Connecticut Administrative Code
Title 38a - Insurance Department
472f - Network Adequacy
Section 38a-472f-3 - Minimum Standards for Network Adequacy
Universal Citation: CT Reg of State Agencies 38a-472f-3
Current through March 14, 2024
(a) 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) Establish
and monitor the provider network to ensure that a person covered under the
policy or certificate has access to health care services within the maximum
time and distance standards.
(2)
Ensure that the provider network has at least one primary care physician per
two thousand (2,000) covered persons.
(3) Ensure that the percentage of providers
participating in the network that accept new patients is at least seventy
percent (70%).
(4) Establish
reasonable wait times for access to primary care, urgent care, specialist care,
mental health, ancillary services and any other categories of service, and
monitor provider compliance with the requirements established pursuant to this
subdivision.
(5) Demonstrate a good
faith effort to contract with centers of excellence, mobile clinics, walk-in
clinics, urgent care facilities and providers of technological or specialty
care services, to the extent available.
(6) Have an adequate process in place to
provide in-network levels of coverage from nonparticipating providers, without
unreasonable travel or delay or unreasonable wait time for an appointment, when
a participating provider is not available.
(7) Demonstrate a good faith effort to
contract with hospital-based providers.
(8) Ensure that covered persons:
(A) Have access to emergency services, as
defined in section 38a-477aa of the Connecticut General Statutes, twenty-four
(24) hours a day, seven (7) days a week.
(B) Have reasonable access to participating
providers within normal business hours.
(9) Ensure that participating providers shall
have admitting rights to at least one participating hospital, where
appropriate.
(b) No individual or group health insurance policy or certificate that uses a provider network shall be delivered, issued for delivery, renewed, amended or continued in this state if the provider network does not meet the required minimum standards for network adequacy set forth in subsection (a) of this section.
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