W. Va. Code R. § 114-100-4

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

Section 114-100-4 - Network Access Plan Standards

4.1. For health benefit plan years beginning January 1, 2025, a health carrier shall file with the Commissioner an access plan meeting the requirements of this rule and W. Va. Code § 33-55-3. An access plan for a newly offered network must be filed for review and approval on or before July 1st of the year preceding the plan year. For the purposes of this rule, a "newly offered network" includes an existing network at the time this amended rule becomes effective irrespective of whether the Commissioner has approved the network.

4.2. A health carrier shall file, maintain and make available on their website an access plan, absent proprietary information, for each network plan that the carrier offers in West Virginia. The health carrier may request the Commissioner to deem sections of the access plan as proprietary information that not be made public.

4.3. A health carrier shall prepare and file an access plan prior to offering a new network plan, and shall notify the Commissioner of any material change to any existing network plan within 15 business days after the change occurs, including a reasonable timeframe within which it will file an update to an existing access plan.

4.4. A health carrier shall make an access plan, absent proprietary information pursuant to W. Va. Code § 33-55-3, available to any person upon request.

4.5. All health benefit plans and marketing materials of a health carrier shall clearly disclose the existence and availability of the access plan.

4.6. All rights and responsibilities of the covered person under a health benefit plan shall be included in the contract provisions of the health benefit plan, regardless of whether or not such provisions are also specified in the access plan.

4.7. A health carrier shall submit access plans to the Commissioner through SERFF.

4.8. An access plan shall describe, contain, or address the following:

4.8.1. The health carrier's network, including how the use of telemedicine or telehealth or other technology may be used to meet network access standards, if applicable;

4.8.2. The factors used by the health carrier to build its network, including a description of the criteria used to select providers;

4.8.3. Establishing that the health carrier's network has an adequate number of providers and facilities within a reasonable distance of covered persons;

4.8.4. The specific provider and facility types within the network per West Virginia county;

4.8.5. The health carrier's documented, quantifiable and measurable process for monitoring and assuring the sufficiency of the network in order to meet the health care needs of covered persons on an ongoing basis;

4.8.6. The carrier's process to assure that a covered person is able to obtain a covered benefit, at the in-network benefit level, from a non-participating provider should the carrier's network prove to not be sufficient;

4.8.7. The health carrier's procedures for making and authorizing referrals within and outside its network. The procedures should address the health carrier's processes regarding:

4.8.7.a. The provision of a comprehensive listing of the health carrier's network of participating providers and facilities to covered persons and primary care providers;

4.8.7.b. Timely referrals for access to specialty care;

4.8.7.c. Expedition of the referral process when indicated by the covered person's medical condition; and

4.8.7.d. Member access to services outside the network when necessary;

4.8.8. The health carrier's process for enabling covered persons to change primary care providers (PCP), if applicable;

4.8.9. The health carrier's quality assurance standards, which must be adequate to identify, evaluate and remedy problems relating to access, continuity and quality of care;

4.8.10. The health carrier's methods for assessing the health care needs of covered persons and their satisfaction with services;

4.8.11. The health carrier's efforts to address the needs of covered persons, including, but not limited to, children and adults, including those with limited English proficiency or illiteracy, diverse cultural or ethnic backgrounds, physical or mental disabilities, and serious, chronic, or complex medical conditions. This includes the carrier's efforts, when appropriate, to include various types of ECPs in its network;

4.8.12. The health carrier's method of informing covered persons of the plan's covered services and features, including, but not limited to:

4.8.12.a. The plan's grievance and appeal procedures;

4.8.12.b. Its process for choosing and changing providers;

4.8.12.c. Its process for updating its provider directories for each of its network plans;

4.8.12.d. A statement of health care services offered, including those services offered through the preventive care benefit, if applicable; and

4.8.12.e. Its procedures for covering and approving emergency, urgent and specialty care, if applicable;

4.8.13. The health carrier's proposed plan for providing continuity of care in the event of contract termination between the health carrier and any of its participating providers, or in the event of the health carrier's insolvency or other inability to continue operations. The description shall explain how covered persons will be notified of the contract termination, or the health carrier's insolvency or other cessation of operations, and transitioned to other providers in a timely manner; and

4.8.14. The health carrier's process for monitoring access to physician specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology/laboratory services at their participating hospitals. This subdivision does not apply to limited scope vision plans or limited scope dental plans as defined in W.Va. Code § 33-55-1.

4.9. The Commissioner may develop forms to be completed by the health carrier regarding the information required by subsection 4.8 of this rule.

W. Va. Code R. § 114-100-4