Summary Health Insurance Network Adequacy Requirements

Alabama

Ala. Admin. Code R. 420-5-6-.06

States that a health maintenance organization shall have available sufficient personnel to meet the standards set forth in this Chapter and its contractual obligations, standards include (but are not limited to):

• The distance from the health maintenance organization’s geographic service area boundary to the nearest primary care delivery site and to the nearest institutional service site shall be a radius of no more than 30 miles. 
• Frequently utilized specialty services shall be within a radius of no more than 60 miles. 
• The department may waive this requirement if the distance limit is not feasible in a particular geographic area.

Alaska

N/A

N/A

Arizona

Ariz. Admin. Code § 20-6-1901, et seq.

Health Care Services Organizations Oversight: Each HCSO’s health care plan shall provide within the geographic area served the following basic care services covered by the monthly charges in the evidence of coverage:

• Emergency care that includes emergency services and inpatient emergency care.
• Inpatient care.
• Specialty care, primary care, or ancillary care that includes diagnostic and therapeutic services.
• Outpatient care.
• Preventative care.
• Emergency ambulance services.
• Primary care services from a contracted PCP located within 10 miles or 30 minutes of enrollee’s home in urban areas. 
• PCP must be within 30 miles or 90 minutes in rural areas.
• General hospitals must be within 25 miles or 75 minutes of enrollee’s home in urban areas. 

Arkansas

054-00-14 Ark. Code. R. § 2

Establishes minimum standards for the creation and maintenance of networks by Health Carriers and to assure the adequacy, accessibility and quality of Health Care Services offered under Health Benefit Plans.

• Arkansas primarily uses geographic location to determine network adequacy.
• Emergency services must be available 24/7 within 30-minute travel time or 30 miles.
• Primary care must be within 30-minute travel time or 30 miles.

California

Cal. Code Regs. 10 § 2240.1, et seq.

Requires that network providers are duly licensed or accredited and that they are sufficient, in number or size, to be capable of furnishing the health care services covered by the insurance contract, taking into account the number of covered persons, their characteristics and medical needs including the frequency of accessing needed medical care within the prescribed geographic distances outlined herein and projected demand for services by type of services.

For example, a network must include:

• Primary care providers within a maximum travel time of 30 minutes or maximum travel distance of 15 miles of an enrollee’s residence or workplace.
• A network hospital within 30 minutes or 15 miles of a covered person’s residence or workplace.
• Medically required network specialists with sufficient capacity to accept covered persons within 60 minutes or 30 miles of a covered person's residence or workplace.
• A mental health professional within 30 minutes or 15 miles of a covered person's residence or workplace.

Provider-patient ratio examples include:

• At least one full-time primary care provider per 2,000 covered persons and at least one full-time physician per 1,200 covered persons.

Colorado

3 Colo. Code Regs. § 702-4-2-53

3 Colo. Code Regs. § 702-4-2-54

Provides carriers offering ACA compliant health benefit plans with standards and guidance on Colorado filing requirements for health benefit plan adequacy filings. Network adequacy standards include travel distance requirements, availability standards (e.g., provider to patient ratios) and minimum wait times for primary care and specialty services. For time and distance examples include:

• Primary care and OB/GYN must be within 10 miles in regular metropolitan areas and 30 miles in rural areas.
• Acute inpatient hospitals must be within 30 miles in metropolitan areas and 60 miles in rural areas.
• Psychiatry and psychology must be within 30 miles in metropolitan areas and 60 miles in rural areas.

Required provider-patient ratio examples include:

• Primary care, OB/GYN and mental health, behavioral health and substance use disorder care providers must maintain a provider to enrollee ratio of 1:1000 in all areas.

Connecticut

Conn. Gen. Stat. § 38a-472f

Conn. Agencies Regs. § 38a-472f-3

Each health carrier shall establish and maintain a network that includes a sufficient number and appropriate types of participating providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered benefits will be accessible to all such health carrier's covered persons without unreasonable travel or delay.

