Requirements for managed care plan
(1) A managed care plan shall arrange for a sufficient number and type of primary care providers and specialists throughout the plan’s service area to meet the needs of enrollees. Each managed care plan shall demonstrate that it offers:
(a) An adequate number of accessible acute care hospital services, where physically available;
(b) An adequate number of accessible primary care providers, including family practice and general practice physicians, internists, obstetricians/gynecologists, and pediatricians, where available;
(c) An adequate number of accessible specialists and subspecialists, and when the specialist needed for a specific condition is not represented on the plan’s list of participating specialists, enrollees have access to nonparticipating health care providers with prior plan approval;
(d) The availability of specialty services; and
(e) A provider network that meets the following accessibility requirements:
1. For urban areas, a provider network that is available to all persons enrolled in the plan within thirty (30) miles or thirty (30) minutes of each person’s place of residence or work, to the extent that services are available; or
2. For areas other than urban areas, a provider network that makes available primary care physician services, hospital services, and pharmacy services within thirty (30) minutes or thirty (30) miles of each enrollee’s place of residence or work, to the extent those services are available. All other providers shall be available to all persons enrolled in the plan within fifty (50) minutes or fifty (50) miles of each enrollee’s place of residence or work, to the extent those services are available.
(2) A managed care plan shall provide telephone access to the plan during business hours to ensure plan approval of nonemergency care. A managed care plan shall provide adequate information to enrollees regarding access to urgent and emergency care.
(3) A managed care plan shall establish reasonable standards for waiting times to obtain appointments, except as provided for emergency care.