Md. Code Regs. 31.10.44.05

Current through Register Vol. 51, No. 22, November 1, 2024
Section 31.10.44.05 - Travel Distance Standards
A. Sufficiency Standards.
(1) Standard and Methodology.
(a) Except as stated in §B of this regulation, each provider panel of a carrier shall have within the geographic area served by the carrier's network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §A(5) of this regulation for each type of geographic area.
(b) The distances listed in §A(5) of this regulation shall be:
(i) Measured from the enrollee's place of residence to the practicing location of the provider or facility; and
(ii) Calculated based on road travel distance.
(c) Except for those provider types excluded under §A(3) of this regulation, for each provider type and facility type included on the carrier's provider panel, the carrier shall:
(i) Map the residences of all Maryland enrollees covered under health benefit plans that use the provider panel;
(ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
(iii) For each zip code, identify the total number of enrollees residing in the zip code and the number of enrollees residing within an area where the applicable distance standard is not met;
(iv) For each zip code, calculate the percentage of enrollees residing within an area where the applicable distance standard is met;
(v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees residing in the zip code;
(vi) For each of the urban, rural, and suburban areas identify the total number of enrollees residing in the geographic area;
(vii) For each of the urban, rural, and suburban areas identify the total number of enrollees residing within an area where the applicable distance standard is not met; and
(viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees residing within an area where the applicable distance standard is met.
(d) Instead of independently calculating the road travel distance for each enrollee as described in §A(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:
(i) Maps the practicing locations of every participating provider within the geographic area served by the carrier's network or networks;
(ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
(iii) Enables the carrier to accurately identify the information and perform the calculations described in §A(1)(c)(iii)-(viii) of this regulation.
(e) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:
(i) Geo-access maps for each provider type and facility type except for those excluded under §A(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence outside the applicable distance standard;
(ii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier's provider panel that provide adolescent services; and
(iii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier's provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
(f) A carrier shall report each number and percentage described in §A(1)(c)(iii)-(viii) of this regulation as part of the annual access plan filing.
(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the standards listed in §A(5) of this regulation.
(3) The travel distance standards listed in §A(5) of this regulation do not apply to the following:
(a) Home health care;
(b) Durable medical equipment;
(c) Heart transplant programs;
(d) Heart or lung transplant programs;
(e) Kidney transplant programs;
(f) Liver transplant programs;
(g) Lung transplant programs; or
(h) Pancreas transplant programs.
(4) All other providers and facility types included on the carrier's provider panel but not listed in the chart in §A(5) of this regulation, including physical therapists and licensed dietitian-nutritionist, shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.
(5) Chart of Travel Distance Standards.

Urban Area Maximum Distance (miles)

Suburban Area Maximum Distance (miles)

Rural

Area Maximum Distance (miles)

Provider Type:

Addiction Medicine

10

25

60

Allergy and Immunology

15

30

75

Applied Behavioral Analyst

15

30

60

Cardiovascular Disease

10

20

60

Chiropractic

15

30

75

Dermatology

10

30

60

Endocrinology

15

40

90

ENT/Otolaryngology

15

30

75

Gastroenterology

10

30

60

General Surgery

10

20

60

Gynecology, OB/GYN, Nurse-Midwifery/Certified Midwifery

5

10

30

Licensed Clinical Social Worker

10

25

60

Licensed Professional Counselor

10

25

60

Nephrology

15

25

75

Neurology

10

30

60

Oncology-Medical and Surgical

10

20

60

Oncology-Radiation/Radiation Oncology

15

40

90

Ophthalmology

10

20

60

Pediatrics-Routine/Primary Care

5

10

30

Physiatry, Rehabilitative Medicine

15

30

75

Plastic Surgery

15

40

90

Podiatry

10

30

60

Primary Care (non-pediatric)

5

10

30

Psychiatry-Adolescent and Child, Outpatient

10

25

60

Psychiatry-Geriatric, Outpatient

10

25

60

Psychiatry-Outpatient

10

25

60

Psychology

10

25

60

Pulmonology

10

30

60

Rheumatology

15

40

90

Urology

10

30

60

All Other licensed or certified providers under contract with a carrier not listed

15

40

90

Facility Type:

