West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Section 114-100-4 - Network Access Plan Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				For health benefit plan years beginning January 1, 2025, a health carrier shall
				file with the Commissioner an access plan meeting the requirements of this rule
				and W. Va. Code §
									33-55-3. An access plan for a newly offered network must
				be filed for review and approval on or before July 1st of the year preceding
				the plan year. For the purposes of this rule, a "newly offered network"
				includes an existing network at the time this amended rule becomes effective
				irrespective of whether the Commissioner has approved the network.
4.2. A health carrier shall file, maintain
				and make available on their website an access plan, absent proprietary
				information, for each network plan that the carrier offers in West Virginia.
				The health carrier may request the Commissioner to deem sections of the access
				plan as proprietary information that not be made public.
4.3. A health carrier shall prepare and file
				an access plan prior to offering a new network plan, and shall notify the
				Commissioner of any material change to any existing network plan within 15
				business days after the change occurs, including a reasonable timeframe within
				which it will file an update to an existing access plan.
4.4. A health carrier shall make an access
				plan, absent proprietary information pursuant to W. Va. Code
				§
									33-55-3, available to any person upon request.
4.5. All health benefit plans and marketing
				materials of a health carrier shall clearly disclose the existence and
				availability of the access plan.
4.6. All rights and responsibilities of the
				covered person under a health benefit plan shall be included in the contract
				provisions of the health benefit plan, regardless of whether or not such
				provisions are also specified in the access plan.
4.7. A health carrier shall submit access
				plans to the Commissioner through SERFF.
4.8. An access plan shall describe, contain,
				or address the following:
4.8.1. The health
				carrier's network, including how the use of telemedicine or telehealth or other
				technology may be used to meet network access standards, if
				applicable;
4.8.2. The factors used
				by the health carrier to build its network, including a description of the
				criteria used to select providers;
4.8.3. Establishing that the health carrier's
				network has an adequate number of providers and facilities within a reasonable
				distance of covered persons;
4.8.4.
				The specific provider and facility types within the network per West Virginia
				county;
4.8.5. The health carrier's
				documented, quantifiable and measurable process for monitoring and assuring the
				sufficiency of the network in order to meet the health care needs of covered
				persons on an ongoing basis;
4.8.6.
				The carrier's process to assure that a covered person is able to obtain a
				covered benefit, at the in-network benefit level, from a non-participating
				provider should the carrier's network prove to not be sufficient;
4.8.7. The health carrier's procedures for
				making and authorizing referrals within and outside its network. The procedures
				should address the health carrier's processes regarding:
4.8.7.a. The provision of a comprehensive
				listing of the health carrier's network of participating providers and
				facilities to covered persons and primary care providers;
4.8.7.b. Timely referrals for access to
				specialty care;
4.8.7.c. Expedition
				of the referral process when indicated by the covered person's medical
				condition; and
4.8.7.d. Member
				access to services outside the network when necessary;
4.8.8. The health carrier's process for
				enabling covered persons to change primary care providers (PCP), if
				applicable;
4.8.9. The health
				carrier's quality assurance standards, which must be adequate to identify,
				evaluate and remedy problems relating to access, continuity and quality of
				care;
4.8.10. The health carrier's
				methods for assessing the health care needs of covered persons and their
				satisfaction with services;
4.8.11.
				The health carrier's efforts to address the needs of covered persons,
				including, but not limited to, children and adults, including those with
				limited English proficiency or illiteracy, diverse cultural or ethnic
				backgrounds, physical or mental disabilities, and serious, chronic, or complex
				medical conditions. This includes the carrier's efforts, when appropriate, to
				include various types of ECPs in its network;
4.8.12. The health carrier's method of
				informing covered persons of the plan's covered services and features,
				including, but not limited to:
4.8.12.a. The
				plan's grievance and appeal procedures;
4.8.12.b. Its process for choosing and
				changing providers;
4.8.12.c. Its
				process for updating its provider directories for each of its network
				plans;
4.8.12.d. A statement of
				health care services offered, including those services offered through the
				preventive care benefit, if applicable; and
4.8.12.e. Its procedures for covering and
				approving emergency, urgent and specialty care, if
				applicable;
4.8.13. The
				health carrier's proposed plan for providing continuity of care in the event of
				contract termination between the health carrier and any of its participating
				providers, or in the event of the health carrier's insolvency or other
				inability to continue operations. The description shall explain how covered
				persons will be notified of the contract termination, or the health carrier's
				insolvency or other cessation of operations, and transitioned to other
				providers in a timely manner; and
4.8.14. The health carrier's process for
				monitoring access to physician specialist services in emergency room care,
				anesthesiology, radiology, hospitalist care and pathology/laboratory services
				at their participating hospitals. This subdivision does not apply to limited
				scope vision plans or limited scope dental plans as defined in W.Va. Code
				§
										33-55-1.