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California
Cal. Welf. & Inst. Code § 14132.275.
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The Department of Health Services shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program and the federal Medicare Program. Includes provisions to ensure network adequacy. |
2010, 2011, 2012, 2013, 2014
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Cal. Welf. & Inst. Code
§ 14182.16 and § 14182.17.
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- Requires the department to monitor the provider networks of managed health plans to ensure network adequacy.
- Requires the department to ensure managed health plans compliance with network adequacy requirements, including geographic accessibility of providers, long-term services requirements, the development and maintenance of lists of providers currently accepting new patients and monitoring of networks to ensure an adequate number of providers in a given area.
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2012, 2013, 2013
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West's Ann.Cal.Health & Safety Code § 1367.035
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Requires health care service plans to provide the department with data related to network adequacy.
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2015 |
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West's Ann.Cal.Ins.Code § 12693.37
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"(b)(1) In its selection of participating plans the board shall take all reasonable steps to assure the range of choices available to each applicant, other than a purchasing credit member, shall include plans that include in their provider networks and have signed contracts with traditional and safety net providers.
(2) Participating health plans shall be required to submit to the board on an annual basis a report summarizing their provider network. The report shall provide, as available, information on the provider network as it relates to:
(A) Geographic access for the subscribers.
(B) Linguistic services.
(C) The ethnic composition of providers.
(D) The number of subscribers who selected traditional and safety net providers."
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2001 |
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Colorado
Colo. Rev. Stat. Ann. § 10-16-704.
CO regulation: (25.5-5-403;
3 CCR 702-4
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“A carrier providing a managed care plan 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.”
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1997, 2001, 2002, 2003, 2006, 2010, 2013
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Connecticut
Conn. Gen. Stat. Ann. § 38a-472f
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Requires carriers to ensure that their networks have adequate numbers of providers. Requires consistency with the standards set by the National Committee for Quality Assurance “or URAC's provider network access and availability standards.”
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2011
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Conn. Gen. Stat. Ann. § 38a-1085
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Allows the inclusion of limited network dental plans to be included in the Exchange if those plans provide for pediatric dentistry.
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2011
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Conn. Gen. Stat. Ann. § 38a-1086
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Establishes the standards required for plans to be included on the Exchange, established in 2011 by C.G.S.A. § 38a-1081. Requires carriers to “charge the same premium rate for each qualified health plan without regard to whether the plan is offered through the exchange or directly by the health carrier or through an insurance producer.”
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2011
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Florida
Fla. Stat. Ann. §409.967
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Requires the agency to enter into a five-year contract with a managed health plan. The plan must have an adequate regional network of providers.
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2011, 2012
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Fla. Stat. Ann. §409.975
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Allows managed care networks which are part of the managed medical assistance program to “limit the providers in their networks based on credentials, quality indicators, and price.”
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2011, 2012
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Fla. Stat. Ann. §409.91211
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Establishes a pilot program that will be limited to Broward County. Requires the agency to ensure that capitated managed care programs provide adequate access to providers.
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2005, 2007, 2009, 2010, 2011
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Hawaii
Hawaii Rev. Stat. § 432F-2.
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Requires managed care plans to demonstrate the adequacy of their provider networks to the commissioner no later than Jan. 1 of each year.
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2013
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Hawaii Rev. Stat. § 435H-11
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“The commissioner shall provide the Hawaii health connector, established in 2011 by HRS § 435H-2 with a list of qualified health plans that meet network adequacy standards as determined by the commissioner.”
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2013
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Illinois
Ill. Stat. Ann. ch. 325 §20/13.20
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Allows managed care plans to specify that children be treated by providers within the plan’s network, so long as certain conditions are met, including:
- “the network provider is immediately available to receive the referral and to begin providing services to the child;”
- “the network provider is enrolled as a provider in the Illinois early intervention system and fully credentialed under the current policy or rule of the lead agency;”
- “the network provider can provide the services to the child in the manner required in the individualized service plan;”
- “the family would not have to travel more than an additional 15 miles or an additional 30 minutes to the network provider than it would have to travel to a non-network provider who is available to provide the same service; and”
- “the family's managed care plan does not allow for billing (even at a reduced rate or reduced percentage of the claim) for early intervention services provided by non-network providers.”
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2001
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Kentucky
KRS § 304.17A-515
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Requires managed care plans to demonstrate network adequacy through quantifiable criteria, including:
"(a) An adequate number of accessible acute care hospital services, where available;
(b) An adequate number of accessible primary care providers, including family practice and general practice physicians, internists, obstetricians/gynecologists, and pediatricians, where available;
(c) An adequate number of accessible specialists and subspecialists, and when the specialist needed for a specific condition is not represented on the plan's list of participating specialists, enrollees have access to nonparticipating health care providers with prior plan approval;
(d) The availability of specialty services; and
(e) A provider network that meets the following accessibility requirements:
1. For urban areas, a provider network that is available to all persons enrolled in the plan within thirty (30) miles or thirty (30) minutes of each person's place of residence or work, to the extent that services are available; or
2. For areas other than urban areas, a provider network that makes available primary care physician services, hospital services, and pharmacy services within thirty (30) minutes or thirty (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 fifty (50) minutes or fifty (50) miles of each enrollee's place of residence or work, to the extent those services are available."