Acute Inpatient Hospitals

10

30

60

Ambulatory Infusion Therapy Centers

10

30

60

Critical Care Services - Intensive Care Units

10

30

100

Diagnostic Radiology

10

30

60

Inpatient Psychiatric Facility

15

45

75

Opioid Treatment Services Provider

15

25

60

Outpatient Dialysis

10

30

50

Outpatient Mental Health Clinic

15

30

60

Outpatient Substance Use Disorder Facility

15

30

60

Pharmacy

5

10

30

Residential Crisis Services

10

30

60

Skilled Nursing Facilities

10

30

60

Substance Use Disorder Residential Treatment Facility

10

25

60

Surgical Services (Outpatient or Ambulatory Surgical Center)

10

30

60

All other licensed or certified facilities under contract with a carrier not listed

15

40

90

B. Group Model HMO Plans Sufficiency Standards.
(1) Standard and Methodology.
(a) Each group model HMO's health benefit plan's provider panel shall have within the geographic area served by the group model HMO's network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §B(5) of this regulation for each type geographic area.
(b) The distances listed in §B(5) of this regulation shall be:
(i) Measured from the enrollee's place of residence or, at the option of the carrier, place of employment from which the enrollee gains eligibility for participation in the group model HMO's health benefit plan to the practicing location of the provider or facility; and
(ii) Calculated based on road travel distance.
(c) Except for those provider types excluded §B(3) of this regulation, for each provider type and facility type included on the group model HMO's provider panel, the carrier shall:
(i) Map the residences or places of employment of all Maryland enrollees covered under health benefit plans that use the provider panel;
(ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
(iii) For each zip code identify the total number of enrollees with a residence or place of employment in the zip code and the number of enrollees with a residence or a place of employment within an area where the applicable distance standard is not met;
(iv) For each zip code calculate the percentage of enrollees with a residence or place of employment within an area where the applicable distance standard is met;
(v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees with a residence or place of employment within the zip code;
(vi) For each of the urban, rural, and suburban areas identify the total number of enrollees with a residence or place of employment in the geographic area;
(vii) For each of the urban, rural, and suburban areas identify the number of enrollees with a residence or place of employment within an area where the applicable distance standard is not met; and
(viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees with a residence or place of employment within an area where the applicable distance standard is met.
(d) Instead of independently calculating the road travel distance for each enrollee as described in §B(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:
(i) Maps the practicing locations of every participating provider within the geographic area served by the group model HMO's network or networks;
(ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
(iii) Enables the carrier to accurately identify the information and perform the calculations described in §B(1)(c)(iii)-(viii) of this regulation.
(e) When calculating the number or percentage of enrollees with a place of employment within an area or zip code under §B(1)(c)(iii)-(viii) of this regulation, the carrier shall include only those enrollees who gain eligibility for participation in the group model HMO's health benefit plan from their place of employment.
(f) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:
(i) Geo-access maps for each provider type and facility type except for those excluded under §B(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence or place of employment outside the applicable distance standard;
(ii) For any facility types listed in §B(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier's provider panel that provide adolescent services; and
(iii) For any facility types listed in §B(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier's provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
(g) A carrier shall report each number and percentage described in §B(1)(c)(iii)-(viii) of this regulation as part of the annual access plan filing.
(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the standards listed in §B(5) of this regulation.
(3) The travel distance standards listed in §B(5) of this regulation do not apply to the following:
(a) Home health care;
(b) Durable medical equipment;
(c) Heart transplant programs;
(d) Heart or lung transplant programs;
(e) Kidney transplant programs;
(f) Liver transplant programs;
(g) Lung transplant programs; or
(h) Pancreas transplant programs.
(4) All other provider and facility types included on the carrier's provider panel, but not listed in the chart at §B(5) of this regulation, including physical therapists and licensed dietitian-nutritionist, shall individually be required to meet maximum distances standards of 20 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.
(5) Chart of Travel Distance Standards.

