19 Miss. Code. R. 3-14.05 - Network Adequacy
A. A health earner
providing a managed care plan shall maintain a network that is sufficient in
numbers and types of participating providers to ensure that all covered
services to covered persons will be accessible without unreasonable delay. In
the case of emergency facility services, covered persons shall have access
twenty-four (24) hours per day, seven (7) days per week.
B. The sufficiency of health carriers"
networks shall be measured by the network adequacy standards outlined in 45
C.F.R. § 156.230((a)(2)(i) and associated guidance published by the Centers for
Medicare and Medicaid Services.
C.
In any case where the health carrier has an insufficient number or type of
participating providers/facilities to provide a covered benefit to a covered
person consistent with the geographic access standards set forth in Rule
14.05(B). the health carrier shall ensure that the covered person obtains the
covered benefit at no greater cost to the covered person than if the benefit
were obtained from participating providers/facilities, and additionally, if the
covered persons must travel more than one hundred (100) miles one way or more
than the distance standard prescribed by this regulation, whichever is greater,
to obtain the aforementioned covered benefit, the health carrier shall provide
such persons reasonable round trip reimbursement for their food, lodging and
travel. Reimbursement for food and lodging shall be at the prevailing federal
per diem rates, then in effect, as set by the U.S. General Services
Administration. Reimbursement for travel by vehicle shall be reimbursed at the
current Internal Revenue Service mileage standard for miles driven for
transportation or travel expenses. The health carrier's regulatory obligation
in this Subsection C to provide such reimbursement shall not exceed $10,000.00
per covered person in any applicable policy year.
D. The health carrier shall establish and
maintain adequate arrangements to ensure reasonable proximity of participating
providers/facilities to the locations of covered persons. A health carrier may
be deemed to be out of compliance with the geographic access standards in Rule
14.05(B) in the event that the health carrier is not able to meet the
applicable time or distance minimum with respect to covered persons' locations.
In determining whether a health carrier has complied with the geographic access
standards in Rule 14.05(B), the Commissioner shall give due consideration to
the relative availability of health care providers in the geographic area under
consideration. The fact that no provider specialist, adult or pediatric,
provides a covered service within the minimum geographic access standards shall
be taken into consideration when determining whether a health carrier has
complied with the geographic access standards in Rule 14.05(B), and the
Commissioner may accept the attestation of a health carrier as sufficient even
if the health carrier does not comply with Rule 14.05(B) and Rule 14.05(D) if
the Commissioner determines the health carrier has made reasonable efforts to
secure health care providers in the geographic area at issue, but such
providers were not available. The Commissioner's assessment of the health
earner's efforts will be performed consistent with the Managed Care Plan
Certification Regulation, Title 19. Part 3, Chapter 18.
1. A health carrier shall monitor, on an
ongoing basis, the ability, clinical capacity, financial capability, and legal
authority of its providers to furnish all contracted benefits to covered
persons.
2. If a health carrier
does not meet network adequacy standards in a particular geographic area, the
Commissioner shall have authority to request and obtain from the health carrier
data or information pertaining to the health carrier's efforts to comply with
this section and to obtain contracts with providers/facilities and use this
information in his determination under this provision. This authority shall
extend to contracts offered to but declined by providers/facilities, and to
provider applications that were denied by the health carrier. A health carrier
shall maintain records as to all providers/facilities who apply to be a
participating provider but were denied such status, along with an explanation
of why such status was denied by the health carrier.
E. Beginning June 1. 2025, a health carrier
shall file with the Commissioner, in addition to the information required to be
submitted in this Regulation and the Managed Care Plan Certification
Regulation, an access plan meeting the requirements of Rule 14.05 for each of
the managed care plans that the carrier offers in this state. The health
carrier shall make the access plans, absent proprietary or confidential
commercial or financial information, available on its business premises and
shall provide them to any interested party upon request. The health carrier
shall prepare an access plan before offering a new managed care plan and shall
update an existing access plan whenever it makes any material change to an
existing managed care plan. The access plan shall describe or contain at least
the following:
1. The health carrier's
network;
2. The health carrier's
procedures for making referrals within and outside its network;
3. The health carrier's process for
monitoring and assuring on an ongoing basis the sufficiency of the network to
meet the health care needs of populations that enroll in managed care
plans:
4. The health carrier's
efforts to address the needs of covered persons with limited English
proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and
with physical and mental disabilities;
5. The health carrier's methods for assessing
the health care needs of covered persons and their satisfaction with
services;
6. The health earner's
method of informing covered persons of the plan's services and features,
including, but not limited to. the plan's grievance procedures, its process for
choosing and changing providers, and its procedures for providing and approving
emergency and specialty care:
7.
The health carrier's system for ensuring the coordination and continuity of
care for covered persons referred to specialty physicians, for covered persons
using ancillary services, including social services and other community
resources, and for ensuring appropriate discharge planning:
8. The health carrier's process for enabling
covered persons to change primary care professionals:
9. The health carrier's proposed plan for
providing continuity of care in the event of contract termination between the
health carrier and any of its participating providers, or in the event of the
health carrier's insolvency or other inability to continue operations. The
description shall explain how covered persons will be notified of the contract
termination, or the health carrier's insolvency or other cessation of
operations, and transferred to other providers in a timely manner;
and
10. Any other information
required by the Commissioner to determine compliance with the provisions of
this Regulation.
Notes
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