To ensure a health insurance plan’s adequacy, accessibility, transparency, and quality of health care services offered, the Commissioner requires health carriers to annually submit a Network Adequacy Report and, in some instances, an Access Plan to demonstrate compliance with the Rule (26-A DCMR Chapter 47). This is applicable to all health plans sold, issued, or renewed in the District on or after January 1, 2024, including Medicaid.
Submitting a Network Adequacy Report
- A health carrier (“Carrier”) must file a Network Adequacy Report (“Report”) annually on or by September 1, 2026 utilizing the reporting year Network Adequacy checklist sent by email.
- The Report must include information demonstrating compliance with § 4702.5 or § 4702.6, depending on the Carrier. The Report is to reflect the Carrier’s plans sold, issued, or renewed on or after January 1, 2027.
- If a Carrier has difficulty in demonstrating compliance, a Carrier may file a Request for Waiver Form. The Commissioner may request additional information per § 4702.2.
- A Carrier must reflect all other requirements specified in the Rule (e.g., hold harmless provisions (§ 4704.3), provider contract requirements (§§ 4704.2 and 4704.5), provider directories (§ 4705)).
- There is an exception for group health plans: Any adjustments to form filings for group health plans may be submitted to DISB no later than two months prior to their effective date (i.e., a health plan renewing for a large group on February 1, 2027, must file its Report with DISB no later than December 1, 2026).
Additional Requirements to Meet Network Adequacy
- A Carrier must publicize a toll-free number to a call center to provide assistance with identifying providers who have appointments available within the appropriate waiting time standards (§§ 4702.5(d) and 4702.6(d)) and provide a summary of call center activities.
- A Carrier must document and retain a list of all requests to access covered benefits from non-participating providers (§ 4702.8(d)).
- To ensure online provider directory accuracy, a Carrier must maintain a log of reported provider directory inaccuracies (§ 4705.5)
Physican Accessibility
- Pursuant to §§ 4702.5(c) and 4702.6(c), the Commissioner shall release a list of qualified providers with an office located within half a mile of a Metrorail stop.
- The list is located at the following: 2026 DC Licensed Physicians.
- The point of contact will receive access to the list after this year’s reporting reminder is sent out by email.
When to Submit an Access Plan
- A Carrier must file an Access Plan if there is a new or amended network plan (§ 4703.1) and/or a material change to its network plan (§ 4703.2), in addition to a Report.
- Consult § 4703.2 to determine whether there has been a material change to a Carrier’s network plan.
- Consult § 4703.3 for the necessary information to include in the Access Plan.
Contact
If you have any questions or concerns regarding this notice, please contact Pratima Lele,Market Compliance Examinations Manager, at [email protected] or Howard Liebers, Supervisory Insurance Examiner, at [email protected].
