354.603. Sufficiency of health carrier network, requirements, criteria--access plan filed with the department, when.

MISSOURI STATUTES AND CODES

354.603. Sufficiency of health carrier network, requirements, criteria--access plan filed with the department, when.

Sufficiency of health carrier network, requirements,criteria--access plan filed with the department, when.

354.603. 1. A health carrier shall maintain a network that issufficient in number and types of providers to assure that all services toenrollees shall be accessible without unreasonable delay. In the case ofemergency services, enrollees shall have access twenty-four hours per day,seven days per week. The health carrier's medical director shall beresponsible for the sufficiency and supervision of the health carrier'snetwork. Sufficiency shall be determined by the director in accordance withthe requirements of this section and by reference to any reasonable criteria,including but not limited to provider-enrollee ratios by specialty, primarycare provider-enrollee ratios, geographic accessibility, reasonable distanceaccessibility criteria for pharmacy and other services, waiting times forappointments with participating providers, hours of operation, and the volumeof technological and specialty services available to serve the needs ofenrollees requiring technologically advanced or specialty care.

(1) In any case where the health carrier has an insufficient number ortype of participating providers to provide a covered benefit, the healthcarrier shall ensure that the enrollee obtains the covered benefit at nogreater cost than if the benefit was obtained from a participating provider,or shall make other arrangements acceptable to the director.

(2) The health carrier shall establish and maintain adequatearrangements to ensure reasonable proximity of participating providers,including local pharmacists, to the business or personal residence ofenrollees. In determining whether a health carrier has complied with thisprovision, the director shall give due consideration to the relativeavailability of health care providers in the service area under, especiallyrural areas, consideration.

(3) A health carrier shall monitor, on an ongoing basis, the ability,clinical capacity, and legal authority of its providers to furnish allcontracted benefits to enrollees. The provisions of this subdivision shallnot be construed to require any health care provider to submit copies of suchhealth care provider's income tax returns to a health carrier. A healthcarrier may require a health care provider to obtain audited financialstatements if such health care provider received ten percent or more of thetotal medical expenditures made by the health carrier.

(4) A health carrier shall make its entire network available to allenrollees unless a contract holder has agreed in writing to a different orreduced network.

2. A health carrier shall file with the director, in a manner and formdefined by rule of the department of insurance, financial institutions andprofessional registration, an access plan meeting the requirements of sections354.600 to 354.636 for each of the managed care plans that the health carrieroffers in this state. The health carrier may request the director to deemsections of the access plan as proprietary or competitive information thatshall not be made public. For the purposes of this section, information isproprietary or competitive if revealing the information will cause the healthcarrier's competitors to obtain valuable business information. The healthcarrier shall provide such plans, absent any information deemed by thedirector to be proprietary, to any interested party upon request. The healthcarrier shall prepare an access plan prior to offering a new managed careplan, and shall update an existing access plan whenever it makes any change asdefined by the director to an existing managed care plan. The director shallapprove or disapprove the access plan, or any subsequent alterations to theaccess plan, within sixty days of filing. The access plan shall describe orcontain at a minimum the following:

(1) The health carrier's network;

(2) The health carrier's procedures for making referrals within andoutside its network;

(3) The health carrier's process for monitoring and assuring on anongoing basis the sufficiency of the network to meet the health care needs ofenrollees of the managed care plan;

(4) The health carrier's methods for assessing the health care needs ofenrollees and their satisfaction with services;

(5) The health carrier's method of informing enrollees of the plan'sservices and features, including but not limited to the plan's grievanceprocedures, its process for choosing and changing providers, and itsprocedures for providing and approving emergency and specialty care;

(6) The health carrier's system for ensuring the coordination andcontinuity of care for enrollees referred to specialty physicians, forenrollees using ancillary services, including social services and othercommunity resources, and for ensuring appropriate discharge planning;

(7) The health carrier's process for enabling enrollees to changeprimary care professionals;

(8) The health carrier's proposed plan for providing continuity of carein the event of contract termination between the health carrier and any of itsparticipating providers, in the event of a reduction in service area or in theevent of the health carrier's insolvency or other inability to continueoperations. The description shall explain how enrollees shall be notified ofthe contract termination, reduction in service area or the health carrier'sinsolvency or other modification or cessation of operations, and transferredto other health care professionals in a timely manner; and

(9) Any other information required by the director to determinecompliance with the provisions of sections 354.600 to 354.636.

3. In reviewing an access plan filed pursuant to subsection 2 of thissection, the director shall deem a managed care plan's network to be adequateif it meets one or more of the following criteria:

(1) The managed care plan is a Medicare + Choice coordinated care planoffered by the health carrier pursuant to a contract with the federal Centersfor Medicare and Medicaid Services;

(2) The managed care plan is being offered by a health carrier that hasbeen accredited by the National Committee for Quality Assurance at a level of"accredited" or better, and such accreditation is in effect at the time theaccess plan is filed;

(3) The managed care plan's network has been accredited by the JointCommission on the Accreditation of Health Organizations for Network Adequacy,and such accreditation is in effect at the time the access plan is filed. Ifthe accreditation applies to only a portion of the managed care plan'snetwork, only the accredited portion will be deemed adequate; or

(4) The managed care plan is being offered by a health carrier that hasbeen accredited by the Utilization Review Accreditation Commission at a levelof "accredited" or better, and such accreditation is in effect at the time theaccess plan is filed.