Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-200 - Network access-General standards

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must
				maintain each provider network for each health plan in a manner that is
				sufficient in numbers and types of providers and facilities to assure that, to
				the extent feasible based on the number and type of providers and facilities in
				the service area, all health plan services provided to enrollees will be
				accessible in a timely manner appropriate for the enrollee's condition. An
				issuer must demonstrate that for each health plan's defined service area, a
				comprehensive range of primary, specialty, institutional, and ancillary
				services are readily available without unreasonable delay to all enrollees and
				that emergency services are accessible 24 hours per day, seven days per week
				without unreasonable delay.
(2)
				Each enrollee must have adequate choice among health care providers, including
				those providers which must be included in the network under WAC
				284-170-270, and for qualified
				health plans and qualified stand-alone dental plans, under WAC
				284-170-310.
(3) An issuer's service area must not be
				created in a manner designed to discriminate or that results in discrimination
				against persons because of age, gender, gender identity, sexual orientation,
				disability, national origin, sex, family structure, ethnicity, race, health
				condition, employment status, or socioeconomic status.
(4) An issuer must establish sufficiency and
				adequacy of choice of providers based on the number and type of providers and
				facilities necessary within the service area for the plan to meet the access
				requirements set forth in this subchapter. Where an issuer establishes medical
				necessity or other prior authorization procedures, the issuer must ensure
				sufficient qualified staff is available to provide timely prior authorization
				decisions on an appropriate basis, without delays detrimental to the health of
				enrollees.
(5) In any case where
				the issuer has an absence of or an insufficient number or type of participating
				providers or facilities to provide a particular covered health care service,
				the issuer must ensure through referral by the primary care provider or
				otherwise that the enrollee obtains the covered service from a provider or
				facility within reasonable proximity of the enrollee at no greater cost to the
				en-rollee than if the service were obtained from network providers and
				facilities. An issuer must satisfy this obligation even if an alternate access
				delivery request has been submitted and is pending commissioner approval.
An issuer may use facilities in neighboring service areas to
				  satisfy a network access standard if one of the following types of facilities
				  is not in the service area, or if the issuer can provide substantial evidence
				  of good faith efforts on its part to contract with the 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 facility. This applies to the
				  following types of facilities:
(a)
				Tertiary hospitals;
(b) Pediatric
				community hospitals;
(c) Specialty
				or limited hospitals, such as burn units, rehabilitative hospitals, orthopedic
				hospitals, and cancer care hospitals;
(d) Neonatal intensive care units;
				and
(e) Facilities providing
				transplant services, including those that provide solid organ, bone marrow, and
				stem cell transplants.