4702.1A health carrier providing a network plan shall maintain a network that is sufficient in numbers and facilitates access to appropriate types of providers, including those that are (1) racially, ethnically, and gender diverse; (2) culturally aware of and sensitive to the needs of the diverse communities and gender identities in the District; and (3) serve predominantly low-income, medically underserved individuals, to ensure that all covered services to covered persons, including children and adults, will be accessible without unreasonable travel or delay.
4702.2Carriers shall submit to the Commissioner a Network Adequacy Report demonstrating compliance with this section, no later than September 1 of each year, for health plans being sold, issued, or renewed on or after January 1 of the subsequent year. If a carrier is unable to demonstrate compliance with any of the provisions set forth under this chapter, the carrier may submit a Request for Waiver Form for approval by the Commissioner. A health carrier may request that the Commissioner deem portions of its filed Network Adequacy Report or Request for Waiver Form confidential. The Commissioner may request additional information to evaluate efforts to achieve a sufficient network when reviewing a waiver request, including but not limited to:
(a) A list of providers or physicians that the carrier attempted to contract with, identified by name, practice location, and specialty or facility type;(b) A description of when and how many times the carrier last contacted each provider or physician;(c) A description of any reason(s) each provider or physician gave for refusing to contract with the carrier;(d) A description of any modifications to the contract or contracting process offered to providers or facilities described in paragraph (c);(e) Steps the carrier will take to attempt to improve its network to meet the requirements of this section;(f) Carriers that provide a majority of their covered professional services through physicians employed by the carrier, or through a single medical group in contract with the carrier, shall include, in a waiver request, a description of how the carrier otherwise meets the access needs of its enrollees, and a description of expansion plans, if applicable;(g) If this additional information is required because an issuer is not in compliance with any provision of this chapter or requested a waiver, the Commissioner may publish a report for consumers to understand efforts the issuer is taking to come into compliance or why any provision of this chapter does not apply.4702.3The Commissioner shall determine the sufficiency of a network in accordance with the requirements of this section.
4702.4For any provider-to-covered person ratio referenced in this section, the ratio shall be formulated by dividing the number of providers in each network, as listed in the carrier's submitted Centers for Medicare and Medicaid Services (CMS) Qualified Health Plan (QHP) network template, by the number of covered persons with access to that same network. If a carrier submits more than one Network ID, then separate ratios shall be formulated for each Network ID. For plans that do not use QHP templates, separate ratios shall be formulated for each established network and identified in a manner substantially similar to the Network ID.
4702.5For plans sold, issued, or renewed on or after January 1, 2024, carriers that provide a majority of covered professional services through physicians employed by the carrier, or through a single medical group in contract with the carrier, shall provide services consistent with the following requirements:
(a) Provider-to-covered person ratios by specialty using the following standards: Neurology | 1:7,500 |
Cardiology | 1:7,500 |
Hematology/Oncology | 1:7,500 |
Dermatology | 1:7,500 |
Rheumatology | 1:7,500 |
Orthopedics | 1:7,500 |
Nephrology | 1:7,500 |
Plastic Surgery | 1:7,500 |
(b) Provider--to-covered person ratios using the following standards: Primary Care (Medical Doctor, Nurse Provider) | 1:3,000 |
Pediatrics (Board Certified Pediatrician or Family Medicine) | 1:3,000 |
OB/GYN (Board Certified OB/GYN, Nurse Provider, or Midwife) | 1:3,000 |
Behavioral Health & Substance Use (Board Certified Neurology or Psychiatry; PsyD, PhD, Masters level clinician in the areas of Social Work, Family Therapy, Licensed Professional Counselors) | 1:3,000 |
Habilitative Services (Speech, Language and Occupational and Physical Therapists, Applied Behavior Analysis providers) | 1:3,000 |
(c) Physician Accessibility:(1) On or before March 1 of each year, the Commissioner shall make available to the carriers a list of physicians with a fully privileged, active license to practice medicine in the District of Columbia, and other qualified providers if applicable, their primary practice address in the District of Columbia, and identify the physicians with an office located within half (1/2) of a mile of a Metrorail stop. The Commissioner, in consultation with carriers, shall include additional data elements in the listing as necessary to allow for comparison with carrier data. In the event no update is made available, the carriers shall use the prior year's list.(2) The Commissioner shall provide a mechanism for a carrier to report providers who are improperly excluded from the list; included on the list; or improperly identified as having or not having an office within half (1/2) of a mile of a Metrorail stop.(3) Carriers shall have in their network at least fifteen percent (15%) of providers with a primary practice address within the District of Columbia identified as having an office within half (1/2) of a mile of a Metrorail stop on the list of providers.(d) Appointment Wait Times:(1) Carriers shall establish the standards listed below for appointment wait times for services within the network. The standard shall not be defined in terms of an appointment with a specific provider, but rather any qualified provider employed by the carrier or single contracted medical group who is available within a reasonable time frame to see a covered person. SERVICE TYPE | TIME FRAME |
