211 CMR 52.12 - Network Adequacy

Current through Register 1466, April 1, 2022

(1) A Carrier offering a plan(s) that includes a Network(s) shall maintain such Network(s) such that it is adequate in numbers and types of Providers to assure that all covered services will be accessible to Insureds without unreasonable delay. Adequacy shall be determined in accordance with the requirements of this 211 CMR 52.12, and shall be established by reference to reasonable criteria used by the Carrier, which shall include, but not be limited to, the reasonableness of cost-sharing in relation to the Benefits provided. In any case where the Carrier has an inadequate number or type of Participating Provider(s) to provide services for a Covered Benefit, the Carrier shall ensure that the Insured receives the Covered Benefit at the same benefit level as if the Benefit was obtained from a Participating Provider, or shall make other arrangements acceptable to the Commissioner.
(2) In accordance with 211 CMR 52.05(3) and (4), a Carrier shall file with the Commissioner an access analysis that meets the requirements of 211 CMR 52.12 for each plan that includes a Network that the Carrier offers in the Commonwealth. The Carrier shall also prepare an access analysis prior to offering a plan that includes a Provider Network, and shall update an existing access analysis whenever the Carrier makes any Material Change to such an existing plan. The access plan shall describe or contain at least the following:
(a) The Carrier's Network(s);
(b) A summary of the Carrier's Network adequacy standards;
(c) The Carrier's process for monitoring and assuring on an ongoing basis the sufficiency of the Network(s) to meet the health care needs of populations that enroll in plans with Provider Networks;
(d) The Carrier's efforts to address the ability of the Network(s) to meet the needs of Insureds with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, or with disabilities;
(e) The Carrier's methods for assessing the health care needs of Insureds, including but not limited to the Insureds' needs set forth in 211 CMR 52.12(2)(d), and the Insureds' satisfaction with services in relation to the development of the Network(s);
(f) The Carrier's methods for monitoring the ability of Insureds to access services out-of- Network;
(g) A report developed using a Network accessibility analysis system such as GeoNetworks, which shall include the following, or, for Carriers in a new geographic area(s) or an area(s) that does not currently have Insureds, estimates for the following, as applicable;
1. maps showing the residential location of Insureds in Massachusetts, Primary Care Providers for both adults and children, specialty care practitioners, and institutional Providers;
2. the Carrier's Network adequacy standards;
3. geographic access tables illustrating the geographic relationship between Providers and Insureds, or for proposed plans or Service Areas, the population according to the Carrier's standards for every city and town, including at a minimum:
a. The total number of Insureds, if applicable;
b. The total number of Network Primary Care Providers who are accepting new patients;
c. The total number of Network Primary Care Providers who are not accepting new patients;
d. The total number of Network Health Care Professionals who specialize in the treatment of behavioral health and substance use disorders who are accepting new patients;
e. The total number of Network Health Care Professionals who specialize in the treatment of behavioral health and substance use disorders but are not accepting new patients;
f. The total number of Network Health Care Professionals who specialize in the top five types of specialty care by volume of utilization who are accepting new patients;
g. The total number of Network Health Care Professionals who specialize in the top five types of specialty care by volume of utilization who are not accepting new patients;
h. The total number of Network inpatient hospitals that provide treatment for acute and tertiary care;
i. The total number of Network inpatient hospitals that provide treatment for behavioral health and substance use disorders;
j. The percentage of Insureds meeting the Carrier's standard(s) for access through its Network to Primary Care Providers;
k. The percentage of Insureds meeting the Carrier's standard(s) for access through its Network to behavioral health and substance use disorder Health Care Professionals Practitioners:
l. The percentage of Insureds, meeting the Carrier's standard(s) for access through its Network to specialty care Health Care Professionals;
m. The percentage of Insureds meeting the Carrier's standard(s) for access through its Network to inpatient behavioral health and substance use disorder treatment;
n. The percentage of the number of Insureds meeting the Carrier's standard(s) for access through its Network to inpatient acute tertiary care.
(h) If, at any time, the Carrier becomes aware of changes to the numbers of Health Care Professionals or Providers within its Network that would cause the Carrier to not meet any of its standard(s) for access, then within 30 Days of becoming aware the Carrier will submit a corrective action plan for the Commissioner's review and approval that will identify the steps that the Carrier will take to address the geographic areas where it is not meeting its standard(s) and how the Carrier plans to address access to care in those areas until Network changes are made so that the Carrier can once again satisfy its standard(s) for access to care.
(i) In tiered Networks and/or other instances where the Commissioner finds that cost- sharing levels could cause inadequate access to Provider types, Carriers shall provide at the Commissioner's request: a cost-sharing access analysis, illustrating the relationship between Providers at various cost-sharing levels and Insureds; or, for proposed plans or Service Areas, the relationship between Providers and the population, according to the Carrier's standard, for every city and town. For tiered Networks, the analysis shall indicate the relationship between Providers at each tier and associated cost-sharing level and Insureds; or, for proposed plans or Service Areas, the relationship between Providers and the population, according to the Carrier's standard, for every city and town.

Any other information required by the Commissioner to determine compliance with the provisions of 211 CMR 52.12.

(3) A Carrier shall make its selection standards for Participating Providers available for review by the Commissioner.

Notes

211 CMR 52.12
Amended by Mass Register Issue 1345, eff. 8/11/2017.

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