Statute states that the Insurance Commissioner shall determine the sufficiency of a health carrier's network with factors including, but not limited to:

• The ratio of participating providers to covered persons by specialty. 
• The ratio of primary care providers to covered persons.
• The geographic accessibility of participating providers.
• The wait times for appointments with participating providers.
• Covered persons shall have access to emergency services 24 hours a day, seven days a week.

Required provider-enrollee requirements include:

• One primary care physician per 2,000 covered people.
• Percentage of providers accepting new patients must be at least 70%.

Delaware

Medical Issuer Qualified Health Plan Submission Guide (2020)

Qualified health plans must abide by the following quantitative standards:

• Primary care: 15 miles for urban/suburban, 25 for rural.
• OB/GYN: 15 miles for urban/suburban, 25 for rural.
• Behavioral health: 35 miles for urban/suburban, 45 miles for rural.
• Acute-care hospitals: 15 miles for urban/suburban, 25 for rural.
• Psychiatric hospitals: 35 miles for urban/suburban, 45 miles for rural.

Required provider-enrollee ratios include:

• Must have one full-time primary care provider for every 2,000 patients.
• Must have one behavioral health practitioner or mid-level professional supervised by a behavioral health practitioner for every 2,000 patients.

District of Columbia

N/A

N/A

Florida

Fla. Admin. Code r. 59A-12.006

Sets quality of care requirements for each HMO and prepaid health clinics within Florida. This includes ensuring that health care services it provides or arranges for are accessible to the subscriber with reasonable promptness. Requirements include, but are not limited to:

• Average travel time from the HMO geographic service area boundary to the nearest primary care delivery site and to the neared general hospital under arrangement with the HMO to provide health care services of no longer than 30 minutes under normal circumstances.
• Average travel time for specialty physician services, ancillary services, specialty inpatient hospital services and all other health services no longer than 60 minutes under normal circumstances.
• Provision of accessible hours of operation and after-hours emergency services.

Georgia

Ga. Code. §§ 33-20C-1 to 33-20C-6

Georgia’s network adequacy laws require the insurer to make available provider directories, which allow the general public to view all the current providers for a network plan.

Hawaii

Haw. Rev. Stat. § 431:26-103

Network adequacy requirements shall be as follows:

• A health carrier providing a network plan shall maintain a network that is sufficient in numbers and appropriate types of providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered benefits will be accessible without unreasonable travel or delay.
• Covered persons shall have access to emergency services 24 hours per day, seven days per week. 
• The commissioner shall determine sufficiency in accordance with the requirements of this section by considering any reasonable criteria, including factors like provider to enrollee ratios and geographic accessibility. 

Idaho

Idaho Standards for ACA Compliant Individual and Small Group Health Benefit Plans and Qualified Dental Plans

Aligns with federal requirements, stating that a carrier offering QHPs that have a provider network must maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to assure that all services will be accessible to enrollees without unreasonable delay.

Illinois

215 Il. Comp. Stat. § 124/10, et seq.

Network Adequacy and Transparency Act. Requires:

• The network plan shall demonstrate to the director maximum travel and distance standards for plan beneficiaries, which shall be established annually by the department in consultation with the Department of Public Health based upon the guidance from the federal Centers for Medicare and Medicaid Services. These standards shall consist of the maximum minutes or miles to be traveled by a plan beneficiary for each county type, such as large counties, metro counties, or rural counties as defined by department rule.
• For beneficiaries in named metropolitan counties, network adequacy standards for timely and proximate access to treatment shall not have longer travel time than 30 minutes or 30 miles from the beneficiaries’ residence. 
• For beneficiaries outside of named metropolitan counties, the beneficiary shall not have to travel longer than 60 minutes or 60 miles from beneficiaries’ residence.

Required provider-patient ratios include:

• One primary care provider per 1,000 enrollees.
• One OB/GYN per 2,500 enrollees.
• One behavioral health specialist per 5,000 enrollees.
• One hospital per county. 
• One mental health facility per county.

Illinois

IL H 4703 (Enacted 2022)

IL S 471 (Enacted 2021)

Amends the Network Adequacy and Transparency Act.

