Definitions; Network Adequacy Standards; Filing and Content of Access Plan; Travel Distance Standards; Appointment Waiting Time Standards; Provider-to-Enrollee Ratio Standards; Telehealth; Waiver Request Standards; Confidential Information in Access Plans
Section 02. Definitions
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) “Access plan” means the materials that each carrier is required to file annually with the Commissioner to demonstrate that each of the carrier’s provider panels is adequate to meet the needs of its enrollees.
(2) “Ambulatory infusion therapy center” means any location authorized to administer chemotherapy or infusion services on an outpatient basis.
(3) “Behavioral health care” means care for mental health or a substance use disorder.
(4) “Carrier” means:
(a) An insurer authorized to sell health insurance;
(b) A nonprofit health service plan; or
(c) A health maintenance organization.
(5) “Certified registered nurse practitioner” means an individual who is licensed as a certified nurse practitioner under Health Occupations Article, Title 8, Subtitle 3, Annotated Code of Maryland.
(6) “Continuing care patient” means an individual who, with respect to a provider or facility:
(a) Is undergoing a course of treatment for a serious and complex condition from the provider or facility;
(b) Is undergoing a course of institutional or inpatient care from the provider or facility;
(c) Is scheduled to undergo nonelective surgery from the provider or facility, including receipt of postoperative care from such provider or facility with respect to such a surgery;
(d) Is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or
(e) Is or was determined to be terminally ill, as determined under Section 1861(dd)(3)(A) of the Social Security Act, and is receiving treatment for such illness from such provider or facility
(7) “Enrollee” means a person entitled to health care benefits from a carrier under a policy or contract subject to Maryland law.
(8) “Essential community provider” means a provider that serves predominantly low-income or medically underserved individuals. “Essential community provider” includes:
(a) Local health departments;
(b) Outpatient mental health and community based substance use disorder programs;
(c) Any entity listed in 45 CFR §156.235(c);and
(d) School-based health centers.
(9 ) “Group model HMO” means a type of health maintenance organization that:
(a) Contracts with one multispecialty group of physicians who are employed by and shareholders of the multispecialty group; and
(b) Provides or arranges for the provision of physician and other health care services to patients at medical facilities operated by the HMO or employs its own physicians and other providers on a salaried basis in health maintenance organization buildings to provide care to enrollees of the health maintenance organization.
(10) “Health benefit plan” has the meaning stated in Insurance Article, §15-112, Annotated Code of Maryland.
(11) “Health care facility” has the meaning stated in Insurance Article, §15-112, Annotated Code of Maryland.
(12) “Health professional shortage area” means those geographic areas in Maryland which have been designated by the Health Resources and Services Administration as such, as a result of having a shortage of primary medical care or behavioral health providers.
(13) “HEDIS” means the Healthcare Effectiveness Data and Information Set of standardized performance measures, developed and used by the National Committee for Quality Assurance, to evaluate managed care health plan performance for care and services provided.
(14) “Hospital” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.
(15) “Hospital-based physician” has the meaning stated in Insurance Article, §14-201, Annotated Code of Maryland.
(16) “Material change to an access plan” means a change to an access plan that affects a carrier’s ability to comply with the requirements of this chapter.
(17) “Network” means:
(a) A carrier’s participating providers and the health care facilities with which a carrier contracts to provide health care services to the carrier’s enrollees under the carrier’s health benefit plan.
(b) If a carrier uses a provider panel developed by a subcontracting entity, “network” includes providers and health care facilities that contract with the subcontracting entity to provide health care services to the carrier’s enrollees under the carrier’s health benefit plan.
(18) “Network adequacy waiver” means the Commissioner’s decision to relieve a carrier of the obligation to comply with certain network adequacy standards in this chapter for 1 year.
(19) “On-call physician” has the meaning stated in Insurance Article, §14-201, Annotated Code of Maryland.
(20) “Opioid treatment services provider” means a program with a valid and current accreditation-based license under COMAR 10.63 to provide community-based behavioral health services, and authorized to provide opioid treatment services.
(21) “Participating provider” means a provider on a carrier’s provider panel.
(22) “Preventive care” means health care provided for the prevention and early detection of disease, illness, injury or other health condition, and includes all of the services required by 42 U.S.C. §300gg-13.
(23) “Primary care provider” means:
(a) A provider who is responsible for:
(i) Providing initial and primary care to patients;
(ii) Maintaining the continuity of patient care; or
(iii) Initiating referrals for specialist care.
(b) “Primary care provider” includes:
(i) A physician whose practice of medicine is limited to general practice; and
(ii) A board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist or family practitioner.
(24) “Provider” means a person or group of persons licensed, certified, or otherwise authorized by law to provide health care services.
(25) “Provider panel” means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to the carrier’s enrollees under the carrier’s health benefit plan. “Provider panel” does not include an arrangement in which any provider may participate solely by contracting with the carrier to provide health care services at a discounted fee-for-service rate.
(26) “Residential crisis services” has the meaning stated in Insurance Article, §15-840, Annotated Code of Maryland.
(27) “Road travel distance” means:
(a) Actual driving distance measured between two geographic locations based on turn-by-turn directions along public roads; or
(b) Subject to approval by the Commissioner, driving distance between two geographic locations estimated using a methodology that, in the discretion of the Commissioner, sufficiently accounts for significant geographic barriers that are impassable by automobile, such as the Chesapeake Bay.
(28) “Rural area” means a zip code that, according to the Maryland Department of Planning, has a human population of less than 1,000 per square mile.
(29) “School-based health center” means a community health resource described in Health-General Article, § 19-2101, Annotated Code of Maryland that is located within an elementary, middle, or high school and approved by the Maryland Department of Health.