Urban Area Maximum Distance (miles)

Suburban Area Maximum Distance (miles)

Rural Area Maximum Distance (miles)

Provider Type:

Addiction Medicine

15

30

75

Allergy and Immunology

20

30

75

Applied Behavioral Analyst

15

20

60

Cardiovascular Disease

15

25

60

Chiropractic

20

30

75

Dermatology

20

30

60

Endocrinology

20

40

90

ENT/Otolaryngology

20

30

75

Gastroenterology

20

30

60

General Surgery

20

30

60

Gynecology, OB/GYN, Nurse-Midwifery/Certified Midwifery

15

20

45

Licensed Clinical Social Worker

15

30

75

Licensed Professional Counselor

15

30

75

Nephrology

15

30

75

Neurology

15

30

60

Oncology-Medical, Surgical

15

30

60

Oncology-Radiation/Radiation Oncology

15

40

90

Ophthalmology

15

20

60

Pediatrics-Routine/Primary Care

15

20

45

Physiatry, Rehabilitative Medicine

15

30

75

Plastic Surgery

15

40

90

Podiatry

15

30

90

Primary Care (non-pediatric)

15

20

45

Psychiatry-Adolescent and Child, Outpatient

15

30

60

Psychiatry-Geriatric, Outpatient

15

30

60

Psychiatry-Outpatient

15

30

60

Psychology

15

30

60

Pulmonology

15

30

60

Rheumatology

15

40

90

Urology

15

30

60

All Other licensed or certified providers under contract with a carrier not listed

20

40

90

Facility Type:

Acute Inpatient Hospitals

15

30

60

Ambulatory Infusion Therapy Center

15

30

60

Critical Care Services-Intensive Care Units

15

30

120

Diagnostic Radiology

15

30

60

Inpatient Psychiatric Facility

15

45

75

Opioid Treatment Services Provider

15

30

60

Outpatient Dialysis

15

30

60

Outpatient Mental Health Clinic

15

30

60

Outpatient Substance Use Disorder Facility

15

30

60

Pharmacy

5

10

30

Residential Crisis Services

15

30

60

Skilled Nursing Facilities

15

30

60

Substance Use Disorder Residential

Treatment Facility

15

30

60

Surgical Services (Outpatient or Ambulatory Surgical Center)

10

30

60

All other licensed or certified facilities under contract with a carrier not listed

15

40

120

C. Essential Community Providers.
(1) Each provider panel of a carrier, that is not a group model HMO provider panel, shall include:
(a) At least 30 percent of the available essential community providers providing medical services in each of the urban, rural, and suburban areas;
(b) At least 30 percent of the available essential community providers providing mental health services in each of the urban, rural, and suburban areas; and
(c) At least 30 percent of the available essential community providers providing substance use disorder services in each of the urban, rural, and suburban areas.
(2) Methodology for calculating essential community provider inclusion standard.
(a) Except as provided in §§C(2)(b) and (c) of this regulation, a carrier shall use the MHBE ECP Network Inclusion Calculation Methodology that is described in the Instructions on Meeting the Essential Community Provider Plan Certification Standard guidance provided by the Maryland Health Benefit Exchange, which is current as of the date 3 months prior to the due date of the annual access plan.
(b) The calculation described in §C(2)(a) of this regulation shall be performed separately for essential community providers providing medical services, mental health services, and substance use disorder services in each of the urban, rural, and suburban areas.
(c) If the Maryland Health Benefit Exchange changes the MHBE ECP Network Inclusion Calculation Methodology after the effective date of this regulation, a carrier may not use the revised methodology to calculate the essential community provider inclusion standard in §C(1) of this regulation unless the Commissioner has approved the revised methodology for this purpose.
(3) Each group model HMO plan shall demonstrate that its own providers located in Health Professional Shortage Areas or low-income zip codes within its service area perform at or above the 50th percentile on the following two HEDIS measures:
(a) Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment; and
(b) Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults.
(4) Each group model HMO plan shall demonstrate that it has alternative standards for addressing the needs of low income, medically underserved individuals. One manner in which a group model HMO may demonstrate this is by providing the Maryland Insurance Administration with its narrative or alternate standard justification to the essential community provider requirement, which was submitted to and accepted by the Maryland Health Benefit Exchange for certification as a qualified health plan.

Md. Code Regs. 31.10.44.05

Regulation .05 adopted effective 44:25 Md. R. 1180, eff. 12/31/2017; amended and recodified from .04 effective 50:9 Md. R. 380, eff. 5/15/2023