COMAR 31.10.34 · Chapter 34 Carrier Provider Panels

Administrative History Effective date: July 17, 2008 (35:14 Md. R. 1247) Authority Insurance Article, §§ 2-108 ( 2 ) and 15-112 (b)( 1 )(i)1, Annotated Code of Maryland;

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.01 Purpose. The purpose of this chapter is to: A. Establish standards for the creation and maintenance of provider panels by insurers, nonprofit health service plans, and dental plan organizations; and B. Assure the availability of health care providers to meet the health care needs of enrollees.

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.02 Scope. This chapter applies to insurers, nonprofit health service plans, and dental plan organizations that use provider panels.

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.03 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) "Accredited hospital" means a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations. (2) "Carrier" means an insurer, a nonprofit health service plan, or a dental plan organization. (3) "Enrollee" means an individual entitled to health care benefits from a carrier. (4) "Hospital-based physician" means an anesthesiologist, pathologist, radiologist, neonatologist, hospitalist, intensivist, or emergency medicine physician that practices exclusively within an accredited hospital and provides care to enrollees only as a result of the enrollees being directed to the hospital. (5) "Prominent carrier" means a carrier reporting at least $90,000,000 in written premium for medical benefits in Maryland in the most recent annual statement. (6) "Provider" means a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized by law to provide health care services. (7) "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.

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.04 Provider Panel Sufficiency. A. A carrier shall maintain a provider panel that is sufficient in numbers and types of available providers to meet the health care needs of enrollees. B. Standards to meet the health care needs of enrollees shall be determined in accordance with the requirements of this chapter, and may be established by reference to any reasonable criteria used by the carrier, including but not limited to: (1) Provider-enrollee ratios by specialty; (2) Primary care provider-enrollee ratios; (3) Geographic accessibility; (4) Waiting times for appointments with providers; (5) Hours of operation; and (6) The volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.

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.05 Availability Plan. A. A carrier shall implement an availability plan describing: (1) If the carrier is an insurer or nonprofit health service plan, the quantifiable and measurable standards for the number and geographic distribution of: (a) General and internal medicine providers; (b) Family practitioners; (c) Pediatricians; (d) Obstetricians and gynecologists; (e) High-volume specialty behavioral health care providers, including psychiatrists, psychologists, clinical social workers, and any other behavioral health care providers identified by the carrier; and (f) High-volume specialty health care providers, identified by the carrier; or (2) If the carrier is a dental plan organization, or an insurer or nonprofit health service plan that provides coverage only for dental services, the quantifiable and measurable standards for the number and geographic distribution of: (a) Dentists; and (b) Any other dental service provider identified by the carrier. B. The availability plan required by §A of this regulation shall also include: (1) The method used to annually assess the carrier's performance against the standards specified in the availability plan; (2) The method used to ensure timely access to health care services, as identified by the carrier; and (3) The carrier's process for monitoring and assuring on an ongoing basis the sufficiency of the provider panel to meet the health care needs of enrollees. C. Availability Plan and Annual Performance Assessment. (1) A carrier shall: (a) On an annual basis, review and update the availability plan required by §A of this regulation ; (b) On an annual basis, conduct a performance assessment regarding its compliance with its availability plan using the method provided in §B(1) of this regulation ; and (c) Submit its availability plan and its annual performance assessment to the Commissioner upon request. (2) In addition to the requirements of §C(1) of this regulation , a prominent carrier shall submit to the Commissioner the prominent carrier's: (a) Availability plan not later than: (i) 90 days after the effective date of this chapter, if the carrier is a prominent carrier on the effective date of this chapter; or (ii) 90 days after the carrier becomes a prominent carrier, if the carrier becomes a prominent carrier after the effective date of this chapter; and (b) Annual performance assessment: (i) Not later than November 1, 2008, for the period beginning on the effective date of this regulation; and (ii) Within 30 days of completing the annual performance assessment, for calendar year 2009 and thereafter. (3) In addition to the requirements of §C(2) of this regulation , a prominent carrier shall: (a) File with the Commissioner the availability plan described in §C(2)(a) of this regulation not later than 30 days after the carrier makes any change to the availability plan; (b) Provide annually to the Commissioner a list of the hospital-based physician specialties available on the prominent carrier's provider panel; and (c) Submit the report required in §A of this regulation with the submission of the prominent carrier's performance assessment required by §C(2)(b) of this regulation . (4) The Commissioner may request additional information from the carrier in order to evaluate the carrier's performance with the availability plan.

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.06 Enforcement. A. In addition to any other enforcement powers available to the Commissioner, if a carrier violates this chapter, the Commissioner may order a carrier to take reasonably appropriate corrective action. B. The reasonably appropriate corrective action required by the Commissioner in §A of this regulation may include, but not be limited to, ordering the carrier to: (1) Meet the standards specified in the carrier's availability plan by increasing the number of providers by specialty or geographic area in the carrier's provider panel; and (2) Make restitution to an enrollee who received services during the time the carrier failed to meet the standards specified in the carrier's availability plan, from a provider that was not on the carrier's provider panel, if the carrier fails to take a corrective action ordered by the Commissioner.

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