Bulletin No. B-4.91 NETWORK ACCESS PLAN STANDARDS AND REPORTING GUIDANCE FOR HEALTH BENEFIT PLANS I.
Background and Purpose
The purpose of this bulletin is to provide carriers offering health benefit plans with standards and guidance on the filing requirements for NETWORK ACCESS PLAN filings. Network access plans are required pursuant to federal law and § 10-16-704, C.R.S. The standards and reporting guidelines contained in this bulletin will help ensure that the Division receives complete network access plan filings. Bulletins are the Division’s interpretations of existing insurance law or general statements of Division policy. Bulletins themselves establish neither binding norms nor a final determination of issues or rights. II.
Applicability and Scope
This bulletin is intended to inform carriers1 that offer health benefit plans of specific standards and documents required by current Colorado law2. This bulletin does not pertain to any other filings not otherwise required by statute or regulation. III.
Network Access Plan Terms and Definitions
A.
“Covered person” means, for the purpose of this bulletin, a person entitled to receive benefits or services under a health coverage plan3.
B.
“Enrollment” means, for the purpose of this bulletin, the number of covered persons enrolled in a specific health plan or network.
C.
“Emergency medical condition” means, for the purpose of this bulletin, a medical or mental health condition that manifests itself by acute symptoms of sufficient severity, including severe pain, which a prudent layperson, possessing an average knowledge of health and medicine could reasonably expect, in the absence of immediate medical attention, to result in:
1
1.
Placing the health of the individual, or with respect to a pregnant woman, the health of the women or her unborn child in serious jeopardy;
2.
Serious impairment to bodily functions; or
3.
Serious impairment of any bodily organ or part4.
Which includes, but is not limited to, life and health carriers; non-profit hospital, medical-surgical, and health service corporations; health maintenance organizations (HMOs); limited service licensed provider networks (LSLPNs) offering individual and/or group health benefit plans; and dental carriers subject to the requirements of the Affordable Care Act (ACA) 2 § 10-16-704, C.R.S. 3 § 10-16-102(15), C.R.S 4 § 10-16-704(5.5)(b)(I), C.R.S.
D.
“Emergency services” means, for the purposes of this bulletin: 1.
A medical or mental health screening examination that is within the capability of the emergency department of a hospital or freestanding emergency room, including ancillary services routinely available to the emergency department to evaluate the emergency medical or mental health condition; and
2.
Within the capabilities of the staff and facilities available at the hospital, further medical or mental health examination and treatment as required to stabilize the patient to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition.5
E.
“Essential community provider” or “ECP”, means, for the purpose of this bulletin, a provider that serves predominantly low-income, medically underserved individuals, such as health care providers defined in federal law and under part 4 of article 4 of title 25.5, C.R.S.
F.
“Material change” means, for the purposes of this bulletin, changes in the health carrier’s network of providers or type of providers available in the network to provide health care services or specialty health care services to covered persons that renders the health carrier’s network non-compliant with one or more network adequacy standards. Types of changes that could be considered material include: 1.
A significant reduction in the number of primary or specialty care physicians available in a network;
2.
A reduction in a specific type of provider such that a specific covered service is no longer available;
3.
A change to the tiered, multi-tiered, layered or multi-level network plan structure; or
4.
A change in inclusion of a major health system that causes the network to be significantly different from what the covered person initially purchased.
G.
“Mental health, behavioral health, and substance abuse disorder care” means, for the purposes of this bulletin, health care services for a range of common mental or behavioral health conditions, or substance abuse disorders provided by a physician or non-physician professionals.
H.
“Mental health, behavioral health, and substance abuse disorder care providers”, for the purposes of this bulletin and for the purposes of network adequacy measurements, includes psychiatrists, psychologists, psychotherapists, licensed clinical social workers, psychiatric practice nurses, licensed addiction counselors, licensed marriage and family counselors, and licensed professional counselors.
I.
“Network” means, for the purpose of this bulletin, a group of participating providers providing services to a managed care plan. Any subdivision or subgrouping of a network is
5
§ 10-16-704(5.5)(b)(II), C.R.S.
considered a network if covered individuals are restricted to the subdivision or subgrouping for covered benefits under the “Managed care plan.”6 J.
“Primary care” means, for the purpose of this bulletin, health care services for a range of common physical, mental or behavioral health conditions provided by a physician or nonphysician primary care professional.
K.
