Md. Code Regs. 31.10.44.04

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

Section 31.10.44.04 - Filing and Content of Access Plan

A. Using the instructions on the Maryland Insurance Administration's website for submission method and to determine rural, suburban, and urban zip code areas, each carrier subject to this chapter shall file an annual access plan with the Commissioner on or before July 1 of each year for each provider panel used by the carrier, with the first access plan filing due on or before July 1, 2018.

B. If a carrier makes a material change to an access plan, the carrier shall:

(1) Notify the Commissioner of the change in writing within 15 business days after the material change to the access plan occurs; and

(2) Include in the notice required under §B(1) of this regulation a reasonable timeframe within which the carrier will file with the Commissioner an update to the existing access plan for review by the Commissioner.

C. Each annual access plan filed with the Commissioner shall include the following information in the standardized format described on the Maryland Insurance Administration's website:

(1) An executive summary in the form set forth in Regulation .11 of this chapter;

(2) The information and process required by Insurance Article, § 15-112(c)(4), Annotated Code of Maryland, and the methods used by the carrier to comply with the monitoring requirement under §15-112(c)(5);

(3) A description of out-of-network claims received by the carrier in the prior calendar year, which shall include:

(a) The percentage of total claims received that are out-of-network claims;

(b) The percentage of out-of-network claims received that are paid;

(c) The percentage of claims described in §C(3)(a) and (b) of this regulation that the carrier identifies as claims for emergency services, on-call physicians, or hospital-based physicians;

(d) The percentage of total claims received that are out-of-network claims for:

(i) Subject to §G of this regulation, all enrollees with a residence in a zip code where less than 100 percent of enrollees have access to a provider within the applicable travel distance standard in Regulation .05 of this chapter for the provider type in the claim, listed by provider type for each of the rural, suburban, and urban areas;

(ii) Subject to §G of this regulation, the ten provider types with the highest number of out-of-network claims for enrollees with a residence in each of the rural, suburban, and urban areas, listed by provider type and geographic area; and

(iii) Subject to §G of this regulation, the ten provider types with the highest percentage of total claims that are out-of-network claims for enrollees with a residence in each of the rural, suburban, and urban areas, listed by provider type and geographic area;

(e) For each provider type and geographic area described in §C(3)(d) of this regulation, the following information regarding requests to obtain a referral to an out-of-network provider in accordance with Insurance Article, § 15-830, Annotated Code of Maryland:

(i) The number of referral requests received;

(ii) The number of referral requests granted;

(iii) The percentage of out-of-network claims received for which a referral was requested;

(iv) The percentage of out-of-network claims received for which a referral was granted;

(v) The number of single case agreements requested between the carrier and an out-of-network provider;

(vi) The number of single case agreements entered between the carrier and an out-of-network provider;

(vii) The percentage of out-of-network claims received for which a single case agreement was requested between the carrier and an out-of-network provider; and

(viii) The percentage of out-of-network claims received for which a single case agreement was entered between the carrier and an out-of-network provider; and

(f) Any additional information deemed necessary by the carrier to provide context for the information described in §C(3)(a)-(e) of this regulation;

(4) A description of complaints received by the carrier in the prior calendar year relating to access to or availability of providers, which shall include:

(a) The total number of complaints made by enrollees relating to the waiting time or distance of participating providers;

(b) The total number of complaints made by providers, whether or not under contract, relating to the waiting time or distance of participating providers;

(c) The total number of complaints relating to the accuracy of the network directory;

(d) The total number of complaints relating to the dollar amount of reimbursement for out-of-network claims, including balance billing; and

(e) The percentage of complaints described in §C(4)(d) of this regulation that are for claims subject to the federal No Surprises Act;

(5) A description of the carrier's procedures, including training of customer service representatives, detailing how claims will be handled when participating providers are not available and an enrollee obtains health care services pursuant to Insurance Article, § 15-830, Annotated Code of Maryland;

(6) A description of the procedures that the carrier will utilize to assist enrollees in obtaining medically necessary services when no participating provider is available without unreasonable travel or delay, including procedures to coordinate care and to limit the likelihood of costs to the enrollee that exceed the amount that would have been incurred had the health care services been provided by a participating provider;