Indiana

Ind. Code §§ 27-13-36-2 & 27-13-36-3

Each health maintenance organization shall demonstrate to the department that the health maintenance organization offers an adequate number of:

• Acute care hospital services.
• Primary care providers.
• Other appropriate providers that are located within a reasonable proximity of subscribers of the health maintenance organization.

Compliance with National Committee on Quality Assurance standards or guidelines is sufficient.

Iowa

N/A

N/A

Kansas

Kan. Stat. Ann. §§ 40-4601, et seq.

A health insurer providing a health benefit plan shall maintain a provider network that is sufficient in numbers and types of providers to assure that all covered services to an insured will be accessible without unreasonable delay.

Sufficiency of the provider network shall be determined in accordance with the requirements of this section, and may be established by reference to any reasonable criteria used by the health insurer, including but not limited to:

• Provider-insured ratios by specialty. 
• Primary care provider-insured ratios. 
• Geographic accessibility. 
• Waiting times for appointments with participating providers. 
• Hours of operation. 
• The availability of technological and specialty services to serve the needs of insureds requiring technologically advanced or specialty care.

Kentucky

Ky. Rev. Stat. § 304.17A-515

900 Ky. Admin. Regs. 10:200 Sec. 4

Requirements for managed care plans:

• 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 it offers plans that conform with the requirements provided within this statute.
• In urban areas, provider network must be available to all enrollees within 30 miles or 30 minutes of each person’s place or residence or work.
• In non-urban areas, a provider network that makes available primary care physicians, hospital services and pharmacy services within 30 minutes or 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 50 minutes or 50 miles of each enrollee’s residence or place of work. 

Louisiana

La. Stat. 22 § 1019.1, et seq.

Section 1019.2 titled Network Adequacy provides:

• A health insurance issuer providing a health benefit plan shall maintain a network that is sufficient in numbers and types of health care providers to ensure that all health care services to covered persons will be accessible without unreasonable delay. In the case of emergency services and any ancillary emergency health care services, covered persons shall have access 24 hours per day, seven days per week. 
• In determining sufficiency criteria, such criteria shall include but not be limited to ratios of health care providers to covered persons by specialty, ratios of primary care providers to covered persons, geographic accessibility, waiting times for appointments with participating providers, hours of operation, and volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

Maine

02-031-850 Me. Code R. § 7

Me. Stat. tit. 24-A § 4303

A carrier offering or renewing a health plan in this State must meet the following requirements:

• Demonstration of adequate access to providers. A carrier offering or renewing a managed care plan shall provide to its members reasonable access to health care services. A carrier may provide incentives to members to use designated providers based on cost on quality but may not require members to use designated providers of health care services.
• Information about provider networks.
• To the extent reasonably possible, carrier that offer managed care plans utilizing primary care providers shall maintain a minimum ratio of one full-time equivalent primary care provider to 2,000 enrollees. 
• Carriers shall ensure the reasonable availability of behavioral health care practitioners.

Maryland

Md. Code Regs. 31.10.44.04

Allows the state exchange to deny certification to health plans that do not meet standards for network adequacy and plan service area. Some maximum distance quantitative standards are:

• Primary Care Physician: five miles urban area and 30 miles for rural.
• OB/GYN: five miles urban area and 30 miles for rural.
• Acute inpatient hospitals: 10 miles for urban area and 60 miles for rural areas.
• Behavioral health and substance abuse facilities: 10 miles for urban areas and 60 miles for rural areas.

Massachusetts

211 Mass. Reg. 52.12

Bulletin B-2018-1

A carrier offering a plan(s) that includes a network(s) shall maintain such network(s) such that it is adequate in numbers and types of providers to assure that all covered services will be accessible to insureds without unreasonable delay. Requires carriers to prepare access analysis prior to offering a plan that includes a provider network and shall update an existing access analysis whenever the carrier makes any material change to such an existing plan.

Michigan

Mich. Comp. Law § 500.3428

Mich. Comp. Law § 500.3513

An insurer shall establish and maintain a provider network that, at a minimum, satisfies any network adequacy requirements imposed by the commissioner pursuant to federal law.

The director shall ensure that health maintenance organizations operate in the interest of enrollees consistent with overall health care cost containment while delivering acceptable quality of care and services that are available and accessible to enrollees with appropriate administrative costs and health care provider incentives.