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1998, 2000 |
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KRS § 304.17A-300(3)(g) and (h)
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"(3) To qualify as a provider-sponsored integrated health delivery network, an applicant shall submit information acceptable to the department to satisfactorily demonstrate that the provider-sponsored integrated health delivery network:
(g) Has the ability to assure enrollees adequate access to providers, including geographic availability and adequate numbers and types;
(h) Has the ability and procedures to monitor access to its provider network;"
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2010 |
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Louisiana
La. Rev. Stat. Ann. tit. 22 §1019.2
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“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.”
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2013
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LSA-R.S. 22:1019.3
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Outlines the options of the Commissioner in the event a health insurance carrier does not have an adequate network of providers. |
2013 |
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Maine
24-A M.R.S.A. § 4303
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"A carrier offering or renewing a health plan in this State must meet the following requirements.
1. 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 or quality, but may not require members to use designated providers of health care services.
19. Information about provider networks. A carrier offering a managed care plan shall prominently disclose to applicants, prospective enrollees and enrollees information about the carrier's provider network for the applicable managed care plan, including whether there are hospitals, health care facilities, physicians or other providers not included in the plan's network and any differences in an enrollee's financial responsibilities for payment of covered services to a participating provider and to a provider not included in a provider network. The superintendent may adopt rules that set forth the manner, content and required disclosure of the information in accordance with this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A."
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2014 |
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Maryland
Md. Insurance Code §31-115
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Allows the state Exchange to deny certification to health plans that do not meet standards for network adequacy and plan service area.
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2011, 2012, 2013
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Massachusetts
Mass. Gen. Laws Ann. ch. 176J §11
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Requires certain carriers to offer at least one benefit plan in at least one geographic area that provides at least one of the following:
- a reduced or selective network of providers;
- a smart tiering plan in which health services are tiered and member cost sharing is based on the tier placement of the services; or,
- a plan in which providers are tiered and member cost sharing is based on the tier placement of the provider.
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2010, 2011, 2012
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Michigan
Mich. Comp. Laws Ann. §500.3428
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“Beginning Jan. 1, 2014, 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.”
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2013
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Mich. Comp. Laws Ann. §550.1501c
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“Beginning Jan. 1, 2014, a health care corporation shall establish and maintain a provider network that, at a minimum, satisfies any network adequacy requirements imposed by the commissioner pursuant to federal law.”
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2013
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Minnesota
Minn. Stat. Ann. §62D.124 and
Minn. Stat. Ann. §62K.10
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“Within the health maintenance organization'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.”
“Within a health maintenance organization's service area, the maximum travel distance or time shall be the lesser of 60 miles or 60 minutes to the nearest provider of specialty physician services, ancillary services, specialized hospital services and…other health services.”
Establishes the maximum travel time to the nearest “primary care services, mental health services, and general hospital services” be limited to 30 miles or 30 minutes. Requires the travel time to the nearest “provider of specialty physician services, ancillary services, specialized hospital services, and…other health services” be limited to 60 miles or 60 minutes. Requires that networks contain a sufficient number and type of providers.
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1999, 2012, 2013
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Minn. Stat. Ann. §62K.14
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Requires limited scope pediatric dental plans to be offered to the extent permitted under the ACA. Establishes limits and requirements for discontinuing a limited scope pediatric plan. Requires that providers in a limited scope pediatric plan be accessible within 60 miles or 60 minutes travel time. These provisions apply only to plans renewed after Jan. 1, 2015.
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2013
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M.S.A. § 62T.06(1) and (7)
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"Subdivision 1. Authorization. The commissioner may grant waivers from the requirements of law for the contracting arrangement between a health care purchasing alliance and an accountable provider network in the areas listed in subdivisions 2 to 4. The commissioner may not waive the following state consumer protection and quality assurance laws:
(1) laws requiring that enrollees be informed of any restrictions, requirements, or limitations on coverage, services, or access to specialists and other providers;
(7) minimum standards for adequate provider network capacity and geographic access to services;"
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1997, 2000 |
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Missouri
V.A.M.S. 354.603
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"1. 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. In the case of emergency services, enrollees shall have access twenty-four hours per day, seven days per week. The health carrier's medical director shall be responsible for the sufficiency and supervision of the health carrier's network. Sufficiency shall be determined by the director in accordance with the requirements of this section and by reference to any reasonable criteria, including but not limited to provider-enrollee ratios by specialty, primary care provider-enrollee ratios, geographic accessibility, reasonable distance accessibility criteria for pharmacy and other services, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.
