Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.12 - Network Adequacy

Current through Register 1525, July 5, 2024
(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 back grounds, 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
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			 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 Geo Networks,
			 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 geographic areas as appropriate for the Carrier's
			 service area, 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 and a list of those top five
			 types;
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 and
			 a list of those top five types;
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-shaing 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.
(j) Any other information required by the
			 Commissioner to determine compliance with the provisions of
			 211
			 CMR 52.12.