D.C. Mun. Regs. tit. 26, r. 26-A4703

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 26-A4703 - ACCESS PLAN

4703.1

A health carrier shall file an Access Plan prior to or at the time it files a new or amended network plan, in a manner and form set by the Commissioner, separate and apart from the Network Adequacy Report, meeting the requirements of this chapter with the Commissioner by September 1 of each year.

4703.2

A health carrier shall notify the Commissioner of any material change to any existing network plan, as noted in the filed Access Plan, including but not limited to:

(a) A ten percent (10%) or greater change in the carrier's total number of network of providers;

(b) A twenty percent (20%) or greater reduction in the number of primary care providers in the carrier's network;

(c) A twenty percent (20%) or greater reduction in the number of specialty providers available in the carrier's network;

(d) A reduction in a specific type of provider, such that the provider type or a specific covered service is no longer available;

(e) A twenty percent (20%) change to a tiered, multi-tiered, layered, or multilevel network plan structure, including a reduction or greater in the number of providers in any tier, layer, or level; or

(f) An increase or decrease of twenty percent (20%) or more covered persons since the previous filing.

4703.3

A health carrier's Access Plan shall describe or contain the following:

(a) The provider network, including the extent it supports the use of telemedicine or other technology to enhance network access;

(b) The procedures for making and authorizing referrals within and outside the network, if applicable;

(c) The process for monitoring and assuring the sufficiency of the network to meet the health care needs of populations that use the network;

(d) The factors used by the health carrier to build its provider network, including a description of the network and the criteria used to select or tier providers;

(e) The efforts to address the needs of covered persons, including children and adults, persons with limited English proficiency or literacy, persons with diverse cultural and ethnic backgrounds, and persons with physical or mental disabilities or other serious, chronic, or complex medical conditions. This includes a health carrier's efforts, when appropriate, to include various types of essential community providers, as described in §4702.6(e)(2), in its network;

(f) The methods for assessing the health care needs of covered persons and their satisfaction with the services provided;

(g) The method of informing covered persons of covered services and features, including but not limited to:

(1) The grievance and appeals procedures;

(2) The process for selecting and changing providers;

(3) The process for updating provider directories for each network plan;

(4) A statement of health care services offered, including services offered through the preventive care benefit, if applicable; and

(5) The procedures for covering and approving emergency, urgent, and specialty care, if applicable;

(h) The process for ensuring the coordination and continuity of care:

(1) For covered persons referred to specialty providers; and

(2) For covered persons using ancillary services, including social services and other community resources, and for appropriate discharge planning;

(i) The process for covered persons to change primary care professionals, if applicable;

(j) A 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 plan shall explain how covered persons will be notified and transitioned to other providers, in a timely manner, due to termination of a provider contract, the health carrier's insolvency, or other cessation of operations; and

(k) Any other information required by the Commissioner to determine compliance with this chapter.

4703.4

The Commissioner shall publish the filed Access Plan online, and a health carrier may file a written request that the Commissioner deem portions of its filed Access Plan confidential and redact the confidential portions from published version. A written request shall:

(a) Identify the particular information that the carrier requests be deemed confidential; and

(b) Cite the legal basis for the request.

4703.5

The Commissioner shall have the authority to deem the following as confidential:

(a) Proprietary methodology used to annually assess the carrier's performance in meeting the standards established under this rule;

(b) Proprietary methodology used to annually measure timely access to health care services;

(c) Factors used by the carrier to build its network; and

(d) Any other subject-matter recognized as confidential, proprietary, or otherwise prohibited from disclosure under District law.

D.C. Mun. Regs. tit. 26, r. 26-A4703

Final Rulemaking published at 70 DCR 2231 (2/17/2023)