(2) The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers, including local pharmacists, to the business or personal residence of enrollees. In determining whether a health carrier has complied with this provision, the director shall give due consideration to the relative availability of health care providers in the service area under, especially rural areas, consideration."
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1997, 2001, 2003 |
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Montana
Mont. Code Ann. §§33-36-101—402
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“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.”
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1997
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Nebraska
Neb. Rev. Stat. §§ 44-7101—7112
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“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.”
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1998
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Nevada
N.R.S. 687B.490
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"1. A carrier that offers coverage in the group or individual market must, before making any network plan available for sale in this State, demonstrate the capacity to deliver services adequately by applying to the Commissioner for the issuance of a network plan and submitting a description of the procedures and programs to be implemented to meet the requirements described in subsection 2.
2. The Commissioner shall determine, within 90 days after receipt of the application required pursuant to subsection 1, if the carrier, with respect to the network plan:
- (a) Has demonstrated the willingness and ability to ensure that health care services will be provided in a manner to ensure both availability and accessibility of adequate personnel and facilities in a manner that enhances availability, accessibility and continuity of service;
- (b) Has organizational arrangements established in accordance with regulations promulgated by the Commissioner; and
- (c) Has a procedure established in accordance with regulations promulgated by the Commissioner to develop, compile, evaluate and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services and such other matters as may be reasonably required by the Commissioner."
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2014 |
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New Hampshire
N.H. Rev. Stat. § 420-J:7
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“ 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.”
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2008
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N.H. Rev. Stat. §420-N:8
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“In the event a federally-facilitated exchange is established for New Hampshire, the commissioner shall retain authority with respect to insurance products sold in New Hampshire on the federally-facilitated exchange to the maximum extent possible by law as provided in title XXXVII, including but not limited to…network adequacy…”
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2012
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New Jersey
N.J.S.A. 26:2S-18
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"The commissioner shall enforce the provisions of this act.
Within six months of the effective date of this act, in consultation with the Commissioner of Banking and Insurance, the commissioner shall adopt rules and regulations, pursuant to the “Administrative Procedure Act,” P.L.1968, c. 410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act. The regulations shall establish consumer protection and quality standards governing carriers which offer a managed care plan or use a utilization management system that are consistent with the standards governing health maintenance organizations in the State.
The regulations shall include standards for: a quality management program; provider participation in a network; adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network and access to medical specialists, when appropriate; utilization management as required in this act; a covered person complaint system; a patient appeals system as required in this act; the establishment of consumer rights of covered persons; carrier disclosure as required in this act; and outcomes and data reporting requirements as required in this act."
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1997 |
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New York
N.Y. Public Health Law § 4403-f.
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Requires carriers to demonstrate to the commissioner that “the contractual arrangements for providers of health and long term care services in the benefit package are sufficient to ensure the availability and accessibility of such services to the proposed enrolled population consistent with guidelines established by the commissioner” in order to receive certification.
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1997, 2004, 2005, 2006, 2007, 2008, 2010, 2011, 2012, 2013
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North Dakota
NDCC, 26.1-36-42
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"1. An accident and health insurance policy may not be delivered or issued for delivery by an insurance company, as defined in section 26.1-02-01, or any other entity providing a plan of health insurance subject to state insurance regulation to a person in this state unless the entity establishes and maintains a grievance procedure for resolving complaints by covered persons and providers and addressing questions and concerns regarding any aspect of the plan, including access to and availability of services, quality of care, choice and accessibility of providers, and network adequacy. The procedure must include a system to record and document all grievances since the date of its last examination of the grievances.
2. The procedure must be approved by the insurance commissioner. The commissioner may examine the grievance procedures."
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1999 |
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Oregon
Ore. Laws 2012, Ch. 80, § 4.
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Forbids coordinated care organizations from discriminating against health providers who are acting within their scope of practice. In determining whether discrimination has occurred, the authority must consider an organization’s network adequacy.
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2012
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O.R.S. § 743.817(1)
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"An insurer offering managed health insurance or preferred provider organization insurance in this state shall:
(1) File an annual summary with the Department of Consumer and Business Services that reports on the scope and adequacy of the insurer's network and the insurer's ongoing monitoring to ensure that all covered services are reasonably accessible to enrollees. The Director of the Department of Consumer and Business Services shall adopt rules establishing uniform indicators that insurers offering managed health insurance or preferred provider organization insurance must use for reporting under this subsection, including but not limited to reporting on the scope and adequacy of networks. For the purpose of developing the rules, the director shall consult with an advisory committee appointed by the director. The advisory committee must include representatives of persons likely to be affected by the rules, including consumers, purchasers of health insurance and insurers that offer managed health insurance or preferred provider organization insurance."