“Primary care provider” or “PCP” means, for the purposes of this bulletin, a participating health care professional designated by the carrier to supervise, coordinate or provide initial care or continuing care to a covered person, and who may be required by the carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person. For the purposes of network adequacy measurements, PCPs for adults and children may include, but is not limited to, physicians (Pediatrics, General Practice, Family Medicine, Internal Medicine, Geriatrics, Obstetrics/Gynecology); and physician assistants and nurse practitioners supervised by, or collaborating with, a primary care physician.
L.
“Specialist” means a physician or non-physician health care professional who: 1.
Focuses on a specific area of physical, mental or behavioral health conditions or a group of patients; and
2.
Has successfully completed required training and is recognized by the state in which he or she practices to provide specialty care.
“Specialist” includes a subspecialist who has additional training and recognition above and beyond his or her specialty training M.
“Telehealth” means, for the purpose of this bulletin, a mode of delivery of health care services through telecommunications systems, including information, electronic and communication technologies, to facilitate the assessment, diagnosis, consultation, treatment, education, care management, or self-management of a covered person’s health care while the covered person is located at an originating site and the provider is located at a distant site. The term includes synchronous interactions and store-and-forward transfers. Telehealth is addressed more fully in Division of Insurance Bulletin B-4.89, “Telehealth and Cellular Telephones.”
IV.
Division Position
A.
Network Access Plans Network access plans are used by carriers to describe their policies and procedures for maintaining and ensuring that their networks are sufficient and consistent with state and federal requirements. These plans, along with other documents, are filed with the Division annually, and are available upon request to consumers. Pursuant to § 10-16-704(9), C.R.S., a carrier will file, maintain, and make available an access plan for each managed care network that the carrier offers in Colorado. A carrier shall prepare 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 fifteen (15)
6
Managed Care Plan is defined at § 10-16-102(43), C.R.S.
business days after the change occurs, including a reasonable timeframe within which it will file an update to an existing access plan. A carrier shall make the access plans, absent confidential information, available and shall provide them to any interested party upon request. All health benefit plans and marketing materials shall clearly disclose the existence and availability of the access plan. All rights and responsibilities of the covered person under the health benefit plan, however, shall be included in the contract provisions, regardless of whether or not such provisions are also specified in the access plan. Existing law requires carriers to submit all filings through the NAIC System for Electronic Rate and Form Filing (“SERFF”). The carrier shall prepare and file an access plan prior to offering a new managed care network, shall update an existing access plan whenever the carrier makes any material change to an existing managed care network, and shall file the current access plan with the Division not less often than annually. An access plan submitted by a carrier offering a managed care plan must demonstrate that the carrier has:
B.
1.
An adequate network that it is actively maintaining (Appendix A);
2.
Procedures to address referrals within its network and to providers outside of its network (Appendix B);
3.
The required disclosures and notices to inform consumers of the plan’s services and features (Appendix C); and
4.
A documented process and plan for coordination and continuity of care (Appendix D).
Requirements for Annual Network Access Plan Reporting Network access plan filings must be provided along with the other Binder filings for the 2017 plan year health benefit plans. All network access plans, enrollment documents, and network adequacy maps shall be filed for each carrier’s network identification number (ID), and shall not be filed by plan type or group size. This means that the network access plan for carrier network “CON001” may be included in multiple Binder filings, and could be included in the filings for both individual and small group plans. Detailed instructions for preparing and filing these documents are provided in “Colorado PPACA Network Access Plan Filing Procedures for Plan Year 2017.” It is imperative that data provided in the network access plans be specific to each network (i.e. HMO, PPO, EPO, etc.) in the carrier’s service area(s). Network Access Plan (and Cover Sheet) – All carriers must submit access plans for each network they utilize, pursuant to § 10-16-704(9), C.R.S. Carriers must also submit a copy of the Network Access Plan cover sheet (see Appendix E) with the access plan for each network, as this will be used to ensure that the access plan contains all of the required plan information. The access plans, and the carrier’s web address for the location on its website where consumers can find plan-specific network access plans, will be attached to the “Supporting Documentation” tab on the Binder filing. 1.
Enrollment Document - All carriers must submit a separate enrollment document for each network they utilize. Enrollment document instructions are provided in
“Colorado PPACA Network Access Plan Filing Procedures for 2017.” Enrollment documents must be submitted in Excel format using the “DOI Enrollment Document Template.” Counts used for this document should be based on the projected enrollment of all members in the carrier’s individual, small group and/or large group plans utilizing that specific network. 2.
