Md. Code Regs. 14.35.16.07

Current through Register Vol. 51, No. 24, December 2, 2024

Section 14.35.16.07 - Qualified Health Plan Certification - Essential Community Providers

A. For each health benefit plan that a carrier seeks to offer through the Exchange, the carrier shall make all good faith efforts to contract with at least 35 percent of available essential community providers in the plan's service area as part of each plan's provider network, except as specified in §C of this regulation.

B. Additional Essential Community Providers.

(1) Included with its application for certification and in the form provided by the Exchange, the carrier may write in additional essential community providers that are not included in the definition for essential community provider under Regulation .02B of this chapter.

(2) If available, the carrier shall include the following information when writing in additional essential community health providers:

(a) The provider's zip code reflecting a provider location within a low-income zip code or Health Professional Shortage Areas included on the "low-Income and Health Professional Shortage Area Zip Code listing" from CMS;

(b) The provider's service street address, which may not be a Post Office Box number; and

(c) The National Provider Identifier (NPI) number, if the provider has such a number, or an alternate identification, such as a Tax Identification Number, if the provider does not have such a number.

(3) The authorized carrier shall provide information under this section as part of the application submitted under Regulation .04 of this chapter.

C. Carriers Who Are Unable to Meet Contracting Requirements.

(1) If the authorized carrier cannot meet the standard under this section, the authorized carrier may satisfy this requirement under the alternative standard.

(2) To meet the alternative standard, the authorized carrier shall provide a narrative explanation of the authorized carrier's justification that the carrier includes access to sufficient essential community providers within the health benefit plan's network.

(3) The narrative explanation shall describe the extent to which the authorized carrier's provider sites are accessible to, and have services that meet the needs of, specific underserved populations, including:

(a) Individuals with HIV/AIDS, including those with co-morbid behavioral health conditions;

(b) American Indians and Alaska Natives;

(c) low-income and underserved individuals seeking women's health and reproductive health services; and

(d) Other specific populations served by essential community providers in the plan's service area.

(4) The narrative explanation shall demonstrate that low-income members receive appropriate access to care and satisfactory service, including performance on provider quality and patient satisfaction metrics, as specified in the Annual letter to Issuers.

D. For each health benefit plan that a carrier seeks to offer through the Exchange, the carrier shall make all good faith efforts to contract with at least one available essential community provider of each essential community provider type, under §E of this regulation, in each county, or partial county, of the plan's service area as part of each plan's provider network.

E. Authorized carriers shall offer the same provider contract terms in good faith to the following essential community providers that a willing, similarly situated, non-essential community provider would accept or has accepted from the authorized carrier to the following provider types:

(1) All available Indian Health Care Providers in the plan's service area;

(2) Willing local health departments under Insurance Article, § 15-112(b)(3) (Hi), Annotated Code of Maryland, in the plan's service area; and

(3) For each county in the plan's service area, at least one provider from the following provider types, if such a provider is available and provides the medical or dental services, as applicable to plan type:

(a) A health care provider defined in §340B(a)(4) of the Public Health Services Act;

(b) An outpatient mental health center as described in COMAR 10.21.20;

(c) A substance use disorder treatment provider as described at COMAR 10.09.80.03B(1) and (3);

(d) A school based-health center;

(e) A health care provider described in §1927(c)(l)(D)(i)(IV) of the Social Security Act; and

(f) A State-owned, government-owned, or not-for-profit family planning services site that does not receive federal funding.

F. An authorized carrier shall submit verification of essential community provider contract offers to the Exchange upon request.

Md. Code Regs. 14.35.16.07

Regulation .07 adopted effective 46:5 Md. R. 309, eff. 3/11/2019; amended effective 51:3 Md. R. 154, eff. 2/19/2024.