First appointment with a new or replacement Primary Care physician | within 7 business days |
First appointment with a new or replacement provider for Behavioral Health treatment, including Substance Use Treatment | within 7 business days |
First appointment with a new or replacement provider for Prenatal Care treatment | within 15 business days |
First appointment with a new or replacement provider for Specialty Care treatment | within 15 business days |
(2) Carriers shall communicate the appointment wait time standards to all covered persons in their welcome packet, and post or link the standards in online provider directory pages. The language used shall be substantially similar to the following: Requirements for Timely Medical Appointments Some customers of [Company Name] have a right to an appointment with an in-network health care provider within a certain number of days. You have this right if: (1) You buy your health insurance directly or receive it through your employer in the District of Columbia, and (2) The appointment is for your first visit with a provider. A first visit includes when you: a. Schedule your first primary care visit with a provider; b. Have changed primary care providers and need to schedule your first visit with a new primary care provider; or c. Schedule your first visit with a provider other than your primary care provider, your behavioral health / substance use provider, or your prenatal care provider for specialty treatment. How quickly can you expect to be seen? The District of Columbia has set the standards below for appointments with an in network provider. |
SERVICE TYPE | TIME FRAME |
First appointment with a new or replacement Primary Care physician | within 7 business days |
First appointment with a new or replacement provider for Behavioral Health treatment, including Substance Use Treatment | within 7 business days |
First appointment with a new or replacement provider for Prenatal Care treatment | within 15 business days |
First appointment with a new or replacement provider for Specialty Care treatment | within 15 business days |
If you have trouble scheduling an appointment within the timeframes listed, please call [Phone Number] to speak to a [Company Name] representative. That person will help you schedule an appointment within the timeframes listed. |
(3) Carriers shall maintain and publicize a toll-free number to a call center through which covered persons can promptly speak to an individual who shall assist them with identifying providers who have appointments available within the timeframes required based on the date of the initial call to the call center.(4) Carriers shall include information in its Network Adequacy Report summarizing the activities of the call center, including statistics on the number of calls received, the issues addressed, and resolution of the calls.(e) Essential Community Providers: (1) Carriers are required to have a sufficient number and geographic distribution of providers employed by the carrier, or single medical group in contract with the carrier, to ensure reasonable and timely access, consistent with the provisions set forth in this subsection, to a broad range of services for low-income or medically underserved individuals in their service areas.(2) Carriers shall demonstrate that at least twenty percent (20%) of the providers employed by the carrier, or the single medical group in contract with the carrier, are located within Health Professional Shortage Areas (HPSAs), or five-digit ZIP codes designated as Medically Underserved Areas/Populations (MUA/P), as determined by DC Health.4702.6For plans sold, issued, or renewed on or after January 1, 2024, carriers that do not provide a majority of covered professional services through physicians employed by the carrier, or through a single medical group in contract with the carrier, shall provide services consistent with the following requirements:
(a) Provider-to-covered person ratios by specialty using the following standards: Neurology | 1:5,000 |
Cardiology | 1:5,000 |
Hematology/Oncology | 1:5,000 |
Dermatology | 1:5,000 |
Rheumatology | 1:5,000 |
Orthopedics | 1:5,000 |
Nephrology | 1:5,000 |
Plastic Surgery | 1:5,000 |
(b) Provider-to-covered person ratios using the following standards: Primary Care (Medical Doctor, Nurse Provider) | 1:2,000 |
Pediatrics (Board Certified Pediatrician or Family Medicine) | 1:2,000 |
OB/GYN (Board Certified OB/GYN, Nurse Provider, or Midwife) | 1:2,000 |
Behavioral Health & Substance Use (Board Certified Neurology or Psychiatry; PsyD, PhD, Masters level clinician in the areas of Social Work, Family Therapy, Licensed Professional Counselors) | 1:2,000 |
Habilitative Services (Speech, Language and Occupational and Physical Therapists, Applied Behavior Analysis providers) | 1:2,000 |
