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 geographic area. The distances listed in §A(5) of this regulation shall be measured from the enrollee’s place of residence.

(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §A(5) of this regulation.

(3) The travel distance standards listed in §A(5) of this regulation do not apply to the following:

(a) Home health care;

(b) Durable medical equipment;

(c) Heart transplant programs;

(d) Heart or lung transplant programs;

(e) Kidney transplant programs;

(f) Liver transplant programs;

(g) Lung transplant programs; or

(h) Pancreas transplant programs.

(4) All other providers and facility types not listed in the chart in §A(5) of this regulation shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.

(5) Chart of Travel Distance Standards.

Urban Area
Maximum
Distance
(miles)
Suburban
Area
Maximum
Distance
(miles)
Rural
Area
Maximum
Distance
(miles)
Provider Type:
Allergy and Immunology 15 30 75
Applied Behavioral Analyst 15 30 60
Cardiovascular Disease 10 20 60
Chiropractic 15 30 75
Dermatology 10 30 60
Endocrinology 15 40 90
ENT/Otolaryngology 15 30 75
Gastroenterology 10 30 60
General Surgery 10 20 60
Gynecology, OB/GYN 5 10 30
Gynecology Only 15 30 75
Licensed Clinical Social Worker 10 25 60
Nephrology 15 25 75
Neurology 10 30 60
Oncology-Medical and Surgical 10 20 60
Oncology-Radiation/Radiation Oncology 15 40 90
Ophthalmology 10 20 60
Pediatrics-Routine/Primary Care 5 10 30
Physiatry, Rehabilitative Medicine 15 30 75
Plastic Surgery 15 40 90
Podiatry 10 30 60
Primary Care Physician 5 10 30
Psychiatry 10 25 60
Psychology 10 25 60
Pulmonology 10 30 60
Rheumatology 15 40 90
Urology 10 30 60
All Other licensed or certified providers under contract with a carrier not listed 15 40 90
Facility Type:
Acute Inpatient Hospitals 10 30 60
Critical Care Services — Intensive Care Units 10 30 100
Diagnostic Radiology 10 30 60
Inpatient Psychiatric Facility 15 45 75
Outpatient Dialysis 10 30 50
Outpatient Infusion/Chemotherapy 10 30 60
Pharmacy 5 10 30
Skilled Nursing Facilities 10 30 60
Surgical Services (Outpatient or Ambulatory Surgical Center) 10 30 60
Other Behavioral Health/Substance Abuse Facilities 10 25 60
All other licensed or certified facilities under contract with a carrier not listed 15 40 90

B. Group Model HMO Plans Sufficiency Standards.

(1) Each group model HMO’s health benefit plan’s provider panel shall have within the geographic area served by the group model HMO’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 §B(5) of this regulation for each type geographic area. The distances listed in §B(5) of this regulation shall be measured from the enrollee’s place of residence or place of employment from which the enrollee gains eligibility for participation in the group model HMO’s health benefit plan.

(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §B(5) of this regulation.

(3) The travel distance standards listed in §B(5) of this regulation do not apply to the following:

(a) Home health care;

(b) Durable medical equipment;

(c) Heart transplant programs;

(d) Heart or lung transplant programs;

(e) Kidney transplant programs;

(f) Liver transplant programs;

(g) Lung transplant programs; or

(h) Pancreas transplant programs.

(4) All other provider and facility types not listed in the chart at §B(5) of this regulation shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.

(5) Chart of Travel Distance Standards.

Urban Area
Maximum
Distance
(miles)
Suburban
Area
Maximum
Distance
(miles)
Rural
Area
Maximum
Distance
(miles)
Provider Type:
Allergy and Immunology 20 30 75
Applied Behavioral Analyst 15 20 60
Cardiovascular Disease 15 25 60
Chiropractic 20 30 75
Dermatology 20 30 60
Endocrinology 20 40 90
ENT/Otolaryngology 20 30 75
Gastroenterology 20 30 60
General Surgery 20 30 60
Gynecology, OB/GYN 15 20 45
Gynecology Only 15 30 60
Licensed Clinical Social Worker 15 30 75
Nephrology 15 30 75
Neurology 15 30 60
Oncology-Medical, Surgical 15 30 60
Oncology-Radiation/Radiation Oncology 15 40 90
Ophthalmology 15 20 60
Pediatrics-Routine/Primary Care 15 20 45
Physiatry, Rehabilitative Medicine 15 30 75
Plastic Surgery 15 40 90
Podiatry 15 30 90
Primary Care Physician 15 20 45
Psychiatry 15 30 60
Psychology 15 30 60
Pulmonology 15 30 60
Rheumatology 15 40 90
Urology 15 30 60
All Other licensed or certified providers under contract with a carrier not listed 20 40 90
Facility Type:
Acute Inpatient Hospitals 15 30 60
Critical Care Services-Intensive Care Units 15 30 120
Diagnostic Radiology 15 30 60
Inpatient Psychiatric Facility 15 45 75
Outpatient Dialysis 15 30 60
Outpatient Infusion/Chemotherapy 15 30 60
Pharmacy 5 10 30
Skilled Nursing Facilities 15 30 60
Surgical Services (Outpatient or Ambulatory Surgical Center) 10 30 60
Other Behavioral Health/Substance Abuse Facilities 15 30 60
All other licensed or sertified facilities under contract with a carrier not listed 15 40 120

C. Essential Community Providers.

(1) Each provider panel of a carrier, that is not a group model HMO provider panel, shall include at least 30 percent of the available essential community providers in each of the urban, rural, and suburban areas.

(2) Each group model HMO plan shall demonstrate that its own providers located in Health Professional Shortage Areas or low-income zip codes within its service area perform at or above the 50th percentile on the following two HEDIS measures:

(a) Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment; and

(b) Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults.

(3) Each group model HMO plan shall demonstrate that it has alternative standards for addressing the needs of low income, medically underserved individuals. One manner in which a group model HMO may demonstrate this is by providing the Maryland Insurance Administration with its narrative or alternate standard justification to the essential community provider requirement, which was submitted to and accepted by the Maryland Health Benefit Exchange for certification as a qualified health plan.