N.J. Admin. Code § 11:24A-4.10

Current through Register Vol. 56, No. 7, April 1, 2024

Section 11:24A-4.10 - Network adequacy

(a) A carrier shall maintain an adequate network, as set forth in (b) below, of PCPs, specialists and other ancillary providers to assure that covered persons are able to access services in-network and take full advantage of the in-network benefits levels when the policy or contract specifies that there is a differential between the in-network and out-of-network benefits levels for one or more covered services, or the policy or contract is subject to a gatekeeper system.

1. The requirement that the network meet the adequacy standards of (b) below shall apply only to those services for which there is an in-network benefit, and if no in-network benefit exists for a specific service, the carrier is not required to meet the network adequacy standards with respect to the type of provider who typically renders that service.

2. Notwithstanding that a contract or policy may not be subject to a gatekeeper system, if the contract or policy requires that each covered person select or have a PCP, the carrier shall comply with (b) below with respect to the offering of that policy or contract.

(b) The carrier shall meet the following requirements for network adequacy:

1. The carrier shall have a sufficient number of physicians to assure that at least two physicians eligible as PCPs are within 10 miles or 30 minutes driving time or public transit time (if available), whichever is less, of 90 percent of the carrier's covered persons.

i. The carrier shall demonstrate sufficiency of network PCPs to meet the adult, pediatric and primary ob/gyn needs of the current and/or projected number of covered persons by assuming:

(1) Four primary care visits per year per member, averaging one hour per year per member; and

(2) Four patient visits per hour per PCP.

ii. To demonstrate PCP availability, a carrier shall verify that the PCP has committed to providing a specific number of hours for new patients that cumulatively add up to projected clinic hour needs of the projected number of covered persons by county or service area.

iii. The carrier shall demonstrate that the network of PCPs is sufficient to ensure that:

(1) If the carrier provides benefits for emergency services:

(A) Emergencies shall be triaged immediately through the PCP or by a hospital emergency department through medical screening or evaluation;

(B) Urgent care shall be provided within 24 hours of notification of the PCP or carrier; and

(C) In both emergent and urgent care, PCPs shall be required to provide seven day, 24 hour access to triage services;

(2) Routine appointments can be scheduled within at least two weeks; and

(3) Routine physical exams can be scheduled within at least four months.

2. The carrier shall have a sufficient number of the medical specialists, as applicable to the services covered in-network, to assure access within 45 miles or one hour driving time, whichever is less, of 90 percent of covered persons within each county or approved sub-county service area.

i. The carrier shall contract with a sufficient number of optometrists to assure access to an optometrist consistent with the requirements of (b)2 above, and the carrier shall not require that covered persons use the services of an opthalmologist rather than an optometrist in order to obtain benefits, unless referral by a PCP is determined to be medically required, and the care needed outside the scope of practice of an optometrist.

3. For institutional providers, the carrier shall maintain contracts or other arrangements acceptable to the Department sufficient to meet the medical needs of covered persons, and maintain geographic accessibility of the services provided through institutional providers, subject to no less than the following:

i. The carrier shall have a contract or arrangement with at least one licensed acute care hospital with licensed medical-surgical, pediatric, obstetrical and critical care services in any county or service area that is no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of covered persons within the county or service area.

ii. The carrier shall have a contract or arrangement with surgical facilities, including acute care hospitals, licensed ambulatory surgical facilities, and/or Medicare-certified physician surgical practices available in each county or service area that are no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of covered persons within the county or service area.

iii. The carrier shall have a contract or otherwise agree to cover medically necessary trauma services at a reasonable cost with all Level I or II trauma centers designated by the Department of Health and Senior Services, with the provision of benefits at the in-network level.

iv. The carrier shall have contracts or arrangements for the provision of the following specialized services at in-network benefit levels (if covered by one or more of the carrier's health benefits plans in network, and determined to be medically necessary), so that services will be available within 45 miles or 60 minutes average driving time, whichever is less, of 90 percent of covered persons within each county or service area:

(1) At least one hospital providing regional perinatal services;

(2) A hospital offering tertiary pediatric services;

(3) In-patient psychiatric services for adults, adolescents and children;

(4) Residential substance abuse treatment centers;

