Arkansas Administrative Code
Agency 054 - Arkansas Insurance Department
Rule 054.00.14-002 - Rule 106: Network Adequacy Requirements for Health Benefit Plans
Universal Citation: AR Admin Rules 054.00.14-002
Current through Register Vol. 49, No. 2, February 2024
Section 1. Authority
This Rule is issued pursuant to the authority granted the Arkansas Insurance Commissioner ("Commissioner") under Ark. Code Ann. § 23-61-108(a)(1) and by Ark. Code Ann. § 23-61-108(b)(1) to promulgate rules necessary for the effective regulation of the business of insurance and as required for this State to be in compliance with federal laws, namely Section 2702(c) of the Public Health Service Act and 45 CFR § 156.230 which require that Qualified Health Plans provide sufficiently accessible medical providers. In addition, this Rule is issued pursuant to the authority granted the Commissioner to issue regulations related to the provision of adequate health care services by health maintenance organizations under Ark. Code Ann. § 23-76-108(a).
Section 2. Purpose
The purpose of this Rule is to establish standards for the creation and maintenance of networks by Health Carriers and to assure the adequacy, accessibility and quality of Health Care Services offered under Health Benefit Plans.
Section 3. Definitions
For purposes of this Rule:
A. "Accredited Health Carrier" means a Health
Carrier which has an adequate network as certified by an approved accrediting
organization under the provisions of Section Five (5) (K) of this
Rule.
B. "Commissioner" means the
Arkansas Insurance Commissioner.
C.
"Covered Benefits" or "benefits" means those Health Care Services to which a
Covered Person is entitled under the terms of a Health Benefit Plan.
D. "Covered Person" means a policyholder,
subscriber, enrollee or other individual participating in a Health Benefit
Plan.
E. "Emergency Medical
Condition" means the sudden and, at the time, unexpected onset of a health
condition that requires immediate medical attention, where failure to provide
medical attention would result in serious impairment to bodily functions or
serious dysfunction of a bodily organ or part, or would place the person's
health in serious jeopardy.
F.
"Emergency Services" means health care items and services furnished or required
to evaluate and treat an emergency medical condition.
G. "Essential Community Provider" means a
provider that serves predominantly low income, medically underserved
individuals as defined in
45 CFR §
156.235.
H. "Facility" means an institution providing
Health Care Services or a health care setting, including but not limited to
hospitals and other licensed inpatient centers, ambulatory surgical or
treatment centers, skilled nursing centers, residential treatment centers,
diagnostic, laboratory and imaging centers, and rehabilitation and other
therapeutic health settings.
I.
"Health Benefit Plan" means any individual, blanket, or group plan, policy or
contract for Health Care Services issued or renewed by a Health Carrier on or
after January 1, 2015 which requires a Covered Person to use Health Care
Providers managed, owned, under contract with or employed by the Health
Carrier. "Health Benefit Plan" does not include a plan providing Health Care
Services pursuant to the Arkansas Constitution, Article 5, § 32, the Workers'
Compensation Law, §
11-9-101 et seq.,
and the Public Employee Workers' Compensation Act, §
21-5-601 et
seq., nor include an accident-only, specified disease, hospital indemnity,
long-term care, disability income, or limited-benefit health insurance policy.
The provisions of this Rule also do not apply to Medicare Supplement or
Medicare Advantage policies. This Rule does not apply to vision or dental only
plans unless such plans are offered by Stand-alone Dental Carriers as defined
in Section Three (3) (U) of this Rule.
J. "Health Care Professional" means a
physician or other health care practitioner licensed, accredited or certified
to perform physical, behavioral, mental health or substance use disorder and
health services consistent with state law.
K. "Health Care Provider" or "provider" means
a participating health care or dental professional or a facility.
L. "Health Care Services" means services for
the diagnosis, prevention, treatment, cure or relief of a health condition,
illness, injury or disease.
M.
