Md. Code Regs. 31.10.44.09

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

Section 31.10.44.09 - Network Adequacy Waiver Standards

A. If a carrier's provider panel fails to meet one or more of the standards specified in Regulations .05-.07 of this chapter, the carrier shall provide the following information to the Commissioner as part of the annual access plan:

(1) A description of any network adequacy waiver previously granted by the Commissioner;

(2) An explanation of how many providers in each specialty or health care facility type that the carrier reasonably estimates it would need to contract with or otherwise include in its network to satisfy each unmet standard;

(3) A description of the methodology used to calculate the estimated number of providers in §A(2) of this regulation;

(4) A list of physicians, other providers, or health care facilities related to each unmet standard and within the relevant service area that the carrier attempted to contract with, identified by name and specialty, if any, or health care facility type;

(5) A description of how and when the carrier last contacted the physicians, other providers, or health care facilities;

(6) A description of any reason each physician, other provider, or health care facility gave for refusing to contract with the carrier;

(7) An analysis of any trends in the reasons given by physicians, providers, or health care facilities for refusing to contract with the carrier, and a description of the carrier's proposals or attempts to address those reasons and improve future contracting efforts;

(8) Identification of all incentives the carrier offers to providers to join the network;

(9) If applicable, a substantiated statement that there are insufficient numbers of physicians, other providers, or health care facilities available within the relevant service area for a covered service or services for which the carrier failed to meet a standard;

(10) A description of other efforts and initiatives undertaken by the carrier in the past year to enhance its network and address the deficiencies that contributed to each unmet standard;

(11) A description of steps the carrier will take to attempt to improve its network to avoid a future failure to meet a standard;

(12) An explanation of any other mitigating factors that the carrier requests the Commissioner to consider; and

(13) An attestation to the accuracy of the information provided in relation to each unmet standard.

B. The Commissioner may find good cause to grant a network adequacy waiver of one or more of the standards specified in Regulations .05-.07 of this chapter, if the information provided by the carrier under §A of this regulation demonstrates that:

(1) The physicians, other providers, or health care facilities necessary for an adequate network:

(a) Are not available to contract with the carrier;

(b) Are not available in sufficient numbers;

(c) Have refused to contract with the carrier; or

(d) Are unable to reach agreement with the carrier; or

(2) The reported failure to meet a standard is a result of limitations or constraints with the measurement methodology rather than an actual deficiency in the network.

C. The Commissioner shall post a list of all network adequacy waivers that are granted for each annual access plan on the Maryland Insurance Administration's website.

Md. Code Regs. 31.10.44.09

Regulation .09 adopted effective 44:25 Md. R. 1180, eff. 12/31/2017; amended and recodified from .07 effective 50:9 Md. R. 380, eff. 5/15/2023