• Provide, as promptly as appropriate, health services in a manner that ensures continuity and imparts quality health care under conditions the director considers to be in the public interest. 
• Provide health services within its service area that are available and accessible to enrollees 24 hours a day and seven days a week for treatment of emergency episodes of illness or injury.

Minnesota

Minn. Stat. Ann. § 62D.124

Minn. Stat. Ann. § 62K.10

Chapter 62D relates to HMOs and requires that within a HMO’s service area, the maximum travel distance or time shall be the lesser of 30 miles or 30 minutes to the nearest provider of each of the following services:

• Primary care services, mental health services, and general hospital services.
• Chapter 62K relates to health plan market rules requires health care provider system access. Stating, for those counties in which a health carrier actively markets an individual health plan, the health carrier must offer, in those same counties, at least one individual health plan with a provider network that includes in-network access to more than a single health care provider system. This subdivision is applicable only for the year in which the health carrier actively markets an individual health plan. For primary care, mental health services and general hospital services, the maximum travel distance or time shall be the lesser of 30 miles or 30 minutes to the nearest provider of each service.

Mississippi

19 Miss. Code R. § 3-14, et seq.

A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of participating providers to assure that all services to covered persons will be accessible without unreasonable delay.

In the case of emergency facility services, covered persons shall have access 24 hours per day, seven days per week.

Sufficiency shall be determined in accordance with the requirements of this section, and may be established by reference to any reasonable criteria used by the health carrier, including but not limited to:

• Provider covered person ratios by specialty. 
• Primary care provider-covered person ratios. 
• Geographic accessibility. 
• Waiting times for appointments with participating providers. 
• Hours of operation. 
• Volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

Missouri

Mo. Rev. Stat. § 354.603

Mo. Code Regs. tit. 20 § 400-7.095

A health carrier shall maintain a network that is sufficient in number and types of providers to assure that all services to enrollees shall be accessible without unreasonable delay.

Department of Commerce and Insurance section 400.7.095 sets rules regarding HMO Access Plans. Time and distance standard examples:

• Primary care must be within 10 miles in urban areas and 30 miles in rural areas.
• OB/GYN must be within 15 miles in urban areas and 60 miles in rural areas.
• Basic hospitals must be within 30 miles in urban and rural areas.
• Inpatient mental health treatment facilities must be within 25 miles in urban areas and 75 miles in rural areas.

Montana

Mont. Code § 33-36-201

Mont. Admin. R. 37.108.201, et seq.

Mont. Code § 33-36-201 sets network adequacy standards as:

• A health carrier offering a managed care plan in this state shall maintain a network that is sufficient in numbers and types of providers to ensure that all services to covered persons are accessible without unreasonable delay. Sufficiency in number and type of provider is determined in accordance with the requirements of this section. Covered persons must have access to emergency care 24 hours a day, seven days a week. A health carrier providing a managed care plan shall use reasonable criteria to determine sufficiency.

Mont. Admin. R. 37.108.219 sets network adequacy standards as:

• 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.
• In order to be deemed adequate, a health carrier’s network must include one mid-level PCP per 1,500 projected enrollees or one physician PCP per 2,500 projected enrollees.

Nebraska

Neb. Rev. Stat. §§ 44-7101, et seq.

A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all health care services to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have access 24 hours per day, seven days per week.

Sufficiency shall be determined in accordance with the requirements of this section and may be established by reference to any reasonable criteria used by the health carrier, including but not limited to:

• Provider-covered person ratios by specialty. 
• Primary care provider-covered person ratios.
• Geographic accessibility.
• Waiting times for appointments with participating providers.
• Hours of operation
• The volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

Nevada

Nev. Rev. Stat. § 687B.490

Nev. Admin. Code §§ 687B.750 to 687B.784

Requires demonstration of capacity to adequately deliver services by applying to commissioner for issuance of network plan and submission of information; determination by commissioner; certification of plan or specification of deficiency; annual summary; periodic determinations by commissioner concerning availability and accessibility of services of approved plan.