"Health Carrier" means an entity subject to the insurance laws and regulations
of this State, or subject to the jurisdiction of the Commissioner, which
contracts or offers to contract, or enters into an agreement to provide,
deliver, arrange for, pay for or reimburse any of the costs of Health Care
Services, including a health insurer, a health maintenance organization, a
hospital and medical service corporation, or any other entity providing Health
Benefit Plans. A Health Carrier does not include an automobile insurer paying
medical or hospital benefits under Ark. Code Ann. §
23-89-202(1)
nor shall it include a self-insured employer Health Benefits Plan. A Health
Carrier does not include any person, company, or organization, licensed or
registered to issue or who issues any insurance policy or insurance contract in
this State providing medical or hospital benefits for accidental injury or
accidental disability. A Health Carrier shall not include a vision or dental
insurer unless it is a Stand-alone Dental Carrier as defined by Section Three
(3) (U) of this Rule.
N. "Network"
means the group of participating providers providing services to a Health
Benefit Plan.
O. "Provider" means a
provider who, under a contract with a Health Carrier or with its contractor or
subcontractor, has agreed to provide Health Care Services to covered persons
with an expectation of receiving payment, other than coinsurance, copayments or
deductibles, directly or indirectly from the Health Carrier.
P. "Patient Centered Medical Home" ("PCMH")
means a local point of access to care that proactively looks after patients'
health on a "24-7" basis. A PCMH supports patients to connect with other
Providers to form a health services team, customized for their patients' care
needs with a focus on prevention and management of chronic disease through
monitoring patient progress and coordination of care.
Q. "Person" means an individual, a
corporation, a partnership, an association, a joint venture, a joint stock
company, a trust, an unincorporated organization, any similar entity or any
combination of the foregoing.
R.
"Primary Care Professional" means a participating Health Care Professional
practicing within their licensed scope of practice and designated by the Health
Carrier to supervise, coordinate or provide initial care or continuing care to
a covered person, and who may be required by the Health Carrier to initiate a
referral for specialty care and maintain supervision of Health Care Services
rendered to the Covered Person.
S.
"Qualified Health Plan" means an insurance policy that meets the requirements
of
42 U.S.C. §
18021(a)(1).
T. "Specialty Care Professional" means a
participating Health Care Professional that is specially qualified to practice
by having attended an advanced program of study, passed an examination given by
an organization of the members of the specialty, or gained experience through
extensive practice in the specialty.
U. "Stand-alone Dental Carrier" means an
entity subject to the insurance laws and regulations of this State, or subject
to the jurisdiction of the Commissioner, which (i) offers plans through the ACA
approved Marketplace and/or (ii) offers plans outside the ACA approved
Marketplace for the purpose of providing the essential health benefits category
of pediatric level oral benefits.
Section 4. Applicability and Scope
This Rule applies to all Health Carriers that offer Health Benefit Plans in this State which are issued or renewed on or after January 1. 2015.
Section 5. Network Adequacy
A. A Health
Carrier providing a Health Benefit Plan shall maintain a network that is
sufficient in numbers and types of providers to assure that all Health Care
Services to Covered Persons will be accessible without unreasonable delay.
Sufficiency may be established by reference to any reasonable criteria used by
the Health Carrier, including but not limited to: provider to Covered Person
ratios by specialty; Primary Care Professional to Covered Person ratios;
typical referral patterns; provider's hospital admitting privileges; geographic
accessibility; waiting times for appointments with participating providers;
hours of operation; and the volume of technological and specialty services
available to serve the needs of Covered Persons requiring technologically
advanced or specialty care.
B.
Every Health Carrier shall strive to meet the following guidelines related to
geographic accessibility through geographical access maps or other information:
(1) In the case of Emergency Services, a
covered person will have access to Emergency Services, twenty-four (24) hours
per day, seven (7) days per week within a thirty (30) mile radius between the
location of the Emergency Services and the residence of the Covered
Person;
(2) In the case of a
Primary Care Professional, a Covered Person will have access to at least one
Primary Care Professional within a thirty (30) mile radius between the location
of the Primary Care Professional and the residence of the Covered
Person:
(3) In the case of a
Specialty Care Professional, a Covered Person will have access to covered
specialty care services within a sixty (60) mile radius between the location of
the Specialty Care Professional and the residence of the Covered Person;
and
(4) For Qualified Health Plans
participating in the ACA approved Marketplace, in the case of Essential
Community Providers, a Covered Person will have access to at least one
Essential Community Provider within a thirty (30) mile radius between the
location of the Essential Community Provider and the residence of the Covered
Person.
