W. Va. Code R. § 114-100-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-100-3 - Network Adequacy Standards

3.1. The geographic accessibility standards set forth in Appendix A shall be met by a health carrier in order to comply with network adequacy requirements.

3.1.1. The Commissioner shall publish a notice with the county designation of each West Virginia county by July 1st of each year or as soon as that information becomes available from CMS.

3.1.2. The geographic accessibility standards for dental shall be met by limited scope dental plans and by health benefit plans with embedded dental benefits.

3.1.3. At least 90 percent of a health carrier's members must live within the maximum distance to at least one provider of each type to satisfy geographic accessibility network adequacy standards.

3.2. The following appointment wait times standards shall be met by a health carrier in order to comply with network adequacy requirements:

Provider/Facility Specialty Type	Appointments Must Be Available Within
Behavioral Health	10 business days
Primary Care (Routine)	15 business days
Specialty Care (Non-Urgent)	30 business days

3.2.1. At least 90 percent of a health carrier's providers must meet the wait time standards to satisfy network adequacy standards regarding wait times.

3.3. If a carrier cannot meet the network adequacy standards set forth in section 3 of this rule, the carrier must have a process to assure that a covered person obtains a covered benefit at an in-network level of benefits from a nonparticipating provider or make other arrangements acceptable to the Commissioner, which may include contracting with the nearest like provider.

W. Va. Code R. § 114-100-3