Md. Code Regs. 31.10.44.03

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.44.03 - Network Adequacy Standards

A. Sufficiency Standards.

(1) A carrier shall develop and maintain a network of providers in sufficient numbers, geographic locations, and practicing specialties to ensure enrollees have access to participating providers for the full scope of benefits and services covered under the carrier's health benefit plan.

(2) A carrier shall establish written policies and procedures to implement a process for addressing network deficiencies that result in an enrollee lacking access to any providers with the professional training and expertise necessary to deliver a covered service without unreasonable travel or delay.

(3) A carrier shall clearly define and specify referral requirements, if any, to specialty and other providers.

(4) A carrier shall take reasonable steps to ensure that participating providers provide physical access, reasonable accommodations, and accessible equipment for enrollees with physical or mental disabilities.

(5) A carrier's written policies and procedures to monitor availability of services shall include how the carrier will monitor the availability of services for:

(a) Continuing care patients;

(b) Individuals with physical or mental disabilities, including individuals who have disabilities that limit their physical ability to access services; and

(c) Individuals with limited English proficiency, including diverse cultural and ethnic backgrounds.

(6) A carrier shall take reasonable steps to ensure services are delivered in a culturally competent manner to all enrollees, including enrollees:

(a) With limited English proficiency;

(b) With diverse cultural, racial, and ethnic backgrounds; and

(c) Of all genders, sexual orientations, and gender identities.

(7) A carrier must have the ability to identify, by county and for the City of Baltimore, the number of participating providers for each facility type listed in the charts in Regulation .05A(5) and B(5) of this chapter and each provider type code and specialty code listed on the uniform credentialing form described in Insurance Article, § 15-112.1, Annotated Code of Maryland.

(8) The identification of the number of participating providers described in §A(7) of this regulation:

(a) Shall include either:

(i) All participating providers who were credentialed for a specific provider type or specialty code listed in the uniform credentialing form described in Insurance Article, § 15-112.1, Annotated Code of Maryland; or

(ii) All participating providers who reported a specific provider type or specialty code when completing the uniform credentialing form described in Insurance Article, § 15-112.1, Annotated Code of Maryland; and

(b) May include additional participating providers identified by the carrier through other documented means.

(9) A carrier shall retain copies of its policies and procedures required by this chapter for a period of 3 years following the date the policies and procedures were last effective.

(10) At the request of the Commissioner, a carrier shall file with the Commissioner a copy of its current and retained past policies and procedures required by this chapter. A carrier may request a finding by the Commissioner that its policies and procedures are considered confidential commercial information.

B. Monitoring Sufficiency Standards.

(1) A carrier shall continuously monitor its provider network for compliance with this chapter and shall conduct internal compliance audits for the standards listed in Regulations .05, .06, and .07 of this chapter on at least a quarterly basis; and

(2) A carrier shall continuously verify and update its network directory consistent with Insurance Article, § 15-112, Annotated Code of Maryland and §2799A-5 of the Public Health Service Act, enacted by 116 of the federal No Surprises Act.

Md. Code Regs. 31.10.44.03

Regulation .03 adopted effective 44:25 Md. R. 1180, eff. 12/31/2017; amended effective 50:9 Md. R. 380, eff. 5/15/2023