230 R.I. Code R. 230-RICR-20-30-9.7

Current through December 3, 2024

Section 230-RICR-20-30-9.7 - Network Adequacy Requirements

A. For each Network Plan a health care entity must submit to the Office the Network Adequacy policies and procedures that evidence adherence to the following:

1. Each health care entity shall have an ongoing process in place to monitor and assure that its provider network for each of its network plans are sufficient in scope and volume to assure address and monitor its population needs that all covered services for beneficiaries, including children, adults and low-income, medically underserved beneficiaries, children and adults with serious chronic and/or complex health conditions or physical and/or mental disabilities and persons with limited English proficiency are accessible in a timely manner without unreasonable delay.

2. Beneficiaries have access to emergency services twenty-hours (24) hours a day, seven (7) days a week.

3. The health care entity has clear procedures in place that assure its network plan beneficiaries access to a provider in the event that the health care entity fails to maintain sufficient provider contracts, or a network provider is not available to provide covered services to beneficiaries in a timely manner. These procedures must include:

a. A description of the circumstances in which the member is held harmless in the event that a network provider is not available to provide the covered benefit without unreasonable travel or delay;

b. A process to appeal a denial of access to an out of network provider and/or any additional cost shares imposed beyond the beneficiary's in-network coverage, in accordance with R.I. Gen. Laws Chapter 27-18.9;

c. A process to address network inadequacies when the Commissioner has determined that the network plan has not maintained sufficient provider contracts.

4. A documented method to inform and assist beneficiaries on how to:

a. Choose and/or utilize a Network Plan;

b. Select and change a provider;

c. Access an updated provider directory in each network plan; and

d. Inform the beneficiary on the use of tiered networks within a network plan to include changes in beneficiaries' financial liability.

B. Each health care entity shall establish a process to monitor its network plan's network adequacy on quarterly basis. Information to substantiate this process shall be made available to the Office upon request.

C. Health care entities must provide evidence to the Office of adherence to the following transition of care requirements:

1. The network plan has established and maintains a transition of care policy and procedure for use in the event of a network plan change that affects beneficiaries including but not limited to the following types of network plan changes:

a. Narrowing of an existing network plan;

b. Network tiering or changes in network tiering of an existing network plan;

c. Termination of providers in a network plan with beneficiaries in active treatment; and d. New beneficiaries in active treatment.

D. Health care entities shall evidence and maintain the following, to the satisfaction of the Commissioner, regarding network plan provider directories for each network plan.

1. A mechanism to submit provider directories to the Office for review.

2. A process to make the provider directories easily available by the health care entity to consumer and providers in an understandable and reasonably comprehensive format:

a. Location(s) by city, town and county;

b. Providers' Service Category (e.g. physician practice, urgent care, radiology, behavioral health, laboratory, pharmacy, telehealth etc.);

c. For professional provider directories;

(1) Specialty practice/practice type;

(2) If provider is accepting new patients;

(3) Hospital admitting privileges (if applicable) or affiliation with in-network facilities;

(4) Network plan identification and tiering (if applicable) in language easy to understand;

3. That provider directories are available to beneficiaries, providers, and the public according to the following formats:

a. Electronically with search functions;

b. Printed and paper to be made available upon request to a beneficiary or a prospective beneficiary; and

c. Must accommodate individuals with limited English proficiency and/or those with disabilities.

4. Electronic and paper directories must be updated at least monthly with daily updates available telephonically and according to § 9.7(D)(3) of this Part above.

5. Contact information in order to access an updated directory must be referenced on the health care entity website and on the beneficiary's insurance/health plan card.

230 R.I. Code R. 230-RICR-20-30-9.7

Adopted effective 12/16/2018