Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.05 - Travel Distance Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Sufficiency Standards.
(1) Standard and Methodology.
(a) Except as stated in §B of this regulation, each provider panel of a carrier shall have within the geographic area served by the carrier's network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §A(5) of this regulation for each type of geographic area.
(b) The distances listed in §A(5) of this regulation shall be:
(i) Measured from the enrollee's place of residence to the practicing location of the provider or facility; and
(ii) Calculated based on road travel distance.
(c) Except for those provider types excluded under §A(3) of this regulation, for each provider type and facility type included on the carrier's provider panel, the carrier shall:
(i) Map the residences of all Maryland enrollees covered under health benefit plans that use the provider panel;
(ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
(iii) For each zip code, identify the total number of enrollees residing in the zip code and the number of enrollees residing within an area where the applicable distance standard is not met;
(iv) For each zip code, calculate the percentage of enrollees residing within an area where the applicable distance standard is met;
(v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees residing in the zip code;
(vi) For each of the urban, rural, and suburban areas identify the total number of enrollees residing in the geographic area;
(vii) For each of the urban, rural, and suburban areas identify the total number of enrollees residing within an area where the applicable distance standard is not met; and
(viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees residing within an area where the applicable distance standard is met.
(d) Instead of independently calculating the road travel distance for each enrollee as described in §A(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:
(i) Maps the practicing locations of every participating provider within the geographic area served by the carrier's network or networks;
(ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
(iii) Enables the carrier to accurately identify the information and perform the calculations described in §A(1)(c)(iii)-(viii) of this regulation.
(e) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:
(i) Geo-access maps for each provider type and facility type except for those excluded under §A(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence outside the applicable distance standard;
(ii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier's provider panel that provide adolescent services; and
(iii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier's provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
(f) A carrier shall report each number and percentage described in §A(1)(c)(iii)-(viii) of this regulation as part of the annual access plan filing.