Nevada Administrative Code › Chapter 687B - Contracts of Insurance › ADEQUACY OF NETWORK PLANS › Section 687B.768 - Adoption by reference of standards for determining adequacy

Current through June 11, 2024
1. In order for the Commissioner to determine
								 that a network plan made available for sale in this State is adequate, the network plan must contain, at a
								 minimum:
(a) For a network plan other than a stand-alone dental plan,
								 evidence that the network plan provides reasonable access to at least one provider in the specialty area
								 listed in the following table for at least 90 percent of enrollees by complying with the area designations
								 for the maximum time or distance standards in the following table:
Specialty Area
Maximum Time or Distance Standards
																		 (Minutes/Miles)
Metro
Micro
Rural
Counties with Extreme Access
																		 Considerations (CEAC)
Primary Care
15/10
30/20
40/30
70/60
Endocrinology
60/40
100/75
110/90
145/130
Infectious Diseases
60/40
100/75
110/90
145/130
Oncology - Medical/Surgery
45/30
60/45
75/60
110/100
Oncology - Radiation/Radiology
60/40
100/75
110/90
145/130
Psychiatrist
45/30
60/45
75/60
110/100
Psychologist
45/30
60/45
75/60
110/100
Licensed Clinical Social Workers
																		 (LCSW)
45/30
60/45
75/60
110/100
Pediatrics
25/15
30/20
40/30
105/90
Rheumatology
60/40
100/75
110/90
145/130
Hospitals
45/30
80/60
75/60
110/100
Outpatient Dialysis
45/30
80/60
90/75
125/110
(b) For a
								 stand-alone dental plan or a network plan that offers oral pediatric services to satisfy the requirements for
								 essential health benefits set forth in  42 U.S.C. §
										18022(b)(1)(J), evidence that the network plan
								 provides reasonable access to at least one provider in the specialty area listed in the following table for
								 at least 90 percent of enrollees by complying with the area designations for the maximum time or distance
								 standards in the following table:
Specialty Area
Maximum Time or Distance Standards
																		 (Minutes/Miles)
Metro
Micro
Rural
Counties with Extreme Access
																		 Considerations (CEAC)
General Dentist
45/45
60/60
120/100
120/100
Periodontist
45/45
60/60
120/100
120/100
Oral Surgeon
45/45
60/60
120/100
120/100
Orthodontist
45/45
60/60
120/100
120/100
(c) Evidence that
								 the network plan:
(1) Contracts with at least 35 percent of the essential
								 community providers in the service area of the network plan that are available to participate in the provider
								 network of the network plan.
(2) Offers contracts in good faith to
								 all available Indian health care providers in the service area of the network plan, including, without
								 limitation, the Indian Health Service established pursuant to  25 U.S.C. §
											1661, Indian Tribes, tribal
								 organizations and urban Indian organizations, as defined in  25 U.S.C. §
											1603, which apply the special
								 terms and conditions necessitated by federal statutes and regulations as referenced in the
Model
								 Qualified Health Plan Addendum for Indian Health Care Providers
. A copy of the
Model
								 Qualified Health Plan Addendum for Indian Health Care Providers
may be obtained free of charge at
								 the Internet address
https://www.qhpcertification.cms.gov/s/ECP%20and%20Network%20Adequacy
.
(3) For a network plan other than a stand-alone dental plan:
(I) Offers contracts in good faith to all available essential community
								 providers in all counties in the service area of the network plan that are designated pursuant to subsection
								 3 as Counties with Extreme Access Considerations.
(II) Offers
								 contracts in good faith to at least one essential community provider in each category of essential community
								 provider in the following table, in each county in the service area of the network plan, where an essential
								 community provider in that category is available and provides medical or dental services that are covered by
								 the network plan:
Major ECP Category
ECP Provider Types
Family Planning Providers
Title X Family Planning Clinics and Title X
																		 "Look-Alike" Family Planning Clinics
Federally Qualified Health Centers
																		 (FQHCs)
Federally Qualified Health Centers and Federally
																		 Qualified Health Center "Look Alike" Clinics, Outpatient health programs/facilities operated by Indian
																		 tribes, tribal organizations, programs operated by Urban Indian Organizations
Hospitals
Disproportionate Share Hospitals (DSH) and
																		 DSH-eligible Hospitals, Children's Hospitals, Rural Referral Centers, Sole Community Hospital,
																		 Freestanding Cancer Centers, Critical Access Hospitals
Indian Health Care Providers
Indian Health Service providers, Indian Tribes,
																		 Tribal organizations, and urban Indian Organizations
Ryan White Providers
Ryan White HIV/AIDS Program Providers
Other ECP Providers
STD Clinics, TB Clinics, Hemophilia Treatment
																		 Centers, Black Lung Clinics, Community Mental Health Centers, Rural Health Clinics, and other entities that
																		 serve predominantly low-income, medically underserved individuals