House of Representatives
Office of Program Research
Health Care & Wellness Committee
This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.
Brief Description: Providing notice about network adequacy to consumers.
Sponsors: Representatives Jinkins, Cody, Tharinger, Robinson and Reeves.
Hearing Date: 1/23/19
Staff: Jim Morishima (786-7191).
Health carriers are required by federal and state law to maintain provider networks that provide enrollees reasonable access to covered services. Under rules adopted by the Insurance Commissioner, health carriers must meet a variety of geographic and timeliness requirements related to network adequacy.
Geographic Network Maps.
Health carriers must submit a separate map to the Insurance Commissioner for each of the following provider types:
Hospital and Emergency Services. The map must show that each enrollee in the service area has access within 30 minutes in urban areas and 60 minutes in rural areas.
Primary Care Providers. The map must show that 80 percent of enrollees in the service area have access within 30 miles in urban areas and 60 miles in rural areas.
Mental Health and Substance Use Disorder Services. For general mental health services, the map must show that 80 percent of enrollees in the service area have access within 30 miles in urban areas and 60 miles in rural areas. For specialty services and substance use disorder services, 80 percent of enrollees must have access to evaluation and treatment, outpatient mental health and substance use disorder treatment, and behavioral therapy.
Pediatric Services. For general services, the map must show that 80 percent of enrollees in the service area have access within 30 miles in urban areas and 60 miles in rural areas. For specialty services, the map must show that 80 percent of enrollees in the service area have access within 60 miles in urban areas and 90 miles in rural areas.
Specialty Services. The map must show that 80 percent of enrollees in the service area have access to an adequate number of providers and facilities in certain specialties.
Therapy Services. The map must show that 80 percent of enrollees have access to chiropractic, rehabilitative, and habilitative service providers within 30 miles in urban areas and 60 miles in rural areas.
Home Health, Hospice, Vision, and Dental. The map must show each provider or facility to which an enrollee has access in the service area for home health, hospice, vision, and pediatric oral coverage.
Pharmacy. The map must show the geographic distribution of covered pharmacy dispensing services within the service area.
Essential Community Providers. The map must show the geographic distribution of essential community providers in the service area by type of provider or facility.
Health carriers are subject to various timeliness requirements for urgent and non-urgent appointments. For example, an enrollee must have access within 48 hours to urgent appointments that do not require prior authorization. For urgent appointments that require prior authorization, an enrollee must have access within 96 hours. For non-urgent primary care appointments, an enrollee must have access within 10 business days. For non-urgent specialty care appointments, an enrollee must have access within 15 days.
Summary of Bill:
Beginning with the 2020 plan year, a health carrier must post information on its web site regarding the carrier's compliance with network adequacy requirements adopted by the Insurance Commissioner for each health plan. The information must include:
The most current geographic network maps submitted to the Insurance Commissioner; and
An estimate of the percentage of time enrollees are able to access covered services within the time limits required by the Insurance Commissioner. The carrier must post a separate estimate for each category of services for which the Insurance Commissioner has specified time limits.
The health carrier must post the information prominently and in an easily understandable format. The Insurance Commissioner must specify a model format for the information and a health carrier is deemed in compliance with formatting requirements if it uses the model format.
The health carrier must update the information at least quarterly. To help consumers make purchasing decisions, the carrier must continue to post the information for at least two years after the end of the applicable plan year.
The Insurance Commissioner may audit the information a health carrier posts.
Fiscal Note: Requested January 21, 2019.
Effective Date: The bill takes effect 90 days after adjournment of the session in which the bill is passed.