C. In the event
that a Health 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 a participating
provider.
D. In determining whether
a Health Carrier has complied with the requirements in this Section, the
Commissioner shall give due consideration to the relative availability of
Health Care Providers in the service area under consideration.
E. A Health Carrier shall monitor, on an.
ongoing basis, the ability of its participating providers to furnish all
contracted benefits to Covered Persons. A Health Carrier shall reasonably
monitor:
(1) provider to Covered Person
ratios by specialty;
(2) Primary
Care Professional to Covered Person ratios;
(3) typical referral patterns;
(4) provider's hospital admitting
privileges;
(5) geographic
accessibility;
(6) waiting times
for appointments with participating providers;
(7) general hours of operation, including
part or full time status and weekend and after hour availability; and
(8) the volume of technological and specialty
services available to serve the needs of Covered Persons requiring
technologically advanced or specialty care.
F. Geographical access maps and compliance
percentages must be submitted for each of the categories of care referenced in
Section Five (5)(B)(l-4). A Health Carrier shall strive to meet a compliance
percentage of eighty percent (80%) for each of the categories of care
referenced in Section Five (5)(B)(l-4). Requested maps may be submitted
separately or combined and distinguished by color or other method.
The maps must indicate which providers are accepting new patients. The following are special requirements for each category of care:
(1) Health Carriers must provide
geographical access maps for Primary Care Professionals that include each
general/family practitioner, internal medicine provider, and family
practitioner/pediatrician.
(2)
Health carriers must provide geographical access maps for hospitals and
Specialty Care Professionals according to the following categories:
(a) hospitals by Arkansas hospital licensure
type;
(b) home health
agencies;
(c) skilled nursing
Facilities;
(d) all specialty care
categories and sub-specialty categories covered under the Health Benefit
Plan;
(3) Health
Carriers must provide geographical access maps for mental health, behavioral
health, and substance use disorder providers categorized between:
(a) psychiatric and state licensed clinical
psychologists;
(b) substance use
disorder providers; and
(c) other
mental health, behavioral health, and substance use disorder providers with
additional documentation describing the provider and facility types included
within the other category.
(4) Health Carriers must provide geographical
access maps for Essential Community Providers with the providers grouped within
the following categories:
(a) federally
qualified health centers;
(b) Ryan
White provider;
(c) family planning
provider;
(d) Indian
provider;
(e) hospital;
and
(f) other Essential community
providers including but not limited to school based providers.
G. Performance Metrics:
Non-accredited Health Carriers will be required to submit metrics demonstrating
performance for each of the above standards for each county in the service area
and overall service area. Accredited Health Carriers will be required to submit
the following metrics for reporting purposes. These include:
(1) The number of members and percentage of
total members meeting the geographical requirements under Section Five (5)(B)
of this Rule.
(2) The average
distance to first, second, and third closest provider for each provider type.
These figures should be provided overall (entire state) for each category as well as stratified by county for each category. For example, the percent of enrolled members that are within thirty (30) minutes or thirty (30) miles of a general/family practitioner will be submitted with percentages overall and for each county. The average distance to the first, second, and third closest provider will be submitted overall and for each county. Health Carriers who do not yet have enrollees in the State of Arkansas will be exempt from this requirement and must attest to not currently having enrollees in Arkansas.
H.
Essential Community Providers. Health Carriers issuing Qualified Health Plans
are required to meet all federal requirements for inclusion of Essential
Community Providers in the plan network. Qualifying Essential Community
Providers include providers described in section 340B of the PHS Act and
section 1927(c)(1)(D)(i)(IV) of the Social Security Act. In addition, the
following State guidelines must be met regarding Essential Community Providers:
(1) Each Health Carrier issuing Qualified
Health Plans will be required to meet conditions of the Heath Care Independence
Program 1115 Waiver and offer at least one Qualified Health Plan that has at
least one federally qualified health center or rural health center in each
service area of the plan network.
