primary Care. To the extent reasonably possible, carriers that offer managed care plans utilizing primary care providers shall maintain a minimum ratio of one full-time equivalent primary care provider to 2000 enrollees. Carriers shall ensure the availability of practitioners who provide primary care services, including general and internal medicine, family practice, and pediatrics.2)Specialty Care. To ensure reasonable access to specialty care practitioners within its delivery system, the carrier shall: a) Define the types of practitioners who serve as high-volume specialty care practitioners. At a minimum, high-volume specialties shall include obstetrics/gynecology, cardiology, dermatology, ophthalmology, orthopedic surgery, gastroenterology, and other specialties that the carrier determines to be high-volume.b) Establish quantifiable and measurable standards for the number and geographic distribution of each type of high-volume specialty care practitioner.c) Analyze performance against the standards at least annually. The assessment methodology selected must allow direct measurement against standards.3)Behavioral Health Care. Carriers shall ensure the reasonable availability of behavioral health care practitioners. To ensure the reasonable availability of high-volume behavioral health care practitioners within its delivery system, the carrier shall: a) Define the types of practitioners who are considered high-volume behavioral health care practitioners.b) Establish quantifiable and measurable standards for the number and geographic distribution of each type of high-volume behavioral health care practitioner.c) Analyze performance against the standards at least annually. The assessment methodology selected must allow direct measurement against standards.4) Carriers that offer managed care plans must provide enrollee access to medically necessary emergency services at all times, and access to urgent services.5) In any case where the carrier has an insufficient number or type of participating providers to provide a covered benefit, 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, or shall make other arrangements acceptable to the Superintendent.C.Timely Access To Health Care Services1) Health care services shall be made accessible by carriers offering managed care plans to their enrollees on a timely basis in accordance with medically appropriate guidelines consistent with generally accepted standards of care. Using valid methodology, each carrier shall collect and perform an annual analysis of data to measure performance against standards for access to: a) regular and routine care appointments;b) urgent care appointments;c) after-hours care; and d) member services by telephone.2) Using valid methodology, each carrier shall collect and annually analyze data to measure behavioral health care performance against standards for access to: a) care for non-life-threatening emergencies within 6 hours;b) urgent care within 48 hours; and c) an appointment for a routine office visit within 10 business days.D.Incentives to Use Providers That Have Been Designated on the Basis of Cost or Quality1) Carriers may offer enrollees incentives to use designated providers who have been selected on the basis of cost or quality. Any financial incentive to encourage enrollees to use specific providers designated on the basis of cost or quality must be an additional benefit to benefits otherwise provided under the plan.2) The carrier may not offer a financial incentive to obtain emergency services from a specific designated emergency services provider.3) Financial incentives may include, but are not limited to, waiver of copayments or coinsurance, waiver of deductibles, or travel expenses.4) Nothing in this subsection may be construed as superseding any applicable requirements relating to network adequacy, tiering programs, profiling programs, credentialing, or other laws regulating the administration of managed care plans.5) Carriers may not require enrollees to use designated providers as a condition of receiving benefits under the plan.E.Access To Emergency ServicesEmergency services must be provided in accordance with 24-A M.R.S.A. §4320-C.