(30) “Specialty provider” means a provider who:
(a) Focuses on a specific area of physical care or behavioral health care for a group of patients;
(b) Has successfully completed required professional training; and
(c) For a physician, has obtained Board certification or is Board eligible through the American Board of Medical Specialties.
(31) “Suburban area” means a zip code that, according to the Maryland Department of Planning, has a human population equal to or more than 1,000 per square mile, but less than 3,000 per square mile.
(32) “Telehealth” has the meaning stated in Insurance Article, §15-139, Annotated Code of Maryland.
(33) “Urban area” means a zip code that, according to the Maryland Department of Planning, has a human population equal to or greater than 3,000 per square mile.
(34) “Urgent care” means the treatment for a condition of an enrollee that satisfies either of the following:
(a) A medical condition, including a physical condition or a behavioral health condition, that, in the absence of medical care or treatment within 72 hours, could reasonably be expected by an individual, acting on behalf of a carrier and applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, would result in:
(i) Placing the enrollee’s life or health in serious jeopardy;
(ii) The inability of the enrollee to regain maximum function;
(iii) Serious impairment to the enrollee’s bodily function;
(iv) Serious dysfunction of any bodily organ or part of the enrollee; or
(v) The enrollee remaining seriously ill with behavioral health symptoms that cause the enrollee to be a danger to self or others; or
(b) A medical condition of an enrollee, including a physical condition or a behavioral health condition, that, in the absence of medical care or treatment within 72 hours, would, in the opinion of a provider with knowledge of the enrollee’s medical condition, subject the enrollee to severe pain that cannot be adequately managed without the care or treatment.
(35) “Waiting time” means the time from the initial request for health care services by an enrollee or by the enrollee’s treating provider to the earliest date offered for the appointment for services with a provider possessing the appropriate skill and expertise to treat the condition.
Section .03. Network Adequacy Standards.
A. Sufficiency Standards.
(1) A carrier shall develop and maintain a network of providers in sufficient numbers, geographic locations, and practicing specialties to ensure enrollees have access to participating providers for the full scope of benefits and services covered under the carrier’s health benefit plan.
(2) A carrier shall establish written policies and procedures to implement a process for addressing network deficiencies that result in an enrollee lacking access to any providers with the professional training and expertise necessary to deliver a covered service without unreasonable travel or delay.
(3) A carrier shall clearly define and specify referral requirements, if any, to specialty and other providers.
(4) A carrier shall take reasonable steps to ensure that participating providers provide physical access, reasonable accommodations, and accessible equipment for enrollees with physical or mental disabilities.
(5) A carrier’s written policies and procedures to monitor availability of services shall include how the carrier will monitor the availability of services for:
(a) Continuing care patients;
(b) Individuals with physical or mental disabilities, including individuals who have disabilities that limit their physical ability to access services; and
(c) Individuals with limited English proficiency, including diverse cultural and ethnic backgrounds.
(6) A carrier shall take reasonable steps to ensure services are delivered in a culturally competent manner to all enrollees, including enrollees:
(a) With limited English proficiency;
(b) With diverse cultural, racial, and ethnic backgrounds; and
(c) Of all genders, sexual orientations, and gender identities.
(7) A carrier must have the ability to identify, by county and for the City of Baltimore, the number of participating providers for each facility type listed in the charts in Regulation .05A(5) and B(5) of this chapter and each provider type code and specialty code listed on the uniform credentialing form described in Insurance Article, §15-112.1, Annotated Code of Maryland.
(8) The identification of the number of participating providers described in §A(7) of this regulation:
(a) Shall include either:
(i) All participating providers who were credentialed for a specific provider type or specialty code listed in the uniform credentialing form described in Insurance Article, §15-112.1, Annotated Code of Maryland; or
(ii) All participating providers who reported a specific provider type or specialty code when completing the uniform credentialing form described in Insurance Article, §15-112.1, Annotated Code of Maryland; and
(b) May include additional participating providers identified by the carrier through other documented means.
(9) A carrier shall retain copies of its policies and procedures required by this chapter for a period of 3 years following the date the policies and procedures were last effective.
(10) At the request of the Commissioner, a carrier shall file with the Commissioner a copy of its current and retained past policies and procedures required by this chapter. A carrier may request a finding by the Commissioner that its policies and procedures are considered confidential commercial information.
B. Monitoring Sufficiency Standards.
(1) A carrier shall continuously monitor its provider network for compliance with this chapter and shall conduct internal compliance audits for the standards listed in Regulations .05, .06, and .07 of this chapter on at least a quarterly basis; and
(2) A carrier shall continuously verify and update its network directory consistent with Insurance Article, §15-112, Annotated Code of Maryland and §2799A-5of the Public Health Service Act, enacted by 116 of the federal No Surprises Act.
Section .04 Filing and Content of Access Plan
A. Using the instructions on the Maryland Insurance Administration’s website for submission method and to determine rural, suburban, and urban zip code areas, each carrier subject to this chapter shall file an annual access plan with the Commissioner on or before July 1 of each year for each provider panel used by the carrier, with the first access plan filing due on or before July 1, 2018.
B. If a carrier makes a material change to an access plan, the carrier shall:
(1) Notify the Commissioner of the change in writing within 15 business days after the material change to the access plan occurs; and
(2) Include in the notice required under §B(1) of this regulation a reasonable timeframe within which the carrier will file with the Commissioner an update to the existing access plan for review by the Commissioner.
