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31.10.44.00.htm 31.10.44.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE ― GENERAL Chapter 44 Network Adequacy Authority: Insurance Article, §2-109(a)1) and 15-112(a)d) Annotated Code of Maryland
31.10.44.01.htm 31.10.44.01. 01 Scope.. This chapter applies to carriers that issue or renew health benefit plans in Maryland and use a provider panel for a health benefit plan offered in Maryland.
31.10.44.02.htm 31.10.44.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) “Access plan” means the materials that each carrier is required to file annually with the Commissioner to demonstrate that each of the carrier’s provider panels is adequate to meet the needs of its enrollees.2) “Behavioral health care” means care for mental health or a substance use disorder.. 3) “Carrier” means:. a) An insurer authorized to sell health insurance;.
31.10.44.03.htm 31.10.44.03. 03 Filing of Access Plan.. A. Using the instructions on the Maryland Insurance Administration's website to determine rural, suburban, and urban zip code areas, each carrier subject to this chapter shall file an annual access plan with the Commissioner through the System for Electronic Rate and Form Filing (SERFF) on or before July 1 of each year for each provider panel used by the carrier, with the first access plan filing due on or before July 1, 2018.
31.10.44.04.htm 31.10.44.04. 04 Travel Distance Standards.. A. Sufficiency Standards.. 1) Except as stated in §B of this regulation, each provider panel of a carrier shall have within the geographic area served by the carrier’s network or networks, sufficient primary care physicians, specialty providers, behavioral health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §A(5) of this regulation for each type of g
31.10.44.05.htm 31.10.44.05. 05 Appointment Waiting Time Standards.. A. Sufficiency Standards.. 1) Subject to the exceptions in §B of this regulation, each carrier’s provider panel shall meet the waiting time standards listed in §C of this regulation for at least 95 percent of the enrollees covered under health benefit plans that use that provider panel.2) When it is clinically appropriate and an enrollee elects to utilize a telehealth appointment, a carrier may consider that utilization as a part of
31.10.44.06.htm 31.10.44.06. 06 Provider-to-Enrollee Ratio Standards.. A. Except for a Group Model HMO’s health benefit plan, the provider panel for each carrier shall meet the provider-to-enrollee ratio standards listed in §B of this regulation.B. The provider-to-enrollee ratios shall be equivalent to at least 1 full-time physician, or as appropriate, another full-time provider for:1) 1,200 enrollees for primary care;. 2) 2,000 enrollees for pediatric care;.
31.10.44.07.htm 31.10.44.07. 07 Waiver Request Standards.. A. A carrier may apply for a network adequacy waiver, for up to 1 year, of a network adequacy requirement listed in this chapter.B. The Commissioner may find good cause to grant the network adequacy waiver request if the carrier demonstrates that the physicians, other providers, or health care facilities necessary for an adequate network:1) Are not available to contract with the carrier;. 2) Are not available in sufficient numbers;.
31.10.44.08.htm 31.10.44.08. 08 Confidential Information in Access Plans.. A. Subject to §15-802 of the Insurance Article, Annotated Code of Maryland, the following information that is included in a carrier’s access plan shall be considered confidential by the Commissioner:1) Methodology used to annually assess the carrier’s performance in meeting the standards established under this chapter;2) Methodology used to annually measure timely access to health care services; and.
31.10.44.09.htm 31.10.44.09. 09 Network Adequacy Access Plan Executive Summary Form.. A. For each provider panel used by a carrier for a health benefit plan, the carrier shall provide the network sufficiency results for the health benefit plan service area as follows:1) Travel Distance Standards.. a) For each provider type listed in Regulation .04, list the percentage of enrollees for which the carrier met the travel distance standards, in the following format:Urban Area. b) List the total number
31.10.44.9999.htm 31.10.44.9999. Administrative History Effective date: December 31, 2017 (44:25 Md. R. 1180).
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