F.Coordination of Care1) If the carrier offering a managed care plan requires primary care providers to make referrals to specialty physicians and ancillary services, the enrollee's primary care provider or the carrier shall initiate the referrals. Enrollees on whose behalf referrals have been made shall receive timely written notification of the referral including all relevant information.2) Carriers that require primary care providers to make referrals are responsible for the coordination, continuity of care and appropriate discharge planning for enrollees given a referral to specialty physicians, and for enrollees using ancillary services.3) Carriers are responsible for the coordination and continuity of care for enrollees in accordance with the requirements of 24-A M.R.S.A. §4303(6) 'Standing referrals to specialists' and §4303(7) 'Continuity of Care.' HMOs are responsible for the coordination and continuity of care for new enrollees who notify the HMO that, as of the effective date of enrollment in the HMO, they are undergoing care or treatment for covered services by providers not a part of the HMO's provider network. An HMO is not required to provide coverage for out-of-network services if it transfers an enrollee to a network provider without unreasonably disrupting the enrollee's ongoing care or treatment.4) An enrollee dissatisfied with an assigned or selected primary care provider shall be allowed to change primary care providers in accordance with defined carrier procedures and policies but at least after their initial sixty days of coverage and once a year thereafter.5) Carriers shall maintain a written plan providing for continuity of care in the event of contract termination between the carrier and any of its contracted providers, or in the event of site closings involving a primary care provider with more than one location of service. The written plan shall describe how enrollees with special needs or who are at special risk will be identified and how continuity of care will be provided. The written plan shall comply with the requirements of 24-A M.R.S.A. §4303(7)(A).G.Provider Credentialing for Carriers Offering Managed Care Plans (as Applicable)1) A carrier or the entity to whom credentialing is delegated shall credential all health professionals with whom the carrier contracts in accordance with written policies and procedures.2) A carrier shall make credentialing decisions, including those granting or denying credentials, within 60 days after receipt of a completed credentialing application from a provider. The time period for granting or denying credentials may be extended upon written notification from the carrier within 60 days following submission of a completed application stating that information contained in the application requires additional time for verification. All credentialing decisions must be made within 180 days after receipt of a completed application.3) A credentialing application is completed if the application includes all of the information required by the uniform credentialing application used by carriers and providers in this State, such attachments to that application as required by the carrier at the time of application and all corrections required by the carrier. A carrier shall review the entire application before returning it to the provider for corrections with a comprehensive list of all corrections needed at the time the application is first returned to the provider. A carrier may not require that a provider have a home address within the State before accepting an application.4) The carrier shall establish a credentialing committee consisting of licensed physicians and other health professionals to review credentialing information and supporting documents.5) The carrier's application and credentialing policies and procedures shall be made available for review by the health professional upon written request.6) Except as otherwise provided by law and by subparagraph 7(G)(12)(a), all information obtained by the carrier in the credentialing process shall be held confidential.7) The carrier shall retain all records and documents relating to a health professional's credentialing process for at least three years.8) A carrier, to the extent pertinent, shall obtain primary verification of at least the following information regarding the applicant: a) Current license, certificate of authority or registration to practice in the health field which the applicant has applied to practice in Maine;b) Status of hospital privileges;c) Current Drug Enforcement Agency (DEA) registration certificate; andd) Specialty board certification status.9) A carrier shall obtain the following, subject to either primary or secondary verification. Secondary verification may be obtained from the National Practitioner Data Bank or other national data banks authorized by the Superintendent.a) The health professional's license history for the preceding ten years in this and all other states including a chronological history of the health professional's health care license, dates, times and places, of all applications for license privileges, any action taken on the application, any challenges to licensure or registration, or the voluntary or involuntary relinquishment of a license;b) The health professional's malpractice history including any involvement in a professional liability action and any final judgment or settlement involving the individual health professional; andc) The health professional's practice history for the preceding five years including a chronological history of the health professional's health care practice, including staff membership, practice privileges, professional associations, dates and places of practice, any action taken on practice privileges, and the voluntary or involuntary relinquishment, suspension, limitation, reduction or loss of staff membership or practice privileges; andd) Current level of professional liability coverage.10) At least every 3 years the carrier shall obtain primary verification of: a) Current license or certificate of authority to practice medicine, osteopathy or other health profession in Maine;b) Status of hospital privileges; andc) Current DEA registration certificate.11) The carrier shall require all contracting health professionals to notify the carrier of any changes in the status of any of the items above at any time.12)Health Professional Review Processa) To the extent permitted by law, each health professional subject to the credentialing process shall have the right to review all information, including the source of that information, gathered by the carrier in satisfaction of the requirements of this section in the course of its credentialing and recredentialing processes as regards that health professional.b) Each health professional shall be notified of any information obtained during the carrier's credentialing process that does not meet the carrier's credentialing standards or that varies substantially from the information provided to the carrier by the health professional, except that the carrier shall not be required to reveal the source of information if the information is not obtained to meet the requirements of this section, or if disclosure is prohibited by law.c) A health professional shall have the right to submit for correction any erroneous information. Each carrier shall have a formal process whereby a health professional who feels the credentialing body has received incorrect or misleading information may request a reconsideration and submit supplemental information to the credentialing body. Supplemental information shall be subject to confirmation by the carrier.d) The carrier shall have a formal appeal procedure for dealing with: i) health professionals' concerns relating to the denial of credentialing for failure to meet the objective credentialing standards of the plan; and ii) provider concerns relating to the contractual relationship between the health professional and the carrier.e) Nothing in this section shall be construed to require a carrier to select a provider as a participating provider solely because the provider meets the carrier's credentialing verification standards, or to prevent a carrier from utilizing separate or additional criteria in selecting the health care professionals with whom it contracts. A carrier may utilize separate or additional criteria in selecting the health professionals with whom it contracts.02-031 C.M.R. ch. 850, § 7