C. Each annual access plan filed with the Commissioner shall include the following information in the standardized format described on the Maryland Insurance Administration’s website:
(1) An executive summary in the form set forth in Regulation .11 of this chapter;
(2) The information and process required by Insurance Article, §15-112(c)(4), Annotated Code of Maryland, and themethods used by the carrier to comply with the monitoring requirement under §15-112(c)(5);
(3) A description of out-of-network claims received by the carrier in the prior calendar year, which shall include:
(a) The percentage of total claims received that are out-of-network claims;
(b) The percentage of out-of-network claims received that are paid;
(c) The percentage of claims described in §C(3)(a) and (b) of this regulation that the carrier identifies as claims for emergency services, on-call physicians, or hospital-based physicians;
(d) The percentage of total claims received that are out-of-network claims for:
(i) Subject to §G of this regulation, all enrollees with a residence in a zip code where less than 100 percent of enrollees have access to a provider within the applicable travel distance standard in Regulation .05 of this chapter for the provider type in the claim, listed by provider type for each of the rural, suburban, and urban areas;
(ii) Subject to §G of this regulation, the ten provider types with the highest number of out-of-network claims for enrollees with a residence in each of the rural, suburban, and urban areas, listed by provider type and geographic area; and
(iii) Subject to §G of this regulation, the ten provider types with the highest percentage of total claims that are out-of-network claims for enrollees with a residence in each of the rural, suburban, and urban areas, listed by provider type and geographic area;
(e) For each provider type and geographic area described in §C(3)(d) of this regulation, the following information regarding requests to obtain a referral to an out-of-network provider in accordance with Insurance Article, §15-830, Annotated Code of Maryland:
(i) The number of referral requests received;
(ii) The number of referral requests granted;
(iii) The percentage of out-of-network claims received for which a referral was requested;
(iv) The percentage of out-of-network claims received for which a referral was granted;
(v) The number of single case agreements requested between the carrier and an out-of-network provider;
(vi) The number of single case agreements entered between the carrier and an out-of-network provider;
(vii) The percentage of out-of-network claims received for which a single case agreement was requested between the carrier and an out-of-network provider; and
(viii) The percentage of out-of-network claims received for which a single case agreement was entered between the carrier and an out-of-network provider; and
(f) Any additional information deemed necessary by the carrier to provide context for the information described in §C(3)(a)—(e) of this regulation;
(4) A description of complaints received by the carrier in the prior calendar year relating to access to or availability of providers, which shall include:
(a) The total number of complaints made by enrollees relating to the waiting time or distance of participating providers;
(b) The total number of complaints made by providers, whether or not under contract, relating to the waiting time or distance of participating providers;
(c) The total number of complaints relating to the accuracy of the network directory;
(d) The total number of complaints relating to the dollar amount of reimbursement for out-of-network claims, including balance billing; and
(e) The percentage of complaints described in §C(4)(d) of this regulation that are for claims subject to the federal No Surprises Act;
(5) A description of the carrier’s procedures, including training of customer service representatives, detailing how claims will be handled when participating providers are not available and an enrollee obtains health care services pursuant to Insurance Article, §15-830, Annotated Code of Maryland;
(6) A description of the procedures that the carrier will utilize to assist enrollees in obtaining medically necessary services when no participating provider is available without unreasonable travel or delay, including procedures to coordinate care and to limit the likelihood of costs to the enrollee that exceed the amount that would have been incurred had the health care services been provided by a participating provider;
(7) A description of whether the carrier’s provider contracts require health care providers to engage in appointment management, including procedures related to:
(a) No show policies;
(b) Patient appointment confirmation;
(c) Same day appointment slotting;
(d) Patient portals;
(e) Access to a provider performance dashboard to monitor appointment lag time, no show rate, bump rate (health care provider initiated cancelation of a scheduled appointment), and new patient appointments; and
(f) Weekly polling programs of providers to check for appointment availability;
(8) An indication of whether the network directory is searchable by covered benefit, for example, hearing aid, knee surgery, or physical therapist;
(9) An indication of whether the carrier has a patient portal for enrollees to make health care appointments;
(10) A description of whether the carrier has a formal process for assisting enrollees who have been unsuccessful in using the network directory to locate an appropriate provider with the necessary skill and expertise to treat the enrollee’s condition;
(11) A description of whether and how the carrier considered the role of public transportation in addressing the needs of enrollees who do not own a personal automobile when evaluating enrollees’ access to care under the travel distance standards described in Regulation .05 of this chapter;
(12) A description of telehealth utilization as described in Regulation .08 of this chapter;
(13) Documentation justifying to the Commissioner how the access plan meets each network sufficiency standard set forth in Regulations .05 — .07 of this chapter; and
(14) A list of all changes made to the access plan filed the previous year.
D. The Commissioner may require a carrier to include in the annual access plan a report of the number of participating providers described in Regulation .03A(7) of this chapter for designated facility types, provider type codes, and specialty codes, if the Commissioner notifies the carrier in writing and identifies the particular facility types, provider type codes, and specialty codes that must be reported.
E. The description required by Insurance Article, §15-112(c)(4)(iii), Annotated Code of Maryland shall identify whether the carrier has:
(1) Engaged in outreach to minority health care providers; and
(2) Offered financial incentives, such as payment towards loans previously incurred for health care provider education, to encourage health care providers to contract with the carrier.
