Connecticut Administrative Code
Title 38a - Insurance Department
472f - Network Adequacy
Section 38a-472f-2 - Health insurance carrier standards and responsibilities
Current through March 14, 2024
Each health carrier that delivers, issues for delivery, renews, amends or continues any individual or group health insurance policy or certificate in this state that uses a provider network shall:
(1) Contract with the appropriate type and number of health care providers to ensure that each person covered by such health carrier under such a plan or certificate has reasonable access to participating providers located near such covered person's place of residence or employment. Reasonable access includes maintaining a sufficient number and appropriate types of participating providers that predominately serve, without unreasonable travel or delay:
(2) Make additional arrangements to meet the needs of persons covered by such health carrier under such a health insurance policy or certificate if the requirements of subdivision (1) cannot be met, including the needs of:
(3) Establish and maintain a process to ensure that each person covered by such health carrier under such a health insurance policy or certificate receives a covered benefit at an in-network level, including an in-network level of cost-sharing, from a nonparticipating provider, or shall make other arrangements acceptable to the commissioner, when:
(4) Monitor, on an ongoing basis, compliance with provider contracts, and the ability, clinical capacity and legal authority of its participating providers to provide all covered benefits to its covered persons.
(5) Establish and maintain procedures by which a participating provider shall be notified, on an ongoing basis, of the specific covered health care services for which such participating provider shall be responsible, including any limitations on, or conditions of, such services.
(6) Notify participating providers of their obligations, if any:
(7) Establish and maintain procedures by which a participating provider may determine, in a timely manner, at the time benefits are provided whether an individual is a covered person or is within a grace period during which such health carrier may hold a claim for health care services pending receipt of payment of any premium by such health carrier.
(8) Timely notify a health care provider or facility, when the health carrier has included the health care provider or facility as a participating provider for any of such health carrier's health insurance policies or certificates, of such health care provider's or facility's network participation status.
(9) Notify each participating provider of the participating provider's responsibilities with respect to such health carrier's applicable administrative policies and programs, including, but not limited to, payment terms, hold harmless agreements, utilization review, quality assessment and improvement programs, credentialing, grievance and appeals processes, data reporting requirements, reporting requirements for timely notice of changes in practice such as discontinuance of accepting new patients, notice of termination as a network provider, confidentiality requirements, any applicable federal or state programs and obtaining necessary approval of referrals to nonparticipating providers.
(10) Establish and maintain procedures for the resolution of administrative, payment or other disputes between such health carrier and participating providers.
(11) Provide at least sixty (60) days' advance written notice to a participating provider before such health carrier removes the participating provider from such health carrier's participating provider network.
(12) Make a good faith effort to provide written notice, not later than thirty (30) days from receipt of the list of the participating providers' patients who are covered persons, to all covered persons who are patients being treated on a regular basis by such provider. For purposes of this subsection, "treated on a regular basis" means receiving treatment at least once during the twelve (12) months immediately prior to provision of the thirty (30) day notice described in this subdivision.
(13) Require that any subcontracted network meets the standards set forth in this section, including all network adequacy standards, and monitor compliance with those standards.
(14) Disclose to a person covered under such a policy or certificate issued by such health carrier the process to request a covered benefit from a nonparticipating provider, when:
(15) Make a reasonable effort to contract with centers of excellence, mobile clinics, technological and specialty care services, walk-in clinics, urgent care facilities and regionalized specialty care providers, as applicable.
(16) Establish procedures to meet network adequacy standards.
(17) Establish and document any issues of non-compliance and corrective actions.