Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.44 - Network Adequacy
Section 31.10.44.11 - Network Adequacy Access Plan Executive Summary Form
Universal Citation: MD Code Reg 31.10.44.11
Current through Register Vol. 51, No. 19, September 20, 2024
A. For each provider panel used by a carrier for a health benefit plan, the carrier shall provide the following network sufficiency results for the health benefit plan service area in the standardized format described on the Maryland Insurance Administration's website:
(1) Travel Distance Standards.
(a) For each provider type and facility type listed in Regulation .05 of this chapter, list the percentage of enrollees for which the carrier met the travel distance standards, in the following format, with provider types listed first in alphabetical order, followed by facility types in alphabetical order:
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Urban Area |
Suburban Area |
Rural Area |
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Provider Type |
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Facility Type |
(b) All provider and facility types described in §§A(4) and B(4) of Regulation .05 of this chapter and included on the carrier's provider panel shall be listed individually in the chart described in §A(1)(a) of this regulation with the corresponding data for that specific type of provider or facility.
(c) If the telehealth mileage credit described Regulation .08B of this chapter was applied when calculating the percentage of enrollees for which the carrier met the travel distance standards, the carrier shall:
(i) Note the particular provider types and geographic areas to which the credit was applied by including an asterisk in the chart; and
(ii) Include a corresponding footnote stating "As permitted by Maryland regulations, a telehealth mileage credit was applied to up to 10 percent of enrollees for each provider type noted with an asterisk in each of the urban, rural, or suburban geographic areas. The mileage credit is 5 miles for urban areas, 10 miles for suburban areas, and 15 miles for rural areas."
(d) List the total number of certified registered nurse practitioners counted as a primary care provider.
(e) List the total percentage of primary care providers who are certified registered nurse practitioners.
(f) List the total number of essential community providers in the carrier's network in each of the urban, rural, and suburban areas providing:
(i) Medical services;
(ii) Mental health services; and
(iii) Substance use disorder services.
(g) List the total percentage of essential community providers available in the health benefit plan's service area that are participating providers for each of the nine categories described in §A(1)(f) of this regulation.
(h) List the total number and percentage of local health departments in the carrier's network providing:
(i) Medical services;
(ii) Mental health services; and
(iii) Substance use disorder services.
(2) Appointment Waiting Time Standards.
(a) For each appointment type listed in Regulation .06 of this chapter, list the calculated median waiting time to obtain an in-person appointment with a participating provider, in the following format:
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Appointment Waiting Time Standard Results |
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Urgent care for medical services |
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Inpatient urgent care for mental health services |
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Inpatient urgent care for substance use disorder services |
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Outpatient urgent care for mental health services |
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Outpatient urgent care for substance use disorder services |
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Routine primary care |
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Preventive care/Well Visit |
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Non-urgent specialty care |
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Non-urgent mental health care |
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Non-urgent substance use disorder care |
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(b) If the telehealth credit described Regulation .08C of this chapter was applied when determining whether the carrier's provider panel met the waiting time standards under Regulation .06E of this chapter for at least 90 percent of appointments in any category, the carrier may include a statement on the executive summary disclosing the availability of telehealth appointments to supplement the in-person appointments for that category.
(c) If the carrier arranges for telehealth services to be provided from participating providers beyond traditional office hours for an appointment type listed in Regulation .06 of this chapter, the carrier may include a statement on the executive summary disclosing the availability of those services.
(3) Provider-to-Enrollee Ratio Standards.
(a) This subsection does not apply to Group Model HMO health benefit plans.
(b) For all other carriers, summarize the network performance for each provider-to-enrollee ratio standard listed in Regulation .07 of this chapter by listing the calculated number of providers in the provider panel, rounded to the nearest whole number, for each of the following categories of enrollees:
(i) 1,200 enrollees for primary care;
(ii) 2,000 enrollees for pediatric care;
(iii) 2,000 enrollees for obstetrical/gynecological care;
(iv) 2,000 enrollees for mental health care or service; and
(v) 2,000 enrollees for substance use disorder care and services.
B. The network adequacy access plan executive summary form filed by a carrier pursuant to §A of this regulation is not confidential information.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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