Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0222 - Essential community providers for exchange plans-Network access

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must
				include essential community providers in its provider network for qualified
				health plans and qualified stand-alone dental plans in compliance with this
				section and as defined in WAC
				284-43-221.
(2) An issuer must include a sufficient
				number and type of essential community providers in its provider network to
				provide reasonable access to the medically underserved or low-income in the
				service area, unless the issuer can provide substantial evidence of good faith
				efforts on its part to contract with the providers or facilities in the service
				area. Such 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 provider.
(3) The following minimum standards apply to
				establish adequate qualified health plan inclusion of essential community
				providers:
(a) Each issuer must demonstrate
				that at least thirty percent of available primary care providers,
				pediatricians, and hospitals that meet the definition of an essential community
				provider in each plan's service area participate in the provider
				network;
(b) The issuer's provider
				network must include access to one hundred percent of Indian health care
				providers in a service area, as defined in WAC
				284-43-130(16),
				such that qualified enrollees obtain all covered services at no greater cost
				than if the service was obtained from network providers or
				facilities;
(c) Within a service
				area, fifty percent of rural health clinics located outside an area defined as
				urban by the 2010 Census must be included in the issuer's provider
				network;
(d) For essential
				community provider categories of which only one or two exist in the state, an
				issuer must demonstrate a good faith effort to contract with that provider or
				providers for inclusion in its network, which will include documentation about
				the efforts to contract but not the substantive contract terms offered by
				either the issuer or the provider;
(e) For qualified health plans that include
				pediatric oral services or qualified dental plans, thirty percent of essential
				community providers in the service area for pediatric oral services must be
				included in each issuer's provider network;
(f) Ninety percent of all federally qualified
				health centers and FQHC look-alike facilities in the service area must be
				included in each issuer's provider network;
(g) At least one essential community provider
				hospital per county in the service area must be included in each issuer's
				provider network;
(h) At least
				fifteen percent of all providers participating in the 340B program in the
				service area, balanced between hospital and nonhospital entities, must be
				included in the issuer's provider network;
(i) By 2016, at least seventy-five percent of
				all school-based health centers in the service area must be included in the
				issuer's network.