(5) Diagnostic cardiac catheterization services in a hospital;

(6) Specialty out-patient centers for HIV/AIDS, sickle cell disease, hemophilia, and cranio-facial and congenital anomalies; and

(7) Comprehensive rehabilitation services.

v. The carrier shall have a contract or arrangement so that the following specialized services may be provided at in-network benefit levels (if covered by one or more of the carrier's health benefits plans in network, and determined to be medically necessary), so that services will be available within 20 miles or 30 minutes average driving time, whichever is less, of 90 percent of covered persons within each county or service area:

(1) A licensed long-term care facility with Medicare-certified skilled nursing beds;

(2) Therapeutic radiation;

(3) Magnetic resonance imaging center;

(4) Diagnostic radiology, including x-ray, ultrasound, and CAT scan;

(5) Emergency mental health service, including a short term care facility for involuntary psychiatric admissions;

(6) Outpatient therapy for mental health and substance abuse conditions; and

(7) Licensed renal dialysis.

vi. The carrier shall have a contract or arrangement with at least one home health agency licensed by the Department of Health and Senior Services to serve each county where 1,000 or more covered persons reside.

vii. The carrier shall have a contract or arrangement with at least one hospice program certified by Medicare in any county where 1,000 or more covered persons reside, if hospice care is covered under the health benefits plan in-network.

(c) With respect to the provider specifications of (b)4 above, the carrier may request, and will receive, relief from the mileage requirements where the carrier can document to the satisfaction of the Department that appropriate access to alternative sites is available, but documentation shall address travel accommodations and travel times, financial hardship placed on families and other logistical details as requested by the Department from the carrier in order to be a valid request.

(d) In any county or approved service area in which 20 percent or more of a carrier's projected or actual number of covered persons must rely upon public transportation to access health care services, as documented by U.S. Census Data, the driving times set forth in the specifications of (b) above shall be based upon average transit time using public transportation, and the carrier shall demonstrate how it will meet the requirements in its application.

(e) The carrier shall not deny any registered pharmacy or pharmacist the right to participate as a preferred provider if the carrier provides pharmacy services, prescription drugs, or a prescription drug plan and the pharmacy meets the carrier's standards for participation.

1. Carriers shall comply with rules, if any, promulgated by the Department applicable to the type of carrier.

(f) Those providers qualified to function as PCPs may include:

1. A licensed physician who has successfully completed a residency program accredited by the Accreditation Council for Graduate Medical Education or approved by the American Osteopathic Association in family practice, internal medicine, general practice, obstetrics and gynecology or pediatrics;

2. A licensed physician who does not meet the standards of (f)1 above, but who has been evaluated by the carrier's committee charged with setting standards for and reviewing provider credentialing under the direction of the carrier's medical director, and is found by that committee to demonstrate through training, education and experience, equivalent expertise in primary care;

3. Nurse practitioners/clinical nurse specialists certified by the State Board of Nursing in accordance with 45:11-45 et seq. in advance practice categories comparable to family practice, internal medicine, general practice, obstetrics and gynecology or pediatrics, and in hospitals or other facilities;

4. Physician assistants licensed by the New Jersey Board of Medical Examiners;

5. Certified nurse midwives registered by the New Jersey Board of Medical Examiners; and

6. At the discretion of the carrier, appropriate, licensed medical specialists for specified individual covered persons or patient groups who, due to health status or chronic illness, would benefit from medical care management by such a medical specialist.

N.J. Admin. Code § 11:24A-4.10

Amended by R.2005 d.418, effective 11/21/2005.
See: 37 N.J.R. 2174(a), 37 N.J.R. 4536(a).
In (b)3iii, deleted "pursuant to N.J.A.C. 8:33P"; in (f)2, substituted "(f)1" for "(e)1."
Amended by R.2011 d.097, effective 4/4/2011.
See: 42 N.J.R. 2920(a), 43 N.J.R. 880(a).
In the introductory paragraph of (a), substituted "A" for "Except with respect to any selective contracting arrangement approved on or before May 1, 2000 pursuant to N.J.A.C. 11:4-37, a", and in (b)3iii and (b)3vi, inserted "of Health and Senior Services".