Md. Code Regs. 31.10.44.06

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.44.06 - Appointment Waiting Time Standards

A. Network Capacity.

(1) Each carrier shall create and utilize written policies and procedures to monitor the availability of services.

(2) On a semiannual basis, each carrier shall make available to its enrollees the median waiting times to obtain the following in-person appointments with a participating provider as measured from the date of the initial request to the date of the earliest available in-person appointment:

(a) Urgent care for medical services;

(b) Inpatient urgent care for mental health services;

(c) Inpatient urgent care for substance use disorder services;

(d) Outpatient urgent care for mental health services;

(e) Outpatient urgent care for substance use disorder services;

(f) Routine primary care;

(g) Preventive care/well visits;

(h) Non-urgent specialty care;

(i) Non-urgent mental health care; and

(j) Non-urgent substance use disorder care.

(3) To calculate the median waiting times for the appointments described in §A(2) of this regulation, a carrier shall:

(a) Make direct contact with a random selection of provider offices qualified to provide the services for each of the appointment types listed in §A(2) of this regulation to ask for next available in-person appointments; and

(b) Retain documentation of the efforts described in §A(3)(a) of this regulation.

(4) The minimum sample size for the random selection of provider offices described in §A(3)(a) of this regulation shall be equivalent to the lesser of:

(a) Fifty percent of the participating providers qualified to provide the services for each of the appointment types listed in §A(2) of this regulation; or

(b) One hundred provider offices.

(5) The Commissioner may conduct a centralized survey to measure waiting time, by carrier, for each appointment type listed in §A(2) of this regulation.

(a) The survey described in §A(5) of this regulation shall utilize a statistically reliable and valid methodology that includes making direct contact with a random selection of participating providers for each carrier who are qualified to provide the services for each of the appointment types listed in §A(2) of this regulation to ask for next available appointments.

(b) The Commissioner may:

(i) Contract with a vendor to conduct the survey; and

(ii) Charge a carrier a reasonable fee to cover the costs of the survey.

(c) The Commissioner shall publish the methodology used to conduct the survey on the Maryland Insurance Administration's website.

(d) For any semiannual period in which the Commissioner conducts the survey described in §A(5) of this regulation:

(i) The Commissioner shall provide notice to each carrier subject to this chapter of the intent to conduct the survey at least 3 months in advance;

(ii) The Commissioner may require each carrier to submit a current roster of network providers for each provider panel used by the carrier, and any additional information the Commissioner determines is necessary for the survey to be conducted; and

(iii) A carrier is exempt from the requirement to make direct contact with a random selection of provider offices to calculate the median waiting times as described in §A(3) of this regulation.

B. Sufficiency Standards.

(1) On a semiannual basis, a carrier shall determine whether the provider panel meets the waiting time standards listed in §E of this regulation based on the direct contacts with provider offices described in §A(3)(a) of this regulation or the survey described in §A(5) of this regulation.

(2) Subject to the exceptions in §§C and D of this regulation, if a carrier's provider panel fails to meet the waiting time standards listed in §E of this regulation for at least 90 percent of appointments in each category, the carrier shall notify the Administration within 10 business days identifying the deficiency in the provider network and the efforts that have been taken or will be taken to correct the deficiency.

C. Preventive care services and periodic follow-up care, including but not limited to, standing referrals to specialty providers for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating provider acting within the scope of the provider's license, certification, or other authorization.

D. A visit scheduled in advance in accordance with §C of this regulation may be disregarded when determining compliance with the waiting time standards listed in §E of this regulation.

E. Chart of Waiting Time Standards.

Waiting Time Standards
Urgent care for medical services medical, behavioral health, and substance use disorder services)	72 hours
Inpatient urgent care for mental health services	72 hours
Inpatient urgent care for substance use disorder services	72 hours
Outpatient urgent care for mental health services	72 hours
Outpatient urgent care for substance use disorder services	72 hours
Routine primary care	15 calendar days
Preventive care/well visit	30 calendar days
Non-urgent specialty care	30 calendar days
Non-urgent mental health care	10 calendar days
Non-urgent substance use disorder care	10 calendar days

Md. Code Regs. 31.10.44.06

Regulation .06 adopted effective 44:25 Md. R. 1180, eff. 12/31/2017; amended and recodified from .05 effective 50:9 Md. R. 380, eff. 5/15/2023