31.10.34.05

.05 Availability Plan.

A. A carrier shall implement an availability plan describing:

(1) If the carrier is an insurer or nonprofit health service plan, the quantifiable and measurable standards for the number and geographic distribution of:

(a) General and internal medicine providers;

(b) Family practitioners;

(c) Pediatricians;

(d) Obstetricians and gynecologists;

(e) High-volume specialty behavioral health care providers, including psychiatrists, psychologists, clinical social workers, and any other behavioral health care providers identified by the carrier; and

(f) High-volume specialty health care providers, identified by the carrier; or

(2) If the carrier is a dental plan organization, or an insurer or nonprofit health service plan that provides coverage only for dental services, the quantifiable and measurable standards for the number and geographic distribution of:

(a) Dentists; and

(b) Any other dental service provider identified by the carrier.

B. The availability plan required by §A of this regulation shall also include:

(1) The method used to annually assess the carrier's performance against the standards specified in the availability plan;

(2) The method used to ensure timely access to health care services, as identified by the carrier; and

(3) The carrier's process for monitoring and assuring on an ongoing basis the sufficiency of the provider panel to meet the health care needs of enrollees.

C. Availability Plan and Annual Performance Assessment.

(1) A carrier shall:

(a) On an annual basis, review and update the availability plan required by §A of this regulation;

(b) On an annual basis, conduct a performance assessment regarding its compliance with its availability plan using the method provided in §B(1) of this regulation; and

(c) Submit its availability plan and its annual performance assessment to the Commissioner upon request.

(2) In addition to the requirements of §C(1) of this regulation, a prominent carrier shall submit to the Commissioner the prominent carrier's:

(a) Availability plan not later than:

(i) 90 days after the effective date of this chapter, if the carrier is a prominent carrier on the effective date of this chapter; or

(ii) 90 days after the carrier becomes a prominent carrier, if the carrier becomes a prominent carrier after the effective date of this chapter; and

(b) Annual performance assessment:

(i) Not later than November 1, 2008, for the period beginning on the effective date of this regulation; and

(ii) Within 30 days of completing the annual performance assessment, for calendar year 2009 and thereafter.

(3) In addition to the requirements of §C(2) of this regulation, a prominent carrier shall:

(a) File with the Commissioner the availability plan described in §C(2)(a) of this regulation not later than 30 days after the carrier makes any change to the availability plan;

(b) Provide annually to the Commissioner a list of the hospital-based physician specialties available on the prominent carrier's provider panel; and

(c) Submit the report required in §A of this regulation with the submission of the prominent carrier's performance assessment required by §C(2)(b) of this regulation.

(4) The Commissioner may request additional information from the carrier in order to evaluate the carrier's performance with the availability plan.