687B.768 sets adequacy standards and requirements using maximum distance and time standard:

• Primary care in metropolitan areas must be within 15 minutes or 10 miles, and in rural areas 40 minutes or 30 miles.
• Hospitals in metropolitan areas must be within 45 minutes or 30 miles, and in rural areas 75 minutes or 60 miles.
• Psychiatrist or psychologist must be within 45 minutes or 30 miles in urban areas, and 75 minutes or 60 miles in rural areas.

New Hampshire

N.H. Code Admin. R. Ins. 2701.01-2701.10

N.H. Rev. Stat. § 420-J:7

A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.

Geographic access standards are based on the following county groupings: rural and urban. Core services include behavioral health counseling and therapy and obstetrical care.

• Rural requires 30 miles or one hour of driving for core services.
• Urban requires 10 miles or 15 minutes of driving for core services.

New Jersey

N.J. Admin. Code § 11:24A-4.10

A carrier shall maintain an adequate network, as set forth in (b) below, of PCPs, specialists and other ancillary providers to assure that covered persons are able to access services in-network and take full advantage of the in-network benefits levels when the policy or contract specifies that there is a differential between the in-network and out-of-network benefits levels for one or more covered services, or the policy or contract is subject to a gatekeeper system.

• Primary care requirements include a sufficient number of physicians to assure that at least two physicians eligible as primary care are within 10 miles or 30 minutes of driving time or public transit time, whichever is less, of 90% of the carrier’s covered persons.
• Acute care hospital must be within 20 miles or 30 minutes driving time, whichever is less, for 90% of covered enrollees.

Provider-patient ratio examples include:

• The carrier shall demonstrate sufficiency of network primary care providers to meet the adult, pediatric and primary OB/GYN needs of current and/or projected number of covered persons by assuming: (1) four primary care visits per year per member, averaging one hour per year per member; and (2) four patient visits per hour per primary care provider.
• The carrier shall have a contract or arrangement with at least one home health agency licensed by the Department of Health and Senior Services to serve each county where 1,000 or more covered persons reside.

The carrier shall have a contract or arrangement with at least one hospice program certified by Medicare in any county where 1,000 or more covered persons reside, if hospice care is covered under the health benefits plan in-network.

New Mexico

N.M. Code R. § 13.10.22.8

Each health care insurer through its MHCP shall maintain and have available an adequate network of licensed primary care practitioners (PCPs) to provide comprehensive basic health care services to its enrolled population at all times. Those MHCPs currently doing business in New Mexico shall submit to the superintendent for approval an access plan addressing all of the criteria of this section.

Geographic requirements example include:

• In areas of 50,000 or more residents, two primary care practitioners must be available within no more than 20 miles or 20 minutes average driving time for 90% of enrollees. 
• In areas with less than 50,000 residents, two primary care practitioners must be available within no more than 60 miles or 60 minutes of average driving time for 90% of enrollees.

Managed Health Care Plans should provide:

• That each covered person will have four primary care visits annually, averaging a total of one hour.
• That each primary care provider will see an average of four patients per hour.
• That one full-time equivalent primary care provider will be available for every 1,500 covered persons.

New York

N.Y. Ins. Law § 3241

An insurer, a corporation organized pursuant to article 43 of this chapter, a municipal cooperative health benefit plan certified pursuant to article 47 of this chapter, or a student health plan established or maintained pursuant to section 1124 of this chapter, that issues a health insurance policy or contract with a network of health care providers shall ensure that the network is adequate to meet the health needs of insureds and provide an appropriate choice of providers sufficient to render the services covered under the policy or contract.

Example of time and distance standards:

• Primary care providers include 30 minutes by public transportation in metropolitan areas, 30 minutes or 30 miles by public transportation or by car in non-metropolitan areas and rural areas may exceed these standards if justified. 
• Non-primary care providers have a preferred time and distance standard that should meet the 30-minute or 30-mile standard.
• A time and distance standard of 45-minutes or 45-miles may be used for certain rural counties for certain provider types.

