A. Sufficiency Standards.
(1) Subject to the exceptions in §B of this regulation, each carrierís 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 its meeting the standards listed in §C of this regulation.
B. Preventive care services and periodic follow-up care, including but not limited to, standing referrals to specialty providers for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or behavioral health or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating provider acting within the scope of the providerís license, certification, or other authorization.
C. Chart of Waiting Time Standards.
|Waiting Time Standards|
|Urgent care (including medical, behavioral health, and substance use disorder services)||72 hours|
|Routine primary care||15 calendar days|
|Preventive visit/well visit||30 calendar days|
|Non-urgent specialty care||30 calendar days|
|Non-urgent behavioral health/substance use disorder services||10 calendar days|