F. The description required by Insurance Article, §15-112(c)(4)(iv), Annotated Code of Maryland shall include:
(1) The number of primary care providers who report to the carrier that they use any of the following languages in their practices:
(a) American Sign Language;
(b) Spanish;
(c) Korean;
(d) Chinese (Mandarin or Cantonese);
(e) Tagalog; or
(f) French;
(2) A description of outreach efforts to recruit and retain providers from diverse cultural, racial, or ethnic backgrounds;
(3) A copy of the most recent enrollees’ language needs assessment made by or on behalf of the carrier, if one was made;
(4) A copy of the most recent demographic profile of the enrollee population made by or on behalf of the carrier, if one was made;
(5) A copy of any analysis or assessment made of provider network requirements based on an assessment of language needs or demographic profile of the enrollee population;
(6) A copy of any provider manual provisions that describe requirements for access to individuals with physical or mental disabilities; and
(7) Copies of policies and procedures designed to ensure that the provider network is sufficient to address the needs of both adult and child enrollees, including adults and children with:
(a) Limited English proficiency or illiteracy;
(b) Diverse cultural, racial, or ethnic backgrounds;
(c) Physical or mental disabilities; and
(d) Serious, chronic, or complex health conditions.
G. For a group model HMO plan, when an enrollee’s place of employment is used instead of residence to calculate travel distance under Regulation .05B of this chapter, the data described in §C(3) of this regulation that is based on enrollee residence shall be reported based on the enrollee’s place of employment.
H. The requirements found in §§C(3)—(12) and D— G of this regulation shall apply to annual access plans submitted on or after July 1, 2024.
I. A carrier may file the information described in §C(3), (4), and (12) of this regulation separately from the other access plan materials described in §C of this regulation, provided the information described in §C(3), (4), and (12) of this regulation is submitted by a calendar day that shall be designated in a bulletin issued by the Commissioner at least 60 days prior to such filing date. The date by which the information described in §C(3), (4), and (12) of this regulation must be filed shall be set later in time than July 1 of the reporting year.
Section 05. Travel Distance Standards.
A. Sufficiency Standards.
(1) Standard and Methodology.
(a) Except as stated in §B of this regulation, each provider panel of a carrier shall have within the geographic area served by the carrier’s network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §A(5) of this regulation for each type of geographic area.
(b) The distances listed in §A(5) of this regulation shall be:
(i) Measured from the enrollee’s place of residence to the practicing location of the provider or facility; and
(ii) Calculated based on road travel distance.
(c) Except for those provider types excluded under §A(3) of this regulation, for each provider type and facility type included on the carrier’s provider panel, the carrier shall:
(i) Map the residences of all Maryland enrollees covered under health benefit plans that use the provider panel;
(ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
(iii) For each zip code, identify the total number of enrollees residing in the zip code and the number of enrollees residing within an area where the applicable distance standard is not met;
(iv) For each zip code, calculate the percentage of enrollees residing within an area where the applicable distance standard is met;
(v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees residing in the zip code;
(vi) For each of the urban, rural, and suburban areas identify the total number of enrollees residing in the geographic area;
(vii) For each of the urban, rural, and suburban areas identify the total number of enrollees residing within an area where the applicable distance standard is not met; and
(viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees residing within an area where the applicable distance standard is met.
(d) Instead of independently calculating the road travel distance for each enrollee as described in §A(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:
(i) Maps the practicing locations of every participating provider within the geographic area served by the carrier’s network or networks;
(ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
(iii) Enables the carrier to accurately identify the information and perform the calculations described in §A(1)(c)(iii)-(viii) of this regulation.
(e) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:
(i) Geo-access maps for each provider type and facility type except for those excluded under §A(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence outside the applicable distance standard;
(ii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide adolescent services; and
(iii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
(f) A carrier shall report each number and percentage described in §A(1)(c)(iii)—(viii) of this regulation as part of the annual access plan filing.
(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §A(5) of this regulation.
(3) The travel distance standards listed in §A(5) of this regulation do not apply to the following:
(a) Home health care;
(b) Durable medical equipment;
(c) Heart transplant programs;
(d) Heart or lung transplant programs;
(e) Kidney transplant programs;
(f) Liver transplant programs;
(g) Lung transplant programs; or
(h) Pancreas transplant programs.
(4) All other providers and facility types included on the carrier’s provider panel but not listed in the chart in §A(5) of this regulation, including physical therapists and licensed dietitian-nutritionist, shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.
(5) Chart of Travel Distance Standards.
Note: The chart referenced by (5) above could not be reproduced here.
B. Group Model HMO Plans Sufficiency Standards.
(1) Standard and Methodology.
(a) Each group model HMO’s health benefit plan’s provider panel shall have within the geographic area served by the group model HMO’s network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §B(5) of this regulation for each type geographic area.
(b) The distances listed in §B(5) of this regulation shall be:
(i) Measured from the enrollee’s place of residence or, at the option of the carrier, place of employment from which the enrollee gains eligibility for participation in the group model HMO’s health benefit plan to the practicing location of the provider or facility; and
(ii) Calculated based on road travel distance.
(c) Except for those provider types excluded §B(3) of this regulation, for each provider type and facility type included on the group model HMO’s provider panel, the carrier shall:
(i) Map the residences or places of employment of all Maryland enrollees covered under health benefit plans that use the provider panel;
(ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
(iii) For each zip code identify the total number of enrollees with a residence or place of employment in the zip code and the number of enrollees with a residence or a place of employment within an area where the applicable distance standard is not met;
(iv) For each zip code calculate the percentage of enrollees with a residence or place of employment within an area where the applicable distance standard is met;
(v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees with a residence or place of employment within the zip code;
(vi) For each of the urban, rural, and suburban areas identify the total number of enrollees with a residence or place of employment in the geographic area;
(vii) For each of the urban, rural, and suburban areas identify the number of enrollees with a residence or place of employment within an area where the applicable distance standard is not met; and
(viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees with a residence or place f employment within an area where the applicable distance standard is met.