C.
Maps - All carriers must submit maps showing geographic access standards for select providers and facilities for each network they utilize. Instructions for the required maps are provided in “Colorado PPACA Network Access Plan Filing Procedures for 2017.”
Required Attestations In addition to demonstrating the items above in the network access plan, the carrier shall provide an attestation that it meets the network adequacy standards set forth in Bulletins B - 4 .90, B-4.91 and B-4.92 for each portion of the filing. The following attestations will be made on the “Carrier Network Adequacy Attestation Form” submitted with the Binder.
V.
1.
Carrier attests that each of its managed care health benefit plans will maintain a provider network(s) that meets the standards in this Bulletin B-4.90 and is sufficient in number and types of providers, including providers that specialize in mental health, behavioral health, and substance abuse services, to assure that the services will be accessible without unreasonable delay.
2.
Carrier attests that each of its managed care health benefit plans include in its provider network(s) a sufficient number and geographic distribution of essential community providers (ECPs), where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in their service areas.
3.
If the carrier does not immediately meet network adequacy standards, the carrier will include an attestation adequately addressing how it plans to meet network adequacy standards specified in Section IV.A. above. Such changes must be implemented and filed by the carrier in accordance with the reasonable schedule established by the carrier and reviewed by the Division. If the carrier is unable to meet network adequacy standards, the Division may be required to take an administrative enforcement action.
Additional Division Resources Colorado Insurance Regulation 4-2-39 Colorado Insurance Regulation 4-2-41 Colorado Insurance Bulletin No. B-4.81 Colorado Insurance Bulletin No. B 4.89 Colorado Insurance Bulletin No. B-4.90 Colorado Insurance Bulletin No. B-4.92
For More Information Colorado Division of Insurance Life and Health Rates and Forms Section 1560 Broadway, Suite 850 Denver, CO 80202 Tel. 303-894-7499 Toll Free: 1-800-930-3745 Internet: http://www.dora.colorado.gov/insurance VI.
History
Issued March 31, 2016
APPENDIX A - Having and Maintaining Adequate Networks The carrier shall address the following in the network access plan for each network offered by the carrier. A.
A carrier’s network shall have an adequate number of providers and facilities, within a reasonable distance or travel time, or both. Geographic accessibility, in some circumstances may require the crossing of county or state lines or may be available through the use of telehealth. Telehealth is addressed more fully in Colorado Division of Insurance Bulletin B-4.89, “Telehealth and Cellular Telephones.” Specific provider and facility types will be measured and reported in the “Access Plan” and “ Enrollment Document”. Those provider and facility types will include, but are not limited to, the following: 1.
Acute care, hospital services;
2.
Primary care provider (PCP);
3.
Providers who may be available through the use of telehealth;
4.
Pharmacy providers, within a reasonable distance, travel time, delivery time, or all three (nothing precludes the use of a retail or mail-order pharmacy provider); and
5.
Other provider and facility types as specified in Appendix B of Colorado Insurance Bulletin B-4.90, “Network Adequacy Standards and Reporting Guidance for Health Benefit Plans.”
B.
The carrier’s documented quantifiable and measureable process for monitoring and assuring the sufficiency of the network in order to meet the health care needs of populations enrolled in managed care plans on an ongoing basis, pursuant to Colorado Insurance Bulletin B-4.90, “Network Adequacy Standards and Reporting Guidance for Health Benefit Plans.”
C.
The factors a carrier uses to build its provider network, including a description of the network and the criteria used to select and/or tier providers.
D.
The carrier’s quality assurance standards, which must be adequate to identify, evaluate, and remedy problems relating to access, continuity, and quality of care, pursuant to § 1016-704(9)(d), C.R.S.
E.
The carrier’s process to assure that a covered person is able to obtain a covered benefit, at the in-network level of benefits, from a non-participating provider should the carrier’s network prove to not be sufficient. This may require revision to the filed access plan or result in the implementation of a corrective action plan.
F.
The health carrier’s process for monitoring access to physician specialist services for emergency room care, anesthesiology, radiology, hospitalist care and pathology/ laboratory services at its participating hospitals.
APPENDIX B – Procedures for Referrals The network access plan for each network offered by the carrier must include procedures for making referrals both within its networks and outside of its networks and must include the following, at a minimum: A.
A comprehensive listing, made available to covered persons and primary care providers, of the carrier’s network participating providers and facilities, pursuant to § 10-16-704(9)(b)(I), C.R.S.;
B.
