The Department of Insurance, Securities and Banking (DISB) published the network adequacy final rulemaking in the D.C. Register on February 17, 2023 (Vol 70/7; N129228; 26-A4700). This notice serves as sub-regulatory guidance on implementation of the rule, specifically clarification of carrier reporting elements and deadlines, and the Commissioner’s release of health care provider locations.
Key Implementation Dates & Deadlines
- Pursuant to section 4709, the provisions of this rulemaking apply to plans sold, issued, or renewed on or after January 1, 2024.
- Pursuant to sections 4702.2 and 4703.1, the first Network Adequacy Report (“Report”) and the first Access Plan are each due September 1, 2023 and are to reflect those plans to be sold, issued, or renewed on or after January 1, 2024.
- It is the intent to have a Report be filed annually, whereas subsequent Access Plans are only filed in the event there is a new or amended network plan (4703.1) and/or a material change to its network plan (4703.2).
- The call center activities regarding Appointment Wait Times at 4702.5(d) and 4702.6(d) shall begin operations no later than January 1, 2024.
- Any other requirements specified in the rule (for example hold harmless provisions at 4704.3 & provider contract requirements at 4704.21) must also be reflected in plans and plan filings no later than September 1, 2023. However, the Department will offer an exception for group health plans: since group health plans may be sold, issued, or renewed on a rolling basis, any adjustments to form filings may be submitted to DISB no later than two months prior to their effective date (for example a health plan that will renew for a large group on February 1, 2024 will need to be filed with DISB no later than December 1, 2023).
- Pursuant to 4702.5(c) and 4702.6(c), the Commissioner hereby releases the list of providers with an office located within half (1/2) of a mile of a Metrorail stop (Appendix A).
Information to be Included in the Network Adequacy Report
- In a Report, a carrier must demonstrate compliance with:
- 4702.5/4702.6, provider-to-covered person ratios & essential community providers; an attestation that the carrier meets the requirement is not sufficient. The Report must indicate the actual ratio as outlined in 4702.4;
- Provide a link to the current provider directory under 4705.1 / 4705.3 & attest to having shared information with the Exchange as required by 4705.2.
- A Request for Waiver Form has been provided with this Notice (Appendix B).
- Delayed Network Adequacy Report Elements:
- For plan year 2024 the call center activities regarding Appointment Wait Times will not have any data to report. As such, those activities will be included in Report beginning with September 1, 2024 for plan year 2025.
- The same is true for the list of requests to access covered benefits from non-participating providers at 4702.8(d), since this will be a new requirement it will not need to be in the Report until the 2024 filing for plan year 2025.
- Finally, the log regarding provider directory inaccuracies under 4705.5 will not need to be in the Report until the 2024 filing for plan year 2025. However, if the carrier uses a resource as described under 4705.6 they may submit supporting documentation with the 2023 Report for the 2024 plan year.
Information to be Included in the Access Plan
- Describe the procedures the carrier has in place pursuant to 4702.7 & 4702.8
- The information referred to in 4703.3; and 4702.2 when applicable in future years.
If you have any questions or concerns regarding this notice, please contact Howard Liebers, Supervisory Insurance Examiner, at [email protected] or Philip Barlow, Associate Commissioner for Insurance, at [email protected].