(d) Instead of independently calculating the road travel distance for each enrollee as described in §B(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:
(i) Maps the practicing locations of every participating provider within the geographic area served by the group model HMO’s network or networks;
(ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
(iii) Enables the carrier to accurately identify the information and perform the calculations described in §B(1)(c)(iii)—(viii) of this regulation.
(e) When calculating the number or percentage of enrollees with a place of employment within an area or zip code under §B(1)(c)(iii)—(viii) of this regulation, the carrier shall include only those enrollees who gain eligibility for participation in the group model HMO’s health benefit plan from their place of employment.
(f) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:
(i) Geo-access maps for each provider type and facility type except for those excluded under §B(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence or place of employment outside the applicable distance standard;
(ii) For any facility types listed in §B(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide adolescent services; and
(iii) For any facility types listed in §B(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
(g) A carrier shall report each number and percentage described in §B(1)(c)(iii)—(viii) of this regulation as part of the annual access plan filing.
(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §B(5) of this regulation.
(3) The travel distance standards listed in §B(5) of this regulation do not apply to the following:
(a) Home health care;
(b) Durable medical equipment;
(c) Heart transplant programs;
(d) Heart or lung transplant programs;
(e) Kidney transplant programs;
(f) Liver transplant programs;
(g) Lung transplant programs; or
(h) Pancreas transplant programs.
(4) All other provider and facility types included on the carrier’s provider panel, but not listed in the chart at §B(5) of this regulation, including physical therapists and licensed dietitian-nutritionist, shall individually be required to meet maximum distances standards of 20 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.
(5) Chart of Travel Distance Standards.
Note: The chart referenced by (5) above could not be reproduced here.
Section .06 Appointment Waiting Time Standards.
A. Network Capacity.
(1) Each carrier shall create and utilize written policies and procedures to monitor the availability of services.
(2) On a semiannual basis, each carrier shall make available to its enrollees the median waiting times to obtain the following in-person appointments with a participating provider as measured from the date of the initial request to the date of the earliest available in-person appointment:
(a) Urgent care for medical services;
(b) Inpatient urgent care for mental health services;
(c) Inpatient urgent care for substance use disorder services;
(d) Outpatient urgent care for mental health services;
(e) Outpatient urgent care for substance use disorder services;
(f) Routine primary care;
(g) Preventive care/well visits;
(h) Non-urgent specialty care;
(i) Non-urgent mental health care; and
(j) Non-urgent substance use disorder care.
(3) To calculate the median waiting times for the appointments described in §A(2) of this regulation, a carrier shall:
(a) Make direct contact with a random selection of provider offices qualified to provide the services for each of the appointment types listed in §A(2) of this regulation to ask for next available in-person appointments; and
(b) Retain documentation of the efforts described in §A(3)(a) of this regulation.
(4) The minimum sample size for the random selection of provider offices described in §A(3)(a) of this regulation shall be equivalent to the lesser of:
(a) Fifty percent of the participating providers qualified to provide the services for each of the appointment types listed in §A(2) of this regulation; or
(b) One hundred provider offices.
(5) The Commissioner may conduct a centralized survey to measure waiting time, by carrier, for each appointment type listed in §A(2) of this regulation.
(a) The survey described in §A(5) of this regulation shall utilize a statistically reliable and valid methodology that includes making direct contact with a random selection of participating providers for each carrier who are qualified to provide the services for each of the appointment types listed in §A(2) of this regulation to ask for next available appointments.
(b) The Commissioner may:
(i) Contract with a vendor to conduct the survey; and
(ii) Charge a carrier a reasonable fee to cover the costs of the survey.
(c) The Commissioner shall publish the methodology used to conduct the survey on the Maryland Insurance Administration’s website.
(d) For any semiannual period in which the Commissioner conducts the survey described in §A(5) of this regulation:
(i) The Commissioner shall provide notice to each carrier subject to this chapter of the intent to conduct the survey at least 3 months in advance;
(ii) The Commissioner may require each carrier to submit a current roster of network providers for each provider panel used by the carrier, and any additional information the Commissioner determines is necessary for the survey to be conducted; and
(iii) A carrier is exempt from the requirement to make direct contact with a random selection of provider offices to calculate the median waiting times as described in §A(3) of this regulation.
B. Sufficiency Standards.
(1) On a semiannual basis, a carrier shall determine whether the provider panel meets the waiting time standards listed in §E of this regulation based on the direct contacts with provider offices described in §A(3)(a) of this regulation or the survey described in §A(5) of this regulation.
(2) Subject to the exceptions in §§C and D of this regulation, if a carrier’s provider panel fails to meet the waiting time standards listed in §E of this regulation for at least 90 percent of appointments in each category, the carrier shall notify the Administration within 10 business days identifying the deficiency in the provider network and the efforts that have been taken or will be taken to correct the deficiency.
C. Preventive care services and periodic follow-up care, including but not limited to, standing referrals to specialty providers for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating provider acting within the scope of the provider’s license, certification, or other authorization.
D. A visit scheduled in advance in accordance with §C of this regulation may be disregarded when determining compliance with the waiting time standards listed in §E of this regulation.
E. Chart of Waiting Time Standards.
Waiting Time Standards
Urgent care for medical services 72 hours
Inpatient urgent care for mental health services 72 hours
Inpatient urgent care for substance use disorder services 72 hours
Outpatient urgent care for mental health services 72 hours
Outpatient urgent care for substance use disorder services 72 hours
Routine primary care 15 calendar days
Preventive care/well visit 30 calendar days
Non-urgent specialty care 30 calendar days
Non-urgent mental health care 10 calendar days
Non-urgent substance use disorder care 10 calendar days
Section 07. Provider-to-Enrollee Ratio Standards.