(2) Each Health Carrier issuing Qualified
Health Plans must submit a list of school-based providers included in the plan
network.
(3) Each Health Carrier
issuing Qualified Health Plans must offer a contract to at least one
school-based provider in each county in the service area, where a school-based
provider is identifiable and available and meets issuer certification and
credentialing standards.
I. Access plans. A Health carrier shall file
with the Commissioner an access plan meeting the requirements of Section Five
(5)(I)(1)- (12) of this Rule for Health Benefit Plans issued or renewed in this
State on or after January 1, 2015. The Health Carrier shall make the access
plans, absent proprietary information, available to its insureds. The Health
Carrier shall prepare an access plan prior to offering a new Health Benefit
Plan, and shall update an existing access plan whenever it makes any material
change to an existing Health Benefit Plan such as the loss of a material
provider such as a hospital or multi-specialty clinic. The access plan shall
describe or contain at least the following:
(1) The Health Carrier's network;
(2) The Health Carrier's procedures for
making referrals within and outside its network and for notifying enrollees and
potential enrollees regarding availability of network and out-of-network
providers;
(3) The Health Carrier's
process for monitoring and assuring on an ongoing basis the sufficiency of the
network to meet the health care needs of populations that enroll in its health
benefit plans;
(4) The Health
Carrier's efforts to address the needs of covered persons with limited English
proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and
with physical and mental disabilities;
(5) The Health Carrier's methods for
assessing the health care needs of covered persons;
(6) The Health Carrier's method of informing
Covered persons of the plan's services and features, including cost sharing,
the plan's grievance procedures, its process for choosing and changing
providers, and its procedures for providing and approving emergency and
specialty care;
(7) The Health
Carrier's method for assessing consumer satisfaction;
(8) The Health Carrier's method for using
assessments of enrollee complaints and satisfaction to improve carrier
performance;
(9) The Health
Carrier's system for ensuring the coordination and continuity of care for
covered persons referred to specialty providers, for covered persons using
ancillary services, including social services and other community resources,
and for ensuring appropriate discharge planning;
(10) The Health Carrier's process for
enabling Covered Persons to change Primary Care Professionals;
(11) The Health Carrier's proposed plan for
providing continuity of care in the event of contract termination between the
Health Carrier and any of its participating providers, or in the event of the
Health Carrier's insolvency or other inability to continue operations. The
description shall explain how covered persons will be notified of the contract
termination, or the health earner's insolvency or other cessation of
operations, and transferred to other providers in a timely manner;
and
(12) Any other information
required by the Commissioner to determine compliance with the provisions of
this Rule.
J. Provider
Directories. A health carrier shall make a provider directory available for
online publication by the Commissioner and shall also make its provider
directory accessible by a link to the Health Carrier's website and to potential
enrollees in hardcopy upon request. The provider directory shall identify
providers who are currently accepting new patients.
(1) Health Carriers shall update any changes
to the provider directory within fourteen (14) days of that change becoming
effective.
(2) If the provider
directory must be taken off line for any reason for a period to exceed 48
hours, that carrier shall notify the Department at least two (2) weeks in
advance of the provider directory going offline, or as soon as practically
known. In the Department notification, Health Carriers shall state the reason
for online unavailability, what steps are being taken to get the information
back online, and expected online re-launch date.
(3) Online provider directories must be
available in Spanish.
(4) The
directory search must include the ability to filter by each category of
ECP.
(5) The directory search must
include an indication of hours of operation including part-time or full-time as
well as after-hours availability as reported by providers.
(6) Providers who participate in the
Patient-Centered Medical Home program must be indicated in the provider
directory.
K. If a
Health carrier has accreditation that includes an audit of the Health carrier's
network adequacy, the Commissioner will accept that accreditation in lieu of
the Health carrier demonstrating it has complied with the requirements under
Section 5 (A) through (H) of this Rule, if the following conditions are met:
(1) A certificate of accreditation must be
submitted by the certified accrediting entity that is recognized pursuant to
45 CFR §
156.275, or any other certified entity as
recognized by the Arkansas Insurance Department;
(2) The certified accrediting entity has
submitted information showing that its audit includes a review of all
reasonable and/or necessary requirements of state and federal law;
and
(3) The Health Carrier agrees
to provide to the Arkansas Insurance Department any and all material and
information submitted to the certified accrediting entity upon the
Commissioner's request.
