1. (a)

   1. (1) A health carrier providing a health benefit plan shall maintain a network that is sufficient in numbers and types of providers to ensure that all healthcare services to covered persons will be accessible without unreasonable delay.

   2. (2) Sufficiency may be established by reference to any reasonable criteria used by the health carrier and approved by the Insurance Commissioner, including, but not limited to:

      1. (A) Provider-to-covered person ratios by specialty;
      2. (B) Primary care professional-to-covered person ratios;
      3. (C) Typical referral patterns;
      4. (D) Provider’s hospital admitting privileges;
      5. (E) Geographic accessibility;
      6. (F) Waiting times for appointments with participating providers;
      7. (G) Hours of operation; and
      8. (H) The volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

2. (b) Every health carrier shall strive to meet the following minimum guidelines related to geographic accessibility through geographical access data or other information in a format and with content specified by the State Insurance Department set forth in subsection (f) of this section, for the plan year:

   1. (1) In the case of emergency services, a covered person will have access to emergency services twenty-four-hours-per-day, seven-days-per-week within a thirty-mile radius, or within thirty-minute travel time, whichever is shorter, between the location of the emergency services and the residence of the covered person;
   2. (2) In the case of a primary care professional, a covered person will have access to at least one (1) primary care professional within a thirty-mile radius, or within thirty-minute travel time, whichever is shorter, between the location of the primary care professional and the residence of the covered person;
   3. (3) In the case of a specialty care professional, a covered person will have access to covered specialty care services within a sixty-mile radius, or within sixty-minute travel time, whichever is shorter, between the location of the specialty care professional and the residence of the covered person;
   4. (4) For qualified health plans participating in the Affordable Care Act-approved marketplace, in the case of essential community providers, a covered person will have access to at least one (1) essential community provider within a thirty-mile radius, or within thirty-minute travel time, whichever is shorter, between the location of the essential community provider and the residence of the covered person; and

   5. (5)

      1. (A) The health carrier shall provide accurate provider practice addresses to the department.
      2. (B) Practice locations should be current at the time of data submission to the department.
3. (c) In the event that a health carrier has an insufficient number or type of participating providers to provide a covered benefit, the health carrier shall ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit were obtained from a participating provider.
4. (d) In determining whether a health carrier has complied with the requirements in this section, the commissioner shall give due consideration to the relative availability of healthcare providers in the service area under consideration.

5. (e)

   1. (1) A health carrier shall monitor, on an ongoing basis, the ability of its participating providers to furnish all contracted benefits to covered persons.

   2. (2) A health carrier shall reasonably monitor:

      1. (A) Provider-to-covered person ratios by specialty;
      2. (B) Primary care professional-to-covered person ratios;
      3. (C) Typical referral patterns;
      4. (D) Provider’s hospital admitting privileges;
      5. (E) Geographic accessibility;
      6. (F) Waiting times for appointments with participating providers;
      7. (G) General hours of operation, including part-time or full-time status and weekend and after-hours availability; and
      8. (H) The volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

6. (f)

   1. (1) Geographical access data must be submitted for each of the categories of care referenced in subdivisions (b)(1) – (4) of this section.
   2. (2) Data specifications will be published by the department and available online as SERFF Network Adequacy Data Submission Instructions updated for each plan year as necessary and appropriate.
   3. (3) A health carrier shall strive to meet a compliance percentage of eighty percent (80%) for each of the categories of care referenced in subdivisions (b)(1) – (4) of this section.
   4. (4) Provider data must indicate which providers are accepting new patients.

   5. (5) The following are special requirements for each category of care:

      1. (A) Health carriers must provide geographical access maps for primary care professionals that include each:

7. (i) General/family practitioner;

   1. (ii) Internal medicine provider; and

      1. (iii) Family practitioner/pediatrician;

      2. (B) Health carriers must provide geographical access maps for hospitals and specialty care professionals according to the following categories:

         1. (i) Hospitals by Arkansas hospital licensure type;
         2. (ii) Home health agencies;
         3. (iii) Skilled nursing facilities; and
         4. (iv) All specialty care categories and sub-specialty categories covered under the health benefit plan;

      3. (C) Health carriers must provide geographical access maps for mental health, behavioral health, and substance use disorder providers categorized between:

         1. (i) Psychiatric and state-licensed clinical psychologists;
         2. (ii) Substance use disorder providers; and
         3. (iii) Other mental health, behavioral health, and substance use disorder providers with additional documentation describing the provider and facility types included within the other category; and
      4. (D) Health carriers seeking certification through the Affordable Care Act-approved marketplace must provide geographical access data for essential community providers with the providers grouped as set forth in the Affordable Care Act and pursuant to Centers for Medicare & Medicaid Services guidelines.