A. Except for a Group Model HMOs health benefit plan, the provider panel for each carrier shall meet the provider-to-enrollee ratio standards listed in §B of this regulation.
B. The provider-to-enrollee ratios shall be equivalent to at least 1 full-time physician, or as appropriate, another full-time provider for:
(1) 1,200 enrollees for primary care;
(2) 2,000 enrollees for pediatric care;
(3) 2,000 enrollees for obstetrical/gynecological care;
(4) 2,000 enrollees for mental health care or services; and
(5) 2,000 enrollees for substance use disorder care or services.
C. The ratios described in §B of this regulation shall be calculated based on:
(1) The number of enrollees covered under all health benefit plans issued by the carrier in Maryland that use that provider panel; and
(2) The number of providers in that provider panel with practicing locations:
(a) In Maryland; or
(b) Within the applicable maximum travel distance standard specified in Regulation .05 of this chapter outside the geographic boundaries of Maryland.
Section 08. Telehealth.
A. Telehealth Utilization Data Reporting.
(1) For annual access plans submitted on or after July 1, 2024, a carrier shall report the following data on telehealth utilization for the calendar year prior to submission of the annual access plan:
(a) The total number of in-network telehealth claims for each provider type and facility type listed in Regulation .05 of this chapter in each of the urban, rural, and suburban areas and in each Maryland county and Baltimore City; and
(b) The percentage of total in-network claims for each provider type and facility type listed in Regulation .05 of this chapter in each of the urban, rural, and suburban areas and in each Maryland county and Baltimore City that are in-network telehealth claims.
(2) The geographic area for claims data described in §A(1) of this regulation shall be based on:
(a) The enrollee’s place of residence; or
(b) When an enrollee’s place of employment is used instead of residence to calculate travel distance under Regulation .05B of this chapter for a group model HMO, place of employment from which the enrollee gains eligibility for participation in the health benefit plan.
B. Travel Distance Credit.
(1) Subject to approval by the Commissioner as described in §B(5) of this regulation, when calculating the enrollee travel distance for each provider type under Regulation .05A and B of this chapter, a carrier may apply a per-enrollee telehealth mileage credit in a geographic area where the applicable maximum travel distance standard is not met as measured between the practicing location of the nearest provider and the enrollee’s place of residence or, at the option of a group model HMO, place of employment from which the enrollee gains eligibility for participation
in the health benefit plan.
(2) The telehealth mileage credit described in §B(1) of this regulation shall be:
(a) Five miles for an enrollee with a residence or, for a group model HMO, place of employment from which the enrollee gains eligibility for participation in the health benefit plan, in an urban geographic area;
(b) Ten miles for an enrollee with a residence or, for a group model HMO, place of employment from which the enrollee gains eligibility for participation in the health benefit plan, in a suburban geographic area; and
(c) Fifteen miles for an enrollee with a residence or, for a group model HMO, place of employment from which the enrollee gains eligibility for participation in the health benefit plan, in a rural geographic area.
(3) The telehealth mileage credit described in §B(1) of this regulation may be applied to a maximum of 10 percent of enrollees for each provider type in each of the urban, rural, or suburban geographic areas.
(4) A carrier seeking to apply the telehealth mileage credit described in §B(1) of this regulation shall identify:
(a) Each provider type and geographic area to which the credit is being applied;
(b) The percentage of enrollees for which the carrier met the travel distance standard for the provider type and geographic area before the credit was applied; and
(c) The percentage of enrollees for which the carrier met the travel distance standard for the provider type and geographic area after the credit was applied.
(5) The Commissioner may approve the telehealth mileage credit described in §B(1) of this regulation if the carrier sufficiently demonstrates that it provides coverage for and access to clinically appropriate telehealth services from participating providers for the provider type and geographic area to which the credit is being applied, in accordance with the documentation requirements of §D of this regulation.
C. Appointment Waiting Time Credit.
(1) Subject to approval by the Commissioner as described in §C(3) of this regulation, when determining whether the carrier’s provider panel meets the waiting time standards under Regulation .06E of this chapter for at least 90 percent of appointments in each category, a carrier may apply a telehealth credit of up to 10 percentage points for each appointment category where the standard is not met.
(2) A carrier seeking to apply the telehealth credit described in §C(1) of this regulation shall identify:
(a) Each appointment type to which the credit is being applied;
(b) The percentage of appointments for which the carrier met the waiting time standard before the credit was applied; and
(c) The percentage of appointments for which the carrier met the waiting time standard after the credit was applied.
(3) The Commissioner may approve the telehealth credit described in §C(1) of this regulation if a carrier sufficiently demonstrates, in accordance with the documentation requirements of §D of this regulation, that:
(a) The carrier provides coverage for and access to clinically appropriate telehealth services from participating providers for the appointment type to which the credit is being applied;
(b) The carrier provides coverage for a corresponding in-person service if the enrollee chooses not to elect utilization of a telehealth service; and
(c) The carrier establishes, maintains, and adheres to written policies and procedures to assist enrollees for whom a telehealth service is not clinically appropriate, not available, or not accessible with obtaining timely access to an in-person appointment within a reasonable travel distance with:
(i) A participating provider; or
(ii) A nonparticipating provider at no greater cost to the enrollee than if the service was obtained from a participating provider.
