Issuers are required to maintain each provider network for each health plan in a manner that is sufficient in numbers and types of providers and facilities to assure that, to the extent feasible based on the number and type of providers and facilities in the service area, all health plan services provided to enrollees will be accessible in a timely manner appropriate for the enrollee’s condition. An issuer must demonstrate that for each health plan's defined service area, a comprehensive range of primary, specialty, institutional, and ancillary services are readily available without unreasonable delay to all enrollees and that emergency services are accessible twenty-four hours per day, seven days per week without unreasonable delay.
Issuers file with our office a variety of reports that demonstrate they are meeting these requirements. They include:
- Access Plan,
- GeoNetwork Report,
- Provider Network Form A, and
- Provider Directory Certification.
As for the actual review process, this is more difficult to describe in an email, but one example of what we review is issuers are required to meet specific time/distance standards. WAC 284-43-220(3)(e)(i)(F) requires: “Therapy services. An issuer must provide one map that demonstrates that eighty percent of the enrollees have access to the following types of providers within thirty miles in an urban area and sixty miles in a rural area of their residence or workplace: Chiropractor, rehabilitative service providers and habilitative service providers.” (emphasis added)
The Access Plan and GeoNetwork Report describe how the service will be available and map the provider/enrollee location verifying access is being met to the standard. Additionally, the rule specifically defines how an issuer must categorize each county as either urban or rural. Currently, the population density standard published by OFM makes 88% of Washington Counties urban (subject to the more stringent standard) and 12% rural.
When an issuer is unable to meet the above requirements (as set out in WAC 284-43-200) they must file an alternative access delivery request (AADR).
There is an important distinction here in the rule between when an issuer changes providers versus when they loose or cannot obtain a provider. Networks expand and contract throughout their life cycle depending on the covered services in the products and number of enrollees accessing a network. The reporting above demonstrates how the issuer provides access to medically necessary covered services at in-network cost-share without balance billing. My point being, the above is how an issuer shows us the addition and deletion of providers while they are maintaining network access even when the change is a material provider.
The AADR is required to be filed when the issuer cannot meet the requirements in WAC 284-43-200 and is requesting to provide access through an alternative mechanism. This change usually involves a specialty provider or major delivery system that terminates its contract. In this situation, the issuer must file with us:
- Access Plan – AADR
- GeoNetwork Report – AADR
- Provider Network Form A – AADR
- Alternative Access Delivery Request Form C
The difference in these reports from the reports required above, is that are the issuer’s proposal to the Commissioner demonstrating how enrollees will be provided access to medically necessary covered services without balance billing. Our office reviews these proposals, and requires modifications as appropriate, to ensure enrollees are not harmed by the access issue.
For more information, contact Lonnie Johns-Brown, 360 725-7101, LonnieJ@oic.wa.gov