Health benefit plan network access and adequacy rules (Chapter 47, Title 26-A DCMR)
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Regulations establishing network adequacy, access plans, provider directory, and related requirements for health carriers offering network plans in the District of Columbia, including Medicaid, and excluding limited-scope dental and vision-only network plans.
The applicability date was changed from January 1, 2023 to January 1, 2024.
Section 4701.1 was revised to explicitly include Medicaid plans.
Sections on Network Adequacy reporting, confidentiality of proprietary information, and Access Plan confidentiality procedures were clarified or renumbered.
Network Access and Adequacy Requirements
Network adequacy criteria
Network adequacy and access requirements the carrier must meet or document via waiver:
Provider composition and ratio standards (model-dependent)
- Majority-employed or single contracted medical group model: If a carrier provides a majority of covered professional services through physicians employed by the carrier or a single contracted medical group, specialty-specific provider-to-covered-person ratios apply (examples include Primary Care and many specialties and Behavioral Health/Habilitative standards).
- Non-majority-employed model: If a carrier does not provide a majority of services via employed physicians or a single contracted medical group, apply alternative ratios: Primary Care, Behavioral Health, and Habilitative services 1:2,000; many listed specialties 1:5,000; carriers must contract with at least 30% of providers on the Commissioner-provided specialty list.
Access to non-participating providers when network insufficient
When a carrier lacks participating providers able to provide medically necessary covered benefits, carriers must permit access to non-participating providers at in-network benefit levels under specified standards, and provide written procedures for requests and documentation retention.
Provider Ratios, Thresholds, and Codes
| No procedure or diagnosis codes are specified in this definitions section. |
Carrier Reporting, Appointments, and Continuity Rules
Network Adequacy reporting and waiver
Submit an annual Network Adequacy Report to the Commissioner by September 1 each year for plans sold, issued, or renewed on or after January 1 of the subsequent year. If unable to demonstrate compliance, submit a Request for Waiver Form; you may also request that portions of the Network Adequacy Report or Request for Waiver be treated as confidential. The Commissioner may request additional information to evaluate waiver requests, including lists of providers you attempted to contract with, contact attempts and reasons for refusal, contract modifications offered, and steps you will take to improve the network. Carriers that provide a majority of covered professional services through employed physicians or a single contracted medical group must include relevant information as requested.
- Annual submission deadline: September 1 (for plans sold/issued/renewed on/after Jan 1 next year).
- If noncompliant, file a Request for Waiver Form with supporting documentation as described by the Commissioner.
- You may request confidential treatment for portions of filings; Commissioner may request additional evidence of contracting efforts (provider lists, contact history, refusal reasons, contract modifications, remediation steps).
Provider appointment assistance and limitations
Maintain and publicize a toll-free call center and ensure a company representative provides contact information for qualified in-network providers who have appointments available within the required timeframes. Representatives may assist with identifying providers with available appointments but cannot force a specific provider to give an appointment or guarantee an appointment with a previously seen provider.
- Maintain and publicize a toll-free number to a call center that assists covered persons in identifying providers with available appointments.
- Representative will give provider contact information; scheduling may need to be completed by the covered person.
- Representative cannot compel a provider to offer an appointment or guarantee past-provider availability.
Continuity of care and authorized representation
Recognize and apply the definitions for 'Active course of treatment' and 'Authorized representative' when handling continuity-of-care situations and determining who may act on behalf of a covered person. An active course includes life‑threatening or serious acute conditions, certain stages of pregnancy, or treatment where the treating provider attests that discontinuation would worsen the condition. An authorized representative may be a person with written consent, a person authorized by law, or the treating health care professional when the covered person or family member cannot provide consent.
- Active course of treatment covers ongoing care for life‑threatening conditions, serious acute conditions requiring complex ongoing care (e.g., chemotherapy), second/third trimester through postpartum, or treatment the provider attests would worsen if discontinued.
- Authorized representative: person with express written consent, person authorized by law, or treating health care professional when patient/family cannot consent.
Emergency services screening, stabilization, and transfer
Follow the definitions and expectations for emergency care: screen for an 'Emergency medical condition' using the prudent-layperson standard and provide 'Emergency services'—a medical or mental health screening exam and any further examination/treatment within the emergency department's capabilities—to evaluate and stabilize the patient. Transfers and stabilization decisions must adhere to the stated definitions of 'to stabilize' and transfer protocols.
- Emergency medical condition: manifests with acute symptoms that a prudent layperson would expect could result in serious jeopardy, significant impairment, or, for pregnant women in labor, inadequate time to transfer or transfer posing threat.
- Emergency services: screening exam and any further exam/treatment within the emergency department's capabilities to evaluate and stabilize the patient.
- Stabilization/transfer must ensure no material deterioration is likely to result from transfer and follow the 'to stabilize' definition.
Defined Terms
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