D. Required Documentation.
(1) A carrier seeking to apply the telehealth credit described in §B(1) or C(1) of the regulation shall submit the following documentation to demonstrate that it provides coverage for and access to clinically appropriate telehealth services as described in §§B(5) and C(3)(a) of this regulation:
(a) A description of any requirements imposed or incentives provided for participating providers to offer telehealth services;
(b) A detailed description of all telehealth services offered under the health benefit plans issued by the carrier in Maryland that use the provider panel including:
(i) Telehealth modalities covered;
(ii) Types of platforms through which participating providers may deliver telehealth;
(iii) Whether the carrier offers or provides services through a telehealth-only vendor or platform, and which types of services are provided on this basis;
(iv) Whether the carrier arranges for telehealth services to be available on a 24/7 basis, and which types of services are provided on this basis;
(v) Whether the carrier arranges for telehealth kiosks to be installed and maintained in convenient locations throughout Maryland; and
(vi) The specific services available through telehealth for each provider type and appointment type to which the telehealth credit is being applied;
(c) Evidence that telehealth is clinically appropriate and available for the services performed by each provider type and for each appointment type to which the telehealth credit is being applied, which may include:
(i) Actual telehealth utilization data comparing telehealth claims for the specific provider type or appointment type to telehealth claims for all provider types or appointment types;
(ii) Actual telehealth utilization data comparing telehealth claims for the specific provider type or appointment type to all claims for the same provider type or appointment type;
(iii) Survey results or attestations from participating providers indicating that telehealth is offered for the services performed by the specific provider type or for the specific appointment type;
(iv) Enrollee survey results indicating that enrollees have the willingness and ability to use telehealth services for the specific provider type or appointment type; and
(v) Other documentation that, in the discretion of the Commissioner, demonstrates the clinical appropriateness and availability of telehealth services for the provider type or appointment type to which the credit is being applied; and
(d) For the telehealth mileage credit described in §B(1) of this regulation, evidence that telehealth services in general are available and accessible in the zip codes where the telehealth mileage credit is being applied to enrollee’s residence or place of employment, which may include:
(i) Actual telehealth utilization data comparing the ratio of telehealth claims to in-person claims for all types of services on the aggregate in the geographic area of the zip codes where the credit is being applied to the ratio of telehealth claims to in-person claims for all types of services on the aggregate statewide;
(ii) Enrollee survey results indicating that enrollees have the willingness and ability to use telehealth services in general in the geographic area where the credit is being applied; and
(iii) Other documentation that, in the discretion of the Commissioner, demonstrates the availability and accessibility of telehealth services in the zip codes where the credit is being applied.
(2) A carrier seeking to apply the telehealth credit described in §C(1) of the regulation shall submit the following documentation to demonstrate that it provides coverage for a corresponding in-person service and that it establishes, maintains, and adheres to written policies and procedures to assist enrollees with obtaining timely access to an in-person appointment as described in §C(3)(b)—(c) of this regulation:
(a) Excerpts from actual plan materials describing benefits for telehealth and in-person services;
(b) Copies of the actual written policies and procedures;
(c) A description of any information, outreach, and educational materials the carrier provides to enrollees informing them of the assistance available from the carrier to assist with obtaining a timely appointment;
(d) A description of whether the carrier provides assistance on a 24/7 basis to guide enrollees needing urgent care after normal business hours to an appropriate provider, including assistance provided through a customer service telephone option or a contracted telehealth triage service; and
(e) Evidence that the carrier ensures, in practice, that enrollees are able to obtain timely access to an in-person appointment as described in §C(3)(c) of this regulation, which may include:
(i) Documentation of the number of enrollees the carrier assisted with getting appointments within the applicable waiting time standard under Regulation .06E of this chapter;
(ii) Documentation of the number of appointments with a nonparticipating provider for the appointment type to which the credit is being applied where the enrollee received services at no greater cost than if the service was obtained from a participating provider;
(iii) Enrollee survey results indicating satisfaction with the carrier’s efforts to provide assistance with obtaining a timely in-person appointment; and
(iv) Other documentation that, in the discretion of the Commissioner, demonstrates that the carrier regularly assists enrollees in obtaining timely in-person appointments.
Section 09. Waiver Request Standards.
A. If a carrier’s provider panel fails to meet one or more of the standards specified in Regulations .05—.07 of this chapter, the carrier shall provide the following information to the Commissioner as part of the annual access plan:
(1) A description of any network adequacy waiver previously granted by the Commissioner;
(2) An explanation of how many providers in each specialty or health care facility type that the carrier reasonably estimates it would need to contract with or otherwise include in its network to satisfy each unmet standard;
(3) A description of the methodology used to calculate the estimated number of providers in §A(2) of this regulation;
(4) A list of physicians, other providers, or health care facilities related to each unmet standard and within the relevant service area that the carrier attempted to contract with, identified by name and specialty, if any, or health care facility type;
(5) A description of how and when the carrier last contacted the physicians, other providers, or health care facilities;
(6) A description of any reason each physician, other provider, or health care facility gave for refusing to contract with the carrier;
(7) An analysis of any trends in the reasons given by physicians, providers, or health care facilities for refusing to contract with the carrier, and a description of the carrier’s proposals or attempts to address those reasons and improve future contracting efforts;
(8) Identification of all incentives the carrier offers to providers to join the network;
(9) If applicable, a substantiated statement that there are insufficient numbers of physicians, other providers, or health care facilities available within the relevant service area for a covered service or services for which the carrier failed to meet a standard;
(10) A description of other efforts and initiatives undertaken by the carrier in the past year to enhance its network and address the deficiencies that contributed to each unmet standard;
(11) A description of steps the carrier will take to attempt to improve its network to avoid a future failure to meet a standard;
(12) An explanation of any other mitigating factors that the carrier requests the Commissioner to consider; and
(13) An attestation to the accuracy of the information provided in relation to each unmet standard.