A provision that referral options cannot be restricted to less than all providers in the network that are qualified to provide covered specialty services; except that a health benefit plan may offer variable deductibles, coinsurance and/or copayments to encourage the selection of certain providers, pursuant to § 10-16-704(9)(b)(II) (A), C.R.S.;
C.
A health benefit plan that offers variable deductibles, coinsurance, and/or copayments shall provide adequate and clear disclosure, as required by law, of variable deductibles and copayments to enrollees, and the amount of any deductible or copayment shall be reflected on the benefit card provided to the enrollees, pursuant to § 10-16-704(9)(b) (II)(B), C.R.S.;
D.
Timely referrals for access to specialty care, pursuant to § 10-16-704(9)(b)(III), C.R.S.;
E.
A process for expediting the referral process when indicated by medical condition, pursuant to § 10-16-704(9)(b)(IV), C.R.S.;
F.
A provision that referrals approved by the carrier cannot be retrospectively denied except for fraud or abuse, pursuant to § 10-16-704(9)(b)(V)(A), C.R.S.;
G.
A provision that referrals approved by the carrier cannot be changed after the preauthorization is provided unless there is evidence of fraud or abuse, pursuant to § 10-16704(9)(b)(V)(B), C.R.S.; and
H.
The carrier’s process allowing members to access services outside the network when necessary, pursuant to § 10-16-704(9)(b), C.R.S.
APPENDIX C – Disclosures and Notices A carrier must address its method for informing covered persons of the plan's services and features through disclosures and notices to policyholders in the network access plan for each network offered by the carrier. These disclosures must include, but are not limited to, the following: A.
The carrier's grievance procedures, which shall be in conformance with Division rules concerning prompt investigation of health claims involving utilization review and grievance procedures, pursuant to § 10-16-704(9)(g)(I), C.R.S.;
B.
The extent to which specialty medical services, including but not limited to physical therapy, occupational therapy, and rehabilitation services are available, pursuant to § 1016-704(9)(g)(II), C.R.S.;
C.
The carrier's procedures for providing and approving emergency and medical care, pursuant to § 10-16-704(9)(g)(IV), C.R.S.;
D.
The carrier’s process for choosing and changing network providers, pursuant to § 10-16704(9)(g)(III), C.R.S.;
E.
The carrier's documented process to address the needs, including access and accessibility of services, of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with physical or mental disabilities; and processes to identify the potential needs of special populations, pursuant to § 10-16-704(9)(e), C.R.S.; and
F.
The carrier's methods for assessing the health care needs of covered persons, tracking and assessing clinical outcomes from network services, assessing needs on an on-going basis, assessing the needs of diverse populations, and evaluating consumer satisfaction with services provided, pursuant to § 10-16-704(9)(f), C.R.S.
APPENDIX D - Coordination and Continuity of Care A carrier must address its process for ensuring the coordination and continuity of care for its policyholders in the network access plan for each network offered by the carrier. These processes must include, but are not limited to, the following: A.
The carrier's documented process for ensuring the coordination and continuity of care for covered persons referred to specialty providers, pursuant to § 10-16-704(9)(h), C.R.S.;
B.
The carrier's documented process for ensuring the coordination and continuity of care for covered persons using ancillary services, including social services and other community resources;
C.
The carrier's documented process for ensuring appropriate discharge planning;
D.
The carrier's process for enabling covered persons to change primary care professionals, pursuant to § 10-16-704(9)(i), C.R.S.;
E.
The carrier's proposed plan and process for providing continuity of care in the event of contract termination between the carrier and any of its participating providers, as specified in § 10-16-704(2.5)(a) and (d), C.R.S., and § 10-16-705(4 ), C.R.S., or in the event of the carrier's insolvency or other inability to continue operations. The description of this plan and process shall explain how covered persons will be notified in the case of a provider contract termination, the carrier's insolvency, or of any other cessation of operations. The plan and process shall also address how policyholders impacted by these events will be transferred to other providers in a timely manner, pursuant to § 10-16-704(9)(j), C.R.S.; and
F.
A carrier must file and make available upon request the fact that the carrier has a “hold harmless” provision in its provider contracts, prohibiting contracted providers from balance-billing covered persons in the event of the carrier’s insolvency or other inability to continue operations in compliance with § 10-16-705(3), C.R.S.
APPENDIX E - NETWORK ADEQUACY COVER SHEET – ACCESS PLAN – COVER SHEET