(4) The
accredited Health Carrier has submitted annual geographical access maps and
performance metrics as required in Section 5 of this Rule for reporting
purposes only.
(5) Nothing in the
above conditions shall supersede the federal accreditation requirements of
Qualified Health Plans as described in
45 CFR §
156.275.
(6) The Commissioner reserves the right to
re-verify compliance of network adequacy as a part of any quarterly audit or
request for certification of a Qualified Health Plan.
L. The Commissioner will also accept an
accreditation of a Health Carrier's access plan by a certified accrediting
entity that a Health Carrier has an access plan meeting the requirements of
Section Five (5) (I)(1)-(12) of this Rule although such plan must be filed with
the Commissioner.
Section 6. Stand-alone Dental Plans
(A) For stand-alone dental plans offered
through the AC A approved Marketplace or where a stand-alone dental plan is
offered outside of the ACA approved marketplace for the purpose of providing
the essential health benefit category of pediatric oral benefits, all such
stand-alone dental plans must ensure that all covered services to enrollees
will be accessible in a timely manner appropriate for the enrollee's
conditions. Dental networks for oral services must be sufficient for the
enrollee population in the service area based on potential utilization.
Determination of whether a Stand-alone Dental Gamer's network is sufficient
will be based on reasonable criteria used by the Stand-alone Dental Carrier,
including, but not limited to: provider to covered ratios by general dentist;
typical referral patterns; geographic accessibility; waiting times for
appointments with Participating providers; hours of operation; and the volume
of technologically advanced or specialty care. Stand-alone dental carriers
shall strive to meet the following guidelines through geographical access maps
or other information:
(1) In the case of a
non-specialist oral care provider, a covered person will have access to at
least one dentist within a thirty (30) mile radius between the location of the
dentist and the residence of the covered person;
(2) In the case of a specialist oral care
provider, a covered person will have access to at least one specialist dentist
within a sixty (60) mile radius between the location of the Specialty Care
Professional and the residence of the covered person; and
(3) If an Essential Community Provider that
provides oral health services is located within a thirty (30) mile radius
between the location of the Essential Community Provider and the residence of a
covered person, a Stand-alone Dental Carrier must make reasonably best efforts
to provide the covered person access to that Essential Community Provider.
For purposes of satisfying the requirements of Section 6(A) (1)-(3) of this Rule, a Stand-alone Dental Carrier may submit an accreditation that such requirements are met by a certified accredited entity abiding by the same conditions as described in Section Five (5)(K) of this Rule.
(B) Stand-alone Dental
Carriers applying to the Commissioner to participate in the AC A approved
Marketplace or offer a stand-alone dental plan outside of the ACA approved
Marketplace for the purpose of providing the essential health benefit category
of pediatric oral benefits are required to submit metrics demonstrating
performance for each of the standards above for each county in the service area
and overall service area. These figures should be provided overall (entire
state) for each category as well as stratified by county for each category. For
example, the percent of enrolled members that are within thirty (30) minutes or
thirty (30) miles of a general dentist will be submitted with percentages
overall and for each county. The average distance to the first, second, and
third closest provider will be submitted overall and for each county. These
include;
(1) The number of members and
percentage of total members meeting the geographical requirements under Section
6 (A) of this Rule.
(2) The average
distance to first, second, and third closest provider for each provider
type.
(3) Stand alone dental
carriers who do not yet have enrollees in the State of Arkansas will be exempt
from this requirement and must attest to not currently having enrollees in
Arkansas.
(C) In the
event that a Stand-alone Dental 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 a participating
provider, or shall make other arrangements acceptable to the Commissioner that
shall include reasonable criteria utilized by the carrier including but not
limited to:
(1) provider to covered person
ratios by dental specialty;
(2)
general dentist to covered person ratios;
(3) typical referral patterns;
(4) geographic accessibility;
(5) waiting times for appointments with
participating providers;
(6)
general hours of operation, including part or full time status and weekend and
after hour availability; and
(D) In determining whether a health carrier
has complied with the requirements in this Section, the Commissioner shall give
due consideration to the relative availability of dental providers in the
service area under consideration.