(c) Physician Accessibility:(1) On or before March 1 of each year, the Commissioner shall make available to the carriers a list of physicians with a fully privileged, active license to practice medicine in the District of Columbia, and other qualified providers if applicable, among the specialties listed in (3), with their primary practice address in the District of Columbia. The list will identify among those on the list the physicians with an office located within half (1/2) of a mile of a Metrorail stop. The Commissioner, in consultation with carriers, shall include additional data elements in the listing as necessary to allow for comparison with carrier data. In the event no update is made available, the carriers shall use the prior year's list.(2) The Commissioner shall provide a mechanism for a carrier to report providers who are improperly excluded from the list; improperly included on the list; or improperly identified as having or not having an office within half (1/2) of a mile of a Metrorail stop.(3) Carriers shall contract with a minimum of thirty percent (30%) of the providers on the list provided by the Commissioner for each of the specialties listed below: Primary Care
Pediatrics
OB/GYN
Behavioral Health & Substance Use
Neurology
Cardiology
Hematology / Oncology
Dermatology Rheumatology Orthopedics Nephrology
(4) Carriers shall have in their network at least thirty percent (30%) of all providers (not just those on the specialty list) with a primary practice address within the District of Columbia identified as having an office within half (1/2) of a mile of a Metrorail stop on the list of providers.(d) Appointment Wait Times: (1) Carriers shall establish the standards listed below for appointment wait times for services within the network. The standard shall not be defined in terms of an appointment with a specific provider, but rather any qualified in-network provider. SERVICE TYPE | TIME FRAME |
First appointment with a new or replacement Primary Care physician | within 7 business days |
First appointment with a new or replacement provider for Behavioral Health treatment, including Substance Use Treatment | within 7 business days |
First appointment with a new or replacement provider for Prenatal Care treatment | within 15 business days |
First appointment with a new or replacement provider for Specialty Care treatment | within 15 business days |
(2) Carriers shall communicate the appointment wait time standards to all covered persons in their welcome packet, and post or link the standards in online provider directory pages. The language used shall be substantially similar to the following: Requirements for Timely Medical Appointments Some customers of [Company Name] have a right to an appointment with an in-network health care provider within a certain number of days. You have this right if: (1) You buy your health insurance directly or receive it through your employer in the District of Columbia. and (2) The appointment is for your first visit with a provider. A first visit includes when you: a. Schedule your first primary care visit with a provider; b. Have changed primary care providers and need to schedule your first visit with a new primary care provider; or c. Schedule your first visit with a provider other than your primary care provider, your behavioral health / substance use provider, or your prenatal care provider for specialty treatment. How quickly can you expect to be seen? The District of Columbia has set the standards below for appointments with in-network providers. |
SERVICE TYPE | TIME FRAME |
First appointment with a new or replacement Primary Care physician | within 7 business days |
First appointment with a new or replacement provider for Behavioral Health treatment, including Substance Use Treatment | within 7 business days |
First appointment with a new or replacement provider for Prenatal Care treatment | within 15 business days |
First appointment with a new or replacement provider for Specialty Care treatment | within 15 business days |
If you have trouble scheduling an appointment within the timeframes listed, please call [Phone Number] to speak to a [Company Name] representative. That person will help you schedule an appointment within the timeframes listed. Please note: 1. The [Company Name] representative will likely give you the provider's contact information and you may need to schedule the appointment yourself. 2. The [Company Name] representative can't force the specific provider you want to see to give you an appointment within the timeframe, as the provider may have already scheduled appointments with other patients or is otherwise unavailable. Instead, the representative will give you contact information for a qualified, in-network provider who is available to see you within the above timeframe. 3. The [Company Name] representative can't otherwise guarantee an appointment with a provider you've seen before. |
(3) Carriers shall maintain and publicize a toll-free number to a call center through which covered persons can speak to an individual who shall assist them with identifying providers who have appointments available within the timeframes required based on the date of the initial call to the call center.(4) Carrier shall include information in its Network Adequacy Report summarizing the activities of the call center including statistics on the calls received and resolution of the calls.
