Where an issuer's network meets one or
more of the criteria in WAC
, the issuer may submit an alternate
access delivery request for the commissioner's review and approval. The
alternate access delivery request must be made using the Alternate Access
Delivery Request Form C, as provided in WAC
(a) An alternate access delivery system must
provide enrollees with access to medically necessary care on a reasonable basis
without detriment to their health.
The issuer must ensure that the enrollee
obtains all covered services in the alternate access delivery system at no
greater cost to the enrollee than if the service was obtained from network
providers or facilities or must make other arrangements acceptable to the
(i) Copayments and deductible
requirements must apply to alternate access delivery systems at the same level
they are applied to in-network services.
(ii) The alternate access delivery system may
result in issuer payment of billed charges to ensure network access.
(c) An issuer must demonstrate in
its alternate access delivery request a reasonable basis for not meeting a
standard as part of its filing for approval of an alternate access delivery
system, and include an explanation of why the alternate access delivery system
provides a sufficient number or type of the provider or facility to which the
standard applies to enrollees.
An issuer must demonstrate a plan and practice to assist enrollees to locate
providers and facilities in neighboring service areas in a manner that assures
both availability and accessibility. Enrollees must be able to obtain health
care services from a provider or facility within the closest reasonable
proximity of the enrollee in a timely manner appropriate for the enrollee's
Alternate access delivery systems include, but are not
limited to, such provider network strategies as use of out-of-state and out of
county or service area providers, and exceptions to network standards based on
rural locations in the service area.
The commissioner will not approve an
alternate access delivery system unless the issuer provides substantial
evidence of good faith efforts on its part to contract with providers or
facilities, and can demonstrate that there is not an available provider or
facility with which the issuer can contract to meet provider network standards
Such evidence of good faith efforts to
contract, where required, will be submitted as part of the issuer's Alternate
Access Delivery Request Form C submission, as described in WAC
(b) Evidence of good faith efforts to
contract will include documentation about the efforts to contract but not the
substantive contract terms offered by either the issuer or the
practice of entering into a single case provider reimbursement agreement with a
provider or facility in relation to a specific enrollee's condition or
treatment requirements is not an alternate access delivery system for purposes
of establishing an adequate provider network. A single case provider
reimbursement agreement must be used only to address unique situations that
typically occur out of network and out of service area, where an enrollee
requires services that extend beyond stabilization or one time urgent care.
Single case provider reimbursement agreements must not be used to fill holes or
gaps in a network for the whole population of enrollees under a plan, and do
not support a determination of network access.
(4) This section is effective for all plans,
whether new or renewed, with effective dates on or after January 1,
Wash. Admin. Code §
16-07-144, Filed 3/23/2016, effective
Recodified from § 284-43-9971.
16-14-106, Filed 7/6/2016, effective