(E) A Stand-alone Dental Carrier shall
monitor, on an ongoing basis, the ability of its participating providers to
furnish all contracted benefits to Covered Persons.
(F) Access plans. A Stand alone Dental
Carrier shall file with the Commissioner an access plan meeting the
requirements of Section 6(F)(1)- (12) of this Rule for Stand-alone dental plans
issued or renewed in this State on or after January 1, 2015. The Stand-alone
dental carrier shall make the access plans, absent proprietary information,
available to its insureds. The Stand-alone Dental Carrier shall prepare an
access plan prior to offering a new stand-alone dental plan, and shall update
an existing access plan whenever it makes any material change to an existing
stand-alone dental plan such as the loss of a material provider. The access
plan shall describe or contain at least the following:
(1) The Stand-alone Dental carrier's
network;
(2) The Stand-alone Dental
carrier's procedures for making referrals to the extent applicable within and
outside its network and for notifying enrollees and potential enrollees
regarding availability of network and out-of-network providers;
(3) The Stand-alone Dental carrier's process
for monitoring and assuring on an ongoing basis the sufficiency of the network
to meet the health care needs of populations that enroll in its health benefit
plans;
(4) The Stand-alone Dental
carrier's efforts to address the needs of covered persons with limited English
proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and
with physical and mental disabilities;
(5) The Stand-alone Dental carrier's methods
for assessing the health care needs of covered persons;
(6) The Stand-alone Dental carrier's method
of informing covered persons of the plan's services and features, including
cost sharing, the plan's grievance procedures, its process for choosing and
changing providers, and its procedures for providing and approving emergency
and specialty care;
(7) The
Stand-alone Dental carrier's method for assessing consumer
satisfaction;
(8) The Stand-alone
Dental carrier's method for using assessments of enrollee complaints and
satisfaction to improve carrier performance;
(9) The Stand-alone Dental carrier's system
for ensuring the coordination and continuity of care for covered persons
referred to specialty providers, for covered persons using ancillary services,
including social services and other community resources, and for ensuring
appropriate discharge planning;
(10) The Stand-alone Dental carrier's process
for enabling covered persons to change non-specialist dental
providers;
(11) The Stand-alone
Dental earner's proposed plan for providing continuity of care in the event of
contract termination between the health earner and any of its participating
providers, or in the event of the health carrier's insolvency or other
inability to continue operations. The description shall explain how covered
persons will be notified of the contract termination, or the health carrier's
insolvency or other cessation of operations, and transferred to other providers
in a timely manner; and
(12) Any
other information required by the Commissioner to determine compliance with the
provisions of this Rule.
(G) Provider Directories. A Stand-alone
Dental Carrier shall make a provider directory available for online publication
by the Commissioner and shall also make its provider directory accessible by a
link to the Stand-alone dental carrier's website and to potential enrollees in
hardcopy upon request. The provider directory shall identify providers who are
currently accepting new patients.
(1)
Stand-alone Dental Carriers shall update any changes to the provider directory
within fourteen (14) days of that change becoming effective.
(2) If the provider directory must be taken
off line for any reason for a period to exceed 48 hours, that carrier shall
notify the Department at least two (2) weeks in advance of the provider
directory going offline, or as soon as practically known. In the Department
notification, Stand-alone Dental Carriers shall state the reason for online
unavailability, what steps are being taken to get the information back online,
and expected online re-launch date.
(3) Online provider directories must be
available in Spanish.
(4) The
directory search must include the ability to filter by ECP.
(5) The directory search must include an
indication of hours of operation including part-time or full-time as well as
after-hours availability as reported by providers.
Section 7. Enforcement
The penalties, license actions or orders as authorized under Ark. Code Ann. § 23-66-210 shall apply to violations of this Rule.
Section 8. Effective Date
The effective date of this Rule is January 1, 2015.
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