(1) A Carrier
offering a plan(s) that includes a Network(s) shall maintain such Network(s)
such that it is adequate in numbers and types of Providers to assure that all
covered services will be accessible to Insureds without unreasonable delay.
Adequacy shall be determined in accordance with the requirements of this
211
CMR 52.12, and shall be established by
reference to reasonable criteria used by the Carrier, which shall include, but
not be limited to, the reasonableness of Cost-sharing in relation to the
Benefits provided. In any case where the Carrier has an inadequate number or
type of Participating Provider(s) to provide services for a Covered Benefit,
the Carrier shall ensure that the Insured receives the Covered Benefit at the
same benefit level as if the Benefit was obtained from a Participating
Provider, or shall make other arrangements acceptable to the
Commissioner.
(2) In accordance
with 211 CMR 52.05(3) and
(4), a Carrier shall file with the
Commissioner an access analysis that meets the requirements of
211
CMR 52.12 for each plan that includes a
Network that the Carrier offers in the Commonwealth. The Carrier shall also
prepare an access analysis prior to offering a plan that includes a Provider
Network, and shall update an existing access analysis whenever the Carrier
makes any Material Change to such an existing plan. The access plan shall
describe or contain at least the following:
(a) The Carrier's Network(s);
(b) A summary of the Carrier's Network
adequacy standards;
(c) The
Carrier's process for monitoring and assuring on an ongoing basis the
sufficiency of the Network(s) to meet the health care needs of populations that
enroll in plans with Provider Networks;
(d) The Carrier's efforts to address the
ability of the Network(s) to meet the needs of Insureds with limited English
proficiency and illiteracy, with diverse cultural and ethnic back grounds, or
with disabilities;
(e) The
Carrier's methods for assessing the health care needs of Insureds, including
but not limited to the Insureds' needs set forth in
211
CMR 52.12(2)(d), and the
Insureds' satisfaction with services in relation to the development of the
Network(s);
(f) The Carrier's
methods for monitoring the ability of Insureds to access services
out-of-Network;
(g) A report
developed using a Network accessibility analysis system such as Geo Networks,
which shall include the following, or, for Carriers in a new geographic area(s)
or an area(s) that does not currently have Insureds, estimates for the
following, as applicable;
1. maps showing the
residential location of Insureds in Massachusetts, Primary Care Providers for
both adults and children, Specialty Care practitioners, and institutional
Providers;
2. the Carrier's Network
adequacy standards;
3. geographic
access tables illustrating the geographic relationship between Providers and
Insureds, or for proposed plans or Service Areas, the population according to
the Carrier's standards for geographic areas as appropriate for the Carrier's
service area, including at a minimum:
a. The
total number of Insureds, if applicable;
b. The total number of Network Primary Care
Providers who are accepting new patients;
c. The total number of Network Primary Care
Providers who are not accepting new patients;
d. The total number of Network Health Care
Professionals who specialize in the treatment of Behavioral Health and
substance use disorders who are accepting new patients;
e. The total number of Network Health Care
Professionals who specialize in the treatment of Behavioral Health and
substance use disorders, but are not accepting new patients;
f. The total number of Network Health Care
Professionals who specialize in the top five types of Specialty Care by volume
of utilization who are accepting new patients and a list of those top five
types;
g. The total number of
Network Health Care Professionals who specialize in the top five types of
Specialty Care by volume of utilization who are not accepting new patients and
a list of those top five types;
h.
The total number of Network inpatient hospitals that provide treatment for
acute and tertiary care;
i. The
total number of Network inpatient hospitals that provide treatment for
Behavioral Health and substance use disorders;
j. The percentage of Insureds meeting the
Carrier's standard(s) for access through its Network to Primary Care
Providers;
k. The percentage of
Insureds meeting the Carrier's standard(s) for access through its Network to
Behavioral Health and substance use disorder Health Care Professionals
Practitioners:
l. The percentage of
Insureds, meeting the Carrier's standard(s) for access through its Network to
Specialty Care Health Care Professionals;
m. The percentage of Insureds meeting the
Carrier's standard(s) for access through its Network to inpatient Behavioral
Health and substance use disorder treatment;
n. The percentage of the number of Insureds
meeting the Carrier's standard(s) for access through its Network to inpatient
acute tertiary care.
(h) If, at any time, the Carrier becomes
aware of changes to the numbers of Health Care Professionals or Providers
within its Network that would cause the Carrier to not meet any of its
standard(s) for access, then within 30 Days of becoming aware the Carrier will
submit a corrective action plan for the Commissioner's review and approval that
will identify the steps that the Carrier will take to address the geographic
areas where it is not meeting its standard(s) and how the Carrier plans to
address access to care in those areas until Network changes are made so that
the Carrier can once again satisfy its standard(s) for access to
care.
(i) In tiered Networks and/or
other instances where the Commissioner finds that cost-shaing levels could
cause inadequate access to Provider types, Carriers shall provide at the
Commissioner's request: a Cost-sharing access analysis, illustrating the
relationship between Providers at various Cost-sharing levels and Insureds; or,
for proposed plans or Service Areas, the relationship between Providers and the
population, according to the Carrier's standard, for every city and town. For
tiered Networks, the analysis shall indicate the relationship between Providers
at each tier and associated Cost-sharing level and Insureds; or, for proposed
plans or Service Areas, the relationship between Providers and the population,
according to the Carrier's standard, for every city and town.
(j) Any other information required by the
Commissioner to determine compliance with the provisions of
211
CMR 52.12.
(3) A Carrier shall make its selection
standards for Participating Providers available for review by the
Commissioner.