Provider-patient ratio examples include:

• At least one hospital in each county, listed urban counties require three hospitals per county.
• A choice of three primary care physicians in each county, and potentially more based on enrollment and geographic accessibility. 
• At least two of each specialist provider type, and potentially more based on enrollment and geographic accessibility. 
• The insurer will need to include individual providers, outpatient facilities and inpatient facilities in its behavioral health network. 

North Carolina

N.C. Gen. Stat. § 58-50-56(g)

11 N.C. Admin. Code 20.0301 to 20.0304

The commissioner may adopt rules applicable to insurers offering preferred provider benefits plans under this section. These rules shall provide for: 1) accessibility of preferred provider services to individuals within the insured group, 2) the adequacy of the number and location of health care providers, 3) the availability of services at reasonable times, 4) financial solvency.

Carriers shall establish written policies and performance targets that address the following:

• The proximity of network providers, as measured by such means as driving distance or time a member must travel to obtain primary care, specialty care, and hospital services, taking into account local variations in the supply of providers, and geographic considerations.
• The availability to provide emergency services on a 24-hour, seven-day per week basis.
• Emergency provisions within and outside of the service area.
• The average or expected waiting time for urgent, routine, and specialist appointments

North Dakota

N.D. Admin. Code 45-06-07-06

A maintenance organization shall establish and maintain adequate arrangements to provide health services for its enrollees, including:

• Reasonable proximity to the business or personal residences of the enrollees so as not to result in unreasonable barriers to accessibility.
• Reasonable hours of operation and after-hours services.
• Emergency care services available and accessible within the service area 24 hours a day, seven days a week.

Ohio

N/A

N/A

Oklahoma

O.A.C. 365:40-5-40

O.A.C. 365:40-5-110

Oklahoma determines their accessibility of providers based on travel time stating:

• The department shall presume a proposed service area to be reasonable if the mean travel time is 30 minutes or less from six equidistant points on the area boundary to the nearest primary and emergency care delivery sites within that area.
• Emergency services must be available 24 hours a day, seven days per week.

Oregon

Or. Rev. Stat. § 743B.505

Or. Admin. R. 836-053-0330

Or. Admin. R. 836-053-1190

An insurer electing to demonstrate compliance with network adequacy requirements, may evidence network compliance with a nationally recognized standard may use the federal network adequacy standards applicable to Medicare Advantage plans, adjusted to reflect the age demographics of the enrollees in the plan.

Whether the insurer has a process for ensuring network adequacy that includes oversight, communication and monitoring, and the following information about the process:

• The position and department of the individual with the responsibility of ensuring and monitoring the network.
• The telephone number, electronic mail address, address or website that enrollees are requested to use in order to express concerns regarding network adequacy.
• The website at which enrollees can locate the provider director, and the frequency with which the website is updated. 

Pennsylvania

28 Pa. Code §§ 9.678-9.679

A plan shall at all times assure enrollee access to primary care providers, listed specialty care providers, hospitals and psychiatry and services necessary to provide covered benefits. Examples of time and distance requirements:

• A plan shall provide for at least 90% of its enrollees in each county in its service area. 
• Access to covered services that are within 20 miles or 30 minutes travel from an enrollee’s residence or work in county designated as metropolitan. 
• Access to covered services that are within 45 miles or 60 minutes travel from an enrollee’s residence or work in any other county. 

Rhode Island

R.I. Gen. Laws §§ 27-18.8-1, et seq.

For each network plan, health care entities must ensure a number of requirements are met including maintaining access to professional, facility, and other providers sufficient to provide coverage in a timely manner of the benefits covered in the network plan and in a manner to assure that all covered services will be accessible without unreasonable delay, and establish a process acceptable to the commissioner to monitor the status of each network plan’s network adequacy not less frequently than quarterly.

South Carolina

Department of Insurance Bulletin Number 2013-04

Provider-enrollee ratios requires:

• At least one primary care practitioner per 2,000 members accessible within a 30-mile radius for 95% of the population of the area to be served.
• One OB/GYN within a 30-mile radius for 95% of the population in the service area.
• One contract hospital within county or 30-mile radius of 95% of the population in service area if hospital does not have a hospital.

South Dakota

S.D. Codified Laws § 58-17F-1, et seq.

A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all services to covered persons will be accessible without unreasonable delay.