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1997,2001 |
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South Dakota
SD Codified Laws §§58-17F-2-21
Initiative Measure 17
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Requires managed care networks to maintain networks of providers of sufficient adequacy to ensure reasonable access.
"Any Willing Provider" law passed by initiative ballot question, with state residents voting yes 62% to 28%. The ballot measure (IM 17) requires insurers to explicitly outline state evaluation criteria and ensure that providers, including physicians, have a due process to join the insurers' networks if they are able and willing to meet those criteria.
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2011
2014
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Tennessee
Tenn. Code Ann. § 56-7-2356
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“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.”
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1998, 1999, 2008
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Texas
Tex. Insurance Code Ann. § 1301.0055
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Requires the commissioner to adopt network adequacy standards that ensure access to “a full range” of physician providers.
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2009
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V.T.C.A., Insurance Code § 1305.302
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"(b) The network shall ensure that the network's provider panel includes an adequate number of treating doctors and specialists, who must be available and accessible to employees 24 hours a day, seven days a week, within the network's service area. A network must include sufficient numbers and types of health care providers to ensure choice, access, and quality of care to injured employees. An adequate number of the treating doctors and specialists must have admitting privileges at one or more network hospitals located within the network's service area to ensure that any necessary hospital admissions are made.
(g) Each network shall provide that network services are sufficiently accessible and available as necessary to ensure that the distance from any point in the network's service area to a point of service by a treating doctor or general hospital is not greater than 30 miles in nonrural areas and 60 miles in rural areas and that the distance from any point in the network's service area to a point of service by a specialist or specialty hospital is not greater than 75 miles in nonrural areas and 75 miles in rural areas. For portions of the service area in which the network identifies noncompliance with this subsection, the network must file an access plan with the department in accordance with Subsection (h)."
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2005 |
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V.T.C.A., Insurance Code § 845.152
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"As a requirement of participation in a state contract awarded under Section 845.151, the system must satisfactorily address the qualifications for arranging to provide health care services to beneficiaries of certain governmental health care programs as delineated in the contractor's request for proposal, including:
(1) readiness reviews and adequacy of credentialing, medical management, quality assurance, claims payment, information management, provider and patient education, and complaint and grievance procedures; and
(2) adequacy of physician and provider networks, including factors such as diversity, geographic accessibility, inclusion of physicians and other providers that have furnished a significant amount of Medicaid or charity care to beneficiaries, and tertiary and subspecialty services."
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2003 |
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V.T.C.A., Insurance Code § 1305.053
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"Each certificate application must include:
(7) a description and a map of the applicant's service area or areas, with key and scale, that identifies each county or part of a county to be served;
(9) a list of all contracted network providers that demonstrates the adequacy of the network to provide comprehensive health care services sufficient to serve the population of injured employees within the service area and maps that demonstrate that the access and availability standards under Subchapter G are met;..."
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2009 |
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Vermont
Vt. Stat. Ann. tit. 33 §1806
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“A qualified health benefit plan shall meet the following minimum prevention, quality, and wellness requirements, [including]…network adequacy…”
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2011
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Washington
Wash. Rev. Code Ann. §43.71.020 and
Wash. Rev. Code Ann. §43.71.070
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Washington established the Washington Health Benefit Exchange in 2012. The law provides that:
“The board shall establish a rating system consistent with section 1311 of P.L. 111-148 of 2010, as amended, for qualified health plans to assist consumers in evaluating plan choices in the exchange. Rating factors established by the board may include, but are not limited to…network adequacy.”
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2011, 2012
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West's RCWA 71.24.0001
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"The department must collaborate with regional support networks or behavioral health organizations and the Washington state institute for public policy to estimate the capacity needs for evaluation and treatment services within each regional service area. Estimated capacity needs shall include consideration of the average occupancy rates needed to provide an adequate network of evaluation and treatment services to ensure access to treatment. A regional service network or behavioral health organization must develop and maintain an adequate plan to provide for evaluation and treatment needs."
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2015 |
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West Virginia
W. Va. Code, § 33-16D-16(10)
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"A carrier may elect to nonrenew any health benefit plan to an eligible employer if, at any time, the carrier determines, by applying the same network criteria which it applies to other small employer health benefit plans, that it no longer has an adequate network of health care providers accessible for that eligible small employer. If the carrier makes a determination that an adequate network does not exist, the carrier has no obligation to obtain additional health care providers to establish an adequate network;"
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2015 |
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District of Columbia
D.C. Code Ann. §31-3171.02 and
D.C. Code Ann. §31-3171.09
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The District of Columbia established the Health Benefit Exchange Authority in 2012. It requires carriers to meet standards for network adequacy to be certified.
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2012
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