(7) A description of whether the carrier's provider contracts require health care providers to engage in appointment management, including procedures related to:

(a) No show policies;

(b) Patient appointment confirmation;

(c) Same day appointment slotting;

(d) Patient portals;

(e) Access to a provider performance dashboard to monitor appointment lag time, no show rate, bump rate (health care provider initiated cancelation of a scheduled appointment), and new patient appointments; and

(f) Weekly polling programs of providers to check for appointment availability;

(8) An indication of whether the network directory is searchable by covered benefit, for example, hearing aid, knee surgery, or physical therapist;

(9) An indication of whether the carrier has a patient portal for enrollees to make health care appointments;

(10) A description of whether the carrier has a formal process for assisting enrollees who have been unsuccessful in using the network directory to locate an appropriate provider with the necessary skill and expertise to treat the enrollee's condition;

(11) A description of whether and how the carrier considered the role of public transportation in addressing the needs of enrollees who do not own a personal automobile when evaluating enrollees' access to care under the travel distance standards described in Regulation .05 of this chapter;

(12) A description of telehealth utilization as described in Regulation .08 of this chapter;

(13) Documentation justifying to the Commissioner how the access plan meets each network sufficiency standard set forth in Regulations .05 - .07 of this chapter; and

(14) A list of all changes made to the access plan filed the previous year.

D. The Commissioner may require a carrier to include in the annual access plan a report of the number of participating providers described in Regulation .03A(7) of this chapter for designated facility types, provider type codes, and specialty codes, if the Commissioner notifies the carrier in writing and identifies the particular facility types, provider type codes, and specialty codes that must be reported.

E. The description required by Insurance Article, § 15-112(c)(4)(iii), Annotated Code of Maryland shall identify whether the carrier has:

(1) Engaged in outreach to minority health care providers; and

(2) Offered financial incentives, such as payment towards loans previously incurred for health care provider education, to encourage health care providers to contract with the carrier.

F. The description required by Insurance Article, § 15-112(c)(4)(iv), Annotated Code of Maryland shall include:

(1) The number of primary care providers who report to the carrier that they use any of the following languages in their practices:

(a) American Sign Language;

(b) Spanish;

(c) Korean;

(d) Chinese (Mandarin or Cantonese);

(e) Tagalog; or

(f) French;

(2) A description of outreach efforts to recruit and retain providers from diverse cultural, racial, or ethnic backgrounds;

(3) A copy of the most recent enrollees' language needs assessment made by or on behalf of the carrier, if one was made;

(4) A copy of the most recent demographic profile of the enrollee population made by or on behalf of the carrier, if one was made;

(5) A copy of any analysis or assessment made of provider network requirements based on an assessment of language needs or demographic profile of the enrollee population;

(6) A copy of any provider manual provisions that describe requirements for access to individuals with physical or mental disabilities; and

(7) Copies of policies and procedures designed to ensure that the provider network is sufficient to address the needs of both adult and child enrollees, including adults and children with:

(a) Limited English proficiency or illiteracy;

(b) Diverse cultural, racial, or ethnic backgrounds;

(c) Physical or mental disabilities; and

(d) Serious, chronic, or complex health conditions.

G. For a group model HMO plan, when an enrollee's place of employment is used instead of residence to calculate travel distance under Regulation .05B of this chapter, the data described in §C(3) of this regulation that is based on enrollee residence shall be reported based on the enrollee's place of employment.

H. The requirements found in §§C(3)-(12) and D- G of this regulation shall apply to annual access plans submitted on or after July 1, 2024.

I. A carrier may file the information described in §C(3), (4), and (12) of this regulation separately from the other access plan materials described in §C of this regulation, provided the information described in §C(3), (4), and (12) of this regulation is submitted by a calendar day that shall be designated in a bulletin issued by the Commissioner at least 60 days prior to such filing date. The date by which the information described in §C(3), (4), and (12) of this regulation must be filed shall be set later in time than July 1 of the reporting year.

Md. Code Regs. 31.10.44.04

Regulation .04 adopted effective 44:25 Md. R. 1180, eff. 12/31/2017; amended and recodified from .03 effective 50:9 Md. R. 380, eff. 5/15/2023