• In the case of emergency services, covered persons shall have access 24 hours a day, seven days a week. 
• Sufficiency shall be determined in accordance with the requirements of this section and may be established by reference to any reasonable criteria used by the carrier.

Tennessee

Tenn. Code. Ann. § 56-7-2356

Tenn. Comp. R. & Regs. 1200-8-33-.06

Each managed health insurance issuer that offers a plan that limits its enrollees' choice of providers shall maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have access to health care services 24 hours per day, seven days per week.

Time and distance examples for HMOs include:

• HMOs shall ensure that members do not have to travel more than 30 miles distance or 30 minutes travel time at a reasonable speed for primary care physician services.
• HMO shall ensure that members do not have to travel more than approximately 30 minutes to the nearest participating hospital. Travel time may be waived if in a specific geographic area the above time standard is not feasible.

The health maintenance organization shall implement a comprehensive quality improvement program designed to continually assess and improve the quality of care and services provided to members.

Texas

Tex. Ins. Code Ann. § 1301.0055

28 Tex. Admin. Code § 11.1607 (HMO)

28 Tex. Admin. Code § 3.3704 (PPO)

An HMO must make general, special and psychiatric hospital care available and accessible 24 hours per day, seven days per week, within the HMO’s service area.

HMO network adequacy requirements:

• 30 miles for primary care and general care hospital.
• 75 miles for specialty care, special hospitals and single health care plan physicians or providers.

PPO network adequacy requirements:

• 30 miles in non-rural areas and 60 miles in rural areas for primary care and general hospital care. 
• 75 miles for specialty care and specialty hospitals.

Utah

N/A

N/A

Vermont

33 V.S.A. § 1806

A qualified health benefit plan shall meet the following minimum prevention, quality, and wellness requirements:

• Standards for marketing practices, network adequacy, essential community providers in underserved areas, appropriate services to enable access for underserved individuals or populations, accreditation, quality improvement, and information on quality measures for health benefit plan performance as provided by the ACA, and more restrict requirements provided by 8 V.S.A. chapter 107.
• Quality and wellness standards, including a requirement for joint quality improvement activities with other plans, as specified in rule by Secretary of Human Services.
• Standards for participation in the Blueprint for Health as provided in 18 V.S.A. chapter 13.

Virginia

Va. Code Ann. § 38.2-4312.3

A health maintenance organization shall have a system to provide to its members, on a 24-hour basis:

• Access to medical care.
• Access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a member for prompt medical care in cases where there is an immediate, urgent need or medical emergency.

Washington

W.A.C. § 284-170-200

An issuer must 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 24 hours per day, seven days per week without unreasonable delay.

Examples of time and distance standards include:

• Primary care providers must be within 30 miles of 80% of enrollees in urban areas and within 60 miles in a rural area from either their residence or workplace.
• Hospitals and emergency services must be within 30 miles for enrollees in an urban area and 60 miles in rural areas from either their residence or workplace.
• Behavioral health emergency services must be accessible for enrollees within 30 minutes in urban areas and 60 minutes in rural areas from either residence or workplace. 

Washington

WA S 5377 (Enacted 2021)

Requires all standardized health plans offered on the exchange to meet all requirements for qualified health plans including network adequacy standards.

West Virginia

W. Va. Code §§ 33-55-1 to 33-55-10

W.Va. Code R. § 114-100-3

A health carrier providing a network plan shall maintain a network that is sufficient in numbers and appropriate types of providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered services to covered persons, including children and adults, will be accessible without unreasonable travel or delay. Additionally, covered persons must have access to emergency services 24 hours per day, seven days per week.

Examples of time and distance standards include:

• Primary care within 30 minutes or 25 miles of member’s residence.
• Hospital access within 45 minutes or 30 miles of member’s residence.
• OB/GYN within 30 minutes or 25 miles of member’s residence.
• Behavioral health providers within 60 minutes or 45 miles of member’s residence.

Provider-patient ratios include:

• Primary care physician requires 1 for every 500 covered persons.
• OB/GYN requires one for every 1,000 covered persons.

Wisconsin

N/A

N/A

Wyoming

N/A

N/A