B. The Commissioner may find good cause to grant a network adequacy waiver of one or more of the standards specified in Regulations .05—.07 of this chapter, if the information provided by the carrier under §A of this regulation demonstrates that:
(1) The physicians, other providers, or health care facilities necessary for an adequate network:
(a) Are not available to contract with the carrier;
(b) Are not available in sufficient numbers;
(c) Have refused to contract with the carrier; or
(d) Are unable to reach agreement with the carrier.
(2) The reported failure to meet a standard is a result of limitations or constraints with the measurement methodology rather than an actual deficiency in the network.
C. The Commissioner shall post a list of all network adequacy waivers that are granted for each annual access plan on the Maryland Insurance Administration’s website.
Section 10. Confidential Information in Access Plans.
A. Subject to Insurance Article, §15-802, Annotated Code of Maryland, the following information that is included in a carrier’s access plan shall be considered confidential by the Commissioner:
(1) Proprietary methodology used to annually assess the carrier’s performance in meeting the standards established under this chapter;
(2) Proprietary methodology used to annually measure timely access to health care services; and
(3) Factors used by the carrier to build its network.
B. A carrier submitting an access plan or supplemental information required for the network adequacy waiver standards may submit a written request to the Commissioner that specific information included in the plan not be disclosed under the Public Information Act and shall:
(1) Identify the particular information that the carrier requests not be disclosed; and
(2) Cite the statutory authority that permits denial of access to the information.
C. The Commissioner may review a request made under §B of this regulation upon receipt of a request for access pursuant to the Public Information Act.
D. The Commissioner may notify the carrier that made a request under §B of this regulation before granting access to information that was the subject of the request.
Section 11. Network Adequacy Access Plan Executive Summary Form.
A. For each provider panel used by a carrier for a health benefit plan, the carrier shall provide the following network sufficiency results for the health benefit plan service area in the standardized format described on the Maryland Insurance Administration’s website:
(1) Travel Distance Standards.
(a) For each provider type and facility type listed in Regulation .05 of this chapter, list the percentage of enrollees for which the carrier met the travel distance standards, in the following format, with provider types listed first in alphabetical order, followed by facility types in alphabetical order:
Urban Area Suburban Area Rural Area
Provider Type
Facility Type
(b) All provider and facility types described in §§A(4) and B(4) of Regulation .05 of this chapter and included on the carrier’s provider panel shall be listed individually in the chart described in §A(1)(a) of this regulation with the corresponding data for that specific type of provider or facility.
(c) If the telehealth mileage credit described Regulation .08B of this chapter was applied when calculating the percentage of enrollees for which the carrier met the travel distance standards, the carrier shall:
(i) Note the particular provider types and geographic areas to which the credit was applied by including an asterisk in the chart; and
(ii) Include a corresponding footnote stating “As permitted by Maryland regulations, a telehealth mileage credit was applied to up to 10 percent of enrollees for each provider type noted with an asterisk in each of the urban, rural, or suburban geographic areas. The mileage credit is 5 miles for urban areas, 10 miles for suburban areas, and 15 miles for rural areas.”
(d) List the total number of certified registered nurse practitioners counted as a primary care provider.
(e) List the total percentage of primary care providers who are certified registered nurse practitioners.
(f) List the total number of essential community providers in the carrier’s network in each of the urban, rural, and suburban areas providing:
(i) Medical services;
(ii) Mental health services; and
(iii) Substance use disorder services.
(g) List the total percentage of essential community providers available in the health benefit plan’s service area that are participating providers for each of the nine categories described in §A(1)(f) of this regulation.
(h) List the total number and percentage of local health departments in the carrier’s network providing:
(i) Medical services;
(ii) Mental health services; and
(iii) Substance use disorder services.
(2) Appointment Waiting Time Standards.
(a) For each appointment type listed in Regulation .06 of this chapter, list the calculated median waiting time to obtain an in-person appointment with a participating provider, in the following format:
Appointment Waiting Time Standard Results
Urgent care for medical services
Inpatient urgent care for mental health services
Inpatient urgent care for substance use disorder services
Outpatient urgent care for mental health services
Outpatient urgent care for substance use disorder services
Routine primary care
Preventive care/Well Visit
Non-urgent specialty care
Non-urgent mental health care
Non-urgent substance use disorder care
(b) If the telehealth credit described Regulation .08C of this chapter was applied when determining whether the carrier’s provider panel met the waiting time standards under Regulation .06E of this chapter for at least 90 percent of appointments in any category, the carrier may include a statement on the executive summary disclosing the availability of telehealth appointments to supplement the in-person appointments for that category.
(c) If the carrier arranges for telehealth services to be provided from participating providers beyond traditional office hours for an appointment type listed in Regulation .06 of this chapter, the carrier may include a statement on the executive summary disclosing the availability of those services.
(3) Provider-to-Enrollee Ratio Standards.
(a) This subsection does not apply to Group Model HMO health benefit plans.
(b) For all other carriers, summarize the network performance for each provider-to-enrollee ratio standard listed in Regulation .07 of this chapter by listing the calculated number of providers in the provider panel, rounded to the nearest whole number, for each of the following categories of enrollees:
(i) 1,200 enrollees for primary care;
(ii) 2,000 enrollees for pediatric care;
(iii) 2,000 enrollees for obstetrical/gynecological care;
(iv) 2,000 enrollees for mental health care or service; and
(v) 2,000 enrollees for substance use disorder care and services.
B. The network adequacy access plan executive summary form filed by a carrier pursuant to §A of this regulation is not confidential information.