CurrentBaylor Scott & White Health PlanPolicy SWHP.PNO.007.P

Availability of Practitioners and Hospitals

Defines network adequacy standards, measurement and remediation processes for availability of primary care, specialty, behavioral health practitioners and hospitals for Baylor Scott & White Health Plan members across all lines of business.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAvailability of Practitioners and Hospitals

Policy CodePolicy SWHP.PNO.007.P

Change TypeAdministrative — no material changes

Effective DateDec 18, 2020

Next Review Date

Key ActionMaintain and measure network adequacy standards and perform geo-mapping analyses to monitor provider and hospital panel availability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90%Members with PCP within 30 miles

90%Members with SCP within 75 miles

90%Members with Hospital within 30 miles

1:1,000PCP ratio

1:2,000SCP ratio

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Network Adequacy Standards

Network adequacy criteria and deficiency remediation

Availability standards and remediation plan requirements when provider or hospital availability does not meet mileage or ratio thresholds.

Network adequacy is measured by provider-to-member ratios, distance availability for members, and panel/opening standards. Analyses are performed using geo-mapping software.

Primary Care Providers (PCPs)

PCP to member ratio is 1:1,000.
At least 90% of members have 1 PCP with an open panel within 30 miles of their site of eligibility.
At least 80% of PCPs have their panel open for new patients.
PCPs with a panel size over 750 members are reviewed quarterly; members age 65+ are counted as two members for panel size monitoring.

Specialty Care Providers (SCPs)

SCP to member ratio is 1:2,000.
At least 90% of members have 1 SCP within 75 miles of their site of eligibility.

High-Volume Specialty Care Providers (HVSCPs)

HVSCP to member ratio target corridor is 1:1,000–3,500 (dependent on High-Volume Specialist Report).
At least 90% of members have 1 HVSCP within 75 miles of their site of eligibility.

High-Impact Specialty Care Providers (HISCPs)

HISCP to member ratio target corridor is 1:1,000–3,500 (dependent on High-Impact Specialist Report).
At least 90% of members have 1 HISCP within 75 miles of their site of eligibility.

Behavioral Healthcare Providers (BHPs)

BHP to member ratio is 1:2,000.
At least 90% of members have 1 BHP within 75 miles of their site of eligibility.

High-Volume Behavioral Health Providers (HVBHPs)

HVBHP to member ratio is 1:3,000.
At least 90% of members have 1 HVBHP within 75 miles of their site of eligibility.

Hospitals

Hospital to member ratio is 1:3,500.
At least 90% of members have 1 Hospital within 30 miles of their site of eligibility.

Remediation when standards not met

If any covered service, practitioner, or hospital is not available within the specified mileage radii, submit a deficiency plan to the SWHP/ICSW/FirstCare Network Issues Committee (NIC) and Quality Improvement Subcommittee (QIS).
For networks governed by the Texas Department of Insurance (TDI), submit the access plan to TDI at least 30 days prior to implementation.
The access/remediation plan must include: description of the geographic area (county/city/zip/mileage or other identifiers); reasons services/providers are not available; a map with key and scale; SWHP/ICSW/FirstCare's interim plan to make services available until a contracted provider is in place; names and addresses of participating practitioners and hospitals and services they will provide; names and addresses/specialties of other practitioners and hospitals available in the area in addition to network participants; a general description of procedures and plans to develop the provider network for future availability; and any other information necessary to assess provider availability to members.

Distance Thresholds and References

Referencesmixed

NCQA: Standard NET 1	National Committee for Quality Assurance (NCQA): Standard NET 1 - Availability of Practitioners
TDI: Rule §11.1607	Texas Department of Insurance (TDI) - Rule §11.1607- Accessibility and Availability Requirements
HHSC: 45 CFR Part 156	Health and Human Services Commission (HHSC) Code of Federal Regulations: Title 45, Subtitle A, Subchapter B, Part 156 (156.230, 156.235)

Distance availability thresholds

PCP distance standardAt least 90% of members have 1 PCP with an open panel within 30 miles of their site of eligibility

SCP/HVSCP/HISCP/BHP distance standardAt least 90% of members have 1 SCP, HVSCP, HISCP, or BHP within 75 miles of their site of eligibility

Hospital distance standardAt least 90% of members have 1 Hospital within 30 miles of their site of eligibility

Network Monitoring & Provider Panel Management

Prior Authorization

Network adequacy monitoring, panel management, and required remediation actions

Maintain and measure network adequacy for all practitioner and hospital types using geo-mapping analyses, monitor open panels and panel sizes, and take remediation actions when standards are not met.

