Current through Register Vol. XLI, No. 38, September 20, 2024
4.1.
For health benefit plan years beginning January 1, 2025, a health carrier shall
file with the Commissioner an access plan meeting the requirements of this rule
and W. Va. Code §
33-55-3. An access plan for a newly offered network must
be filed for review and approval on or before July 1st of the year preceding
the plan year. For the purposes of this rule, a "newly offered network"
includes an existing network at the time this amended rule becomes effective
irrespective of whether the Commissioner has approved the network.
4.2. A health carrier shall file, maintain
and make available on their website an access plan, absent proprietary
information, for each network plan that the carrier offers in West Virginia.
The health carrier may request the Commissioner to deem sections of the access
plan as proprietary information that not be made public.
4.3. A health carrier shall prepare and file
an access plan prior to offering a new network plan, and shall notify the
Commissioner of any material change to any existing network plan within 15
business days after the change occurs, including a reasonable timeframe within
which it will file an update to an existing access plan.
4.4. A health carrier shall make an access
plan, absent proprietary information pursuant to W. Va. Code
§
33-55-3, available to any person upon request.
4.5. All health benefit plans and marketing
materials of a health carrier shall clearly disclose the existence and
availability of the access plan.
4.6. All rights and responsibilities of the
covered person under a health benefit plan shall be included in the contract
provisions of the health benefit plan, regardless of whether or not such
provisions are also specified in the access plan.
4.7. A health carrier shall submit access
plans to the Commissioner through SERFF.
4.8. An access plan shall describe, contain,
or address the following:
4.8.1. The health
carrier's network, including how the use of telemedicine or telehealth or other
technology may be used to meet network access standards, if
applicable;
4.8.2. The factors used
by the health carrier to build its network, including a description of the
criteria used to select providers;
4.8.3. Establishing that the health carrier's
network has an adequate number of providers and facilities within a reasonable
distance of covered persons;
4.8.4.
The specific provider and facility types within the network per West Virginia
county;
4.8.5. The health carrier's
documented, quantifiable and measurable process for monitoring and assuring the
sufficiency of the network in order to meet the health care needs of covered
persons on an ongoing basis;
4.8.6.
The carrier's process to assure that a covered person is able to obtain a
covered benefit, at the in-network benefit level, from a non-participating
provider should the carrier's network prove to not be sufficient;
4.8.7. The health carrier's procedures for
making and authorizing referrals within and outside its network. The procedures
should address the health carrier's processes regarding:
4.8.7.a. The provision of a comprehensive
listing of the health carrier's network of participating providers and
facilities to covered persons and primary care providers;
4.8.7.b. Timely referrals for access to
specialty care;
4.8.7.c. Expedition
of the referral process when indicated by the covered person's medical
condition; and
4.8.7.d. Member
access to services outside the network when necessary;
4.8.8. The health carrier's process for
enabling covered persons to change primary care providers (PCP), if
applicable;
4.8.9. The health
carrier's quality assurance standards, which must be adequate to identify,
evaluate and remedy problems relating to access, continuity and quality of
care;
4.8.10. The health carrier's
methods for assessing the health care needs of covered persons and their
satisfaction with services;
4.8.11.
The health carrier's efforts to address the needs of covered persons,
including, but not limited to, children and adults, including those with
limited English proficiency or illiteracy, diverse cultural or ethnic
backgrounds, physical or mental disabilities, and serious, chronic, or complex
medical conditions. This includes the carrier's efforts, when appropriate, to
include various types of ECPs in its network;
4.8.12. The health carrier's method of
informing covered persons of the plan's covered services and features,
including, but not limited to:
4.8.12.a. The
plan's grievance and appeal procedures;
4.8.12.b. Its process for choosing and
changing providers;
4.8.12.c. Its
process for updating its provider directories for each of its network
plans;
4.8.12.d. A statement of
health care services offered, including those services offered through the
preventive care benefit, if applicable; and
4.8.12.e. Its procedures for covering and
approving emergency, urgent and specialty care, if
applicable;
4.8.13. 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 carrier's
insolvency or other cessation of operations, and transitioned to other
providers in a timely manner; and
4.8.14. The health carrier's process for
monitoring access to physician specialist services in emergency room care,
anesthesiology, radiology, hospitalist care and pathology/laboratory services
at their participating hospitals. This subdivision does not apply to limited
scope vision plans or limited scope dental plans as defined in W.Va. Code
§
33-55-1.
4.9. The
Commissioner may develop forms to be completed by the health carrier regarding
the information required by subsection 4.8 of this rule.