(e) Essential Community Providers: (1) Carriers are required to have a sufficient number and geographic distribution of essential community providers ("ECPs"), where available. An essential community provider is a provider that serves predominantly low-income, medically underserved individuals, including: a health care provider as defined in Section 340(B)(a)(4) of the Public Health Service Act (PHSA) (42 USC § 256b), or as described in Section 1927(c)(1)(D)(i)(IV) of the Social Security Act (42 USC § 1396r-8); or a State-owned family planning service site, or governmental family planning service site that does not receive Federal funding under special programs, including under Title X of the PHSA (42 USC §§ 300 to 300a-6), unless any of the above providers has lost its status under either of these sections, Section 340(B) of the PHSA, or Section 1902 of the Social Security Act (42 USC § 1396a) as a result of violating Federal law.(2) Carriers shall demonstrate in their Network Adequacy Report that at least twenty percent (20%) of available ECPs in each plan's service area participate in the plan's network.4702.7A health carrier shall have procedures to ensure that a covered person may obtain covered benefits from non-participating providers at in-network benefit levels, including for cost-sharing, or shall make other arrangements acceptable to the Commissioner when the health carrier has met the requirements of this chapter, but does not have participating providers available to provide medically necessary covered benefits which meet any one of the three standards below:
(a) The service or benefit will, or is reasonably expected to, prevent the onset of an illness condition, or disability;(b) The service or benefit will, or is reasonably expected to, reduce, or ameliorate the physical, mental, or developmental effects of an illness, condition, or disability;(c) The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities that take into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.4702.8(a) A health carrier shall provide instructions to covered persons explaining how to make a written request for access to covered benefits from nonparticipating providers under circumstances provided in § 4702.7.(b) The carrier shall treat the health care services received by a covered person from a non-participating provider pursuant to §§4702.7 and 4702.8(a)-(b) as if the services were provided by a participating provider, including crediting the cost-sharing for such services toward the applicable maximum out-of-pocket limit for services obtained from participating providers under the health benefit plan.(c) The procedures described in §4702.8(d) shall ensure that requests to obtain covered benefits from non-participating providers are addressed in a timely fashion relative to the covered person's condition.(d) The carrier shall document and retain copies of all requests for covered benefits from non-participating providers, for as long as the enrollee maintains coverage plus a minimum of one (1) year after an enrollee terminates coverage and shall make the information available to the Commissioner upon request. (1) The procedures established in this subsection are not intended to be used as a substitute for establishing and maintaining a sufficient provider network or to circumvent the use of covered benefits available through a health carrier's network.(2) Nothing in this section prevents a covered person from exercising any right and remedy available under applicable District or federal law relating to internal and external claims grievance and appeals procedures.D.C. Mun. Regs. tit. 26, r. 26-A4702
Final Rulemaking published at 70 DCR 2231 (2/17/2023)