Perform adequacy analyses using geo-mapping software and compare to standards adopted by the Quality Improvement Subcommittee (QIS).
Monitor PCP, SCP, BHP, HVSCP, HISCP, HVBHP, and hospital availability against distance and ratio thresholds (e.g., PCP 1:1,000 and 90% of members with a PCP within 30 miles; SCP 1:2,000 and 90% within 75 miles; hospital 1:3,500 and 90% within 30 miles).
Ensure at least 80% of PCPs have panels open for new patients and review PCPs with panel size >750 quarterly (members 65+ counted as two).
If availability standards are not met, create and submit a remediation plan describing the affected area, reasons, maps, interim access plan, participating and other practitioners/hospitals, and procedures to ensure availability; submit to NIC and QIS and to TDI 30 days prior for TDI-governed networks.

Definitions of Practitioner & Site Types

BHPs — Behavioral Healthcare Practitioners

DefinitionBehavioral Healthcare Practitioners (BHPs) - practitioners in the Scott & White Health Plan (SWHP) or FirstCare Health Plan provider network practicing Psychiatry, Psychology, and Mental Health Counseling.

ScopeIncludes practitioners delivering behavioral health services within the SWHP/FirstCare network.

Related high-volume classSee High-Volume Behavioral Healthcare Practitioners (HVBHPs) for volume-based classification.

HISCPs — High-Impact Specialty Care Practitioners

DefinitionHigh-Impact Specialty Care Practitioners (HISCPs) - practitioners that treat conditions with high mortality and morbidity and require significant resources; at a minimum includes Oncology.

Availability standardAt least 90% of members have 1 HISCP within 75 miles of their site of eligibility.

Ratio guidanceHISCP to member ratio target corridor is 1:1,000–3,500 depending on identified High-Impact specialists.

HVSCPs — High-Volume Specialty Care Practitioners

DefinitionHigh-Volume Specialty Care Practitioners (HVSCPs) - practitioners with greater than 10,000 visits in the prior year and greater than 2% of total visits in a given year; at a minimum includes Obstetrics/Gynecology.

Availability standardAt least 90% of members have 1 HVSCP within 75 miles of their site of eligibility.

Ratio guidanceHVSCP to member ratio objective is within a 1:1,000–3,500 target corridor based on High-Volume Specialist Report.

PCPs — Primary Care Practitioners

DefinitionPrimary Care Practitioners (PCPs) - practitioners in the SWHP/FirstCare provider network practicing Internal Medicine (Community and General), Family Medicine, General Medicine, and Pediatrics, and Non-PCPs/SCPs approved to function as PCPs.

Selection requirementA PCP is not required except for Medicare Advantage with Prescription Drug (MAPD) and Medicaid.

Availability standardAt least 90% of members have 1 PCP with an open panel within 30 miles of their site of eligibility.

SCPs — Specialty Care Practitioners

DefinitionSpecialty Care Practitioners (SCPs) - practitioners within specialties other than Internal Medicine, Family Medicine, General Medicine, and Pediatrics.

Availability standardAt least 90% of members have 1 SCP within 75 miles of their site of eligibility.

Ratio guidanceSCP to member ratio is 1:2,000.

HVBHPs — High-Volume Behavioral Healthcare Practitioners

DefinitionHigh-Volume Behavioral Healthcare Practitioners (HVBHPs) - practitioners in the SWHP/FirstCare provider network practicing Psychiatry, Psychology, and Mental Health Counseling (high visit volume behavioral health providers).

Availability standardAt least 90% of members have 1 HVBHP within 75 miles of their site of eligibility.

Ratio guidanceHVBHP to member ratio is 1:3,000.

Hospitals — Hospitals

DefinitionHospitals - licensed general hospitals that offer services, facilities, and beds for diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; includes clinical laboratory services, diagnostic x-ray services, treatment facilities (such as surgery or obstetrical care), and other definitive medical or surgical treatment of similar extent.

Availability standardAt least 90% of members have 1 Hospital within 30 miles of their site of eligibility.

Ratio guidanceHospital to member ratio is 1:3,500.

Site of Eligibility — residence or work location

DefinitionSite of Eligibility - the residence or work location of a member or prospective member that is located in an area within the SWHP/ICSW service area.

Use in analysesUsed as the point from which distance/mileage availability (e.g., within 30 or 75 miles) is measured in geo-mapping adequacy analyses.

Applies toAll network adequacy availability standards for PCPs, SCPs, BHPs, HVSCPs, HISCPs, HVBHPs, and hospitals.