Geographic Access Criteria
(1) In order to be deemed adequate, a provider network must fulfill all access criteria of the rules in this chapter within the following geographic restrictions:
(a) to the extent that services are covered by the health carrier, the health carrier must have an adequate network of primary care providers; a hospital, critical access hospital, or medical assistance facility; and a pharmacy that is located within a 30 mile radius of each enrollee’s residence or place of work, unless:
(i) the usual and customary travel pattern of the general population within the service area to reach health care providers is further, and if the fact that the usual and customary travel pattern exists is documented by the health carrier; or
(ii) the provider is available but does not meet the health carrier’s reasonable credentialing requirements; and
(b) if no qualified provider for a service covered by the plan exists within a 30 mile radius of an enrollee’s residence or place of work, the health carrier must document how covered services will be provided at no additional charge to enrollees through referrals to qualified providers outside the 30 mile radius.
(2) Enrollees may, at their discretion, select participating primary care providers located farther than 30 miles from their homes and/or places of business.
(3) When an eligible employee in a group health plan neither resides nor works within a 30 mile radius of the network established pursuant to (1), the network may be deemed adequate subject to the following conditions:
(a) Insured employees living and working outside the 30 mile radius of the primary place of work of their employer, as well as their dependents, may not be penalized either in benefits or by being required to travel outside the 30 mile radius from their own place of work to receive routine treatment typically provided by a primary care provider.
(b) The health carrier may require employees to utilize a network primary care provider for referrals, including for referrals for routine treatment provided by a primary care provider. If such a requirement is imposed, access to the network primary care provider must be available to the insured by phone at no cost to the insured. A toll free number to the health carrier would satisfy this requirement.
(c) At the time of initial selection or the renewal of a managed care plan, the maximum number of eligible employees residing and working outside the 30 mile radius of the primary place of work may not exceed the following:
(i) for groups with two to five employees, one;
(ii) for groups with six to 15 employees, two;
(iii) for groups with 16 to 30 employees, three, and
(iv) for groups with 30 or more employees, 10% of the employees.