8. (g) Performance metrics.

   1. (1) Nonaccredited health carriers will be required to submit metrics demonstrating performance for each of the above standards for each county in the service area and overall service area.

   2. (2)

      1. (A) Accredited health carriers will be required to submit the following metrics for reporting purposes.

      2. (B) These include:

         1. (i) The number of members and percentage of total members meeting the geographical requirements under subsection (b) of this section; and
         2. (ii) The average distance to first, second, and third closest provider for each provider type.

      3. (C)

         1. (i) These figures should be provided overall (entire state) for each category as well as stratified by county for each category.
         2. (ii) For example, the percent of enrolled members that are within thirty (30) minutes or thirty (30) miles of a general/family practitioner will be submitted with percentages overall and for each county.
         3. (iii) The average distance to the first, second, and third closest provider will be submitted overall and for each county.
      4. (D) Health carriers who do not yet have enrollees in the State of Arkansas must attest to not currently having enrollees in Arkansas and provide geographical access data calculated using suitable sampling of United States Census data.

9. (h) Essential community providers.

   1. (1) Health carriers issuing qualified health plans are required to meet all federal requirements for inclusion of essential community providers in the plan network.
   2. (2) Qualifying essential community providers include providers described in Section 340B of the Public Health Service Act and Section 1927(c)(1)(D)(i)(IV) of the Social Security Act.

   3. (3) In addition, the following state guidelines must be met regarding essential community providers:

      1. (A) Each health carrier issuing qualified health plans will be required to meet conditions of the Heath Care Independence Program 1115 Waiver and offer at least one (1) qualified health plan that has at least one (1) federally qualified health center or rural health center in each service area of the plan network;
      2. (B) Each health carrier issuing qualified health plans must submit a list of school-based providers included in the plan network; and

      3. (C) Each health carrier issuing qualified health plans must offer a contract to at least one (1) school-based provider in each county in the service area, where a school-based provider is identifiable and available and meets issuer certification and credentialing standards.

         1. (i) Access plans.
   4. (1) A health carrier shall file with the commissioner an access plan meeting the requirements of subdivisions (i)(4)(A) – (L) of this section for health benefit plans issued or renewed in this state on or after January 1, 2023.
   5. (2) The health carrier shall make the access plans, absent proprietary information, available to its insureds.
   6. (3) The health carrier shall prepare an access plan prior to offering a new health benefit plan, and shall update an existing access plan whenever it makes any material change to an existing health benefit plan such as the loss of a material provider such as a hospital or multi-specialty clinic.

   7. (4) The access plan shall describe or contain at least the following:

      1. (A) The health carrier’s network;
      2. (B) The health carrier’s procedures for making referrals within and outside its network and for notifying enrollees and potential enrollees regarding availability of network and out-of-network providers;
      3. (C) The health carrier’s process for monitoring and assuring on an ongoing basis the sufficiency of the network to meet the healthcare needs of populations that enroll in its health benefit plans;

      4. (D) The health carrier’s efforts to address the needs of covered persons with:

         1. (i) Limited English proficiency and illiteracy;
         2. (ii) Diverse cultural and ethnic backgrounds; and
         3. (iii) Physical and mental disabilities;
      5. (E) The health carrier’s methods for assessing the healthcare needs of covered persons;

      6. (F) The health carrier’s method of informing covered persons of the plan's services and features, including:

         1. (i) Cost sharing;
         2. (ii) The plan's grievance procedures;
         3. (iii) Its process for choosing and changing providers; and
         4. (iv) Its procedures for providing and approving emergency and specialty care;
      7. (G) The health carrier’s method for assessing consumer satisfaction;
      8. (H) The health carrier’s method for using assessments of enrollee complaints and satisfaction to improve carrier performance;
      9. (I) The health carrier’s system for ensuring the coordination and continuity of care for covered persons referred to specialty providers, for covered persons using ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning;
      10. (J) The health carrier’s process for enabling covered persons to change primary care professionals;

      11. (K)

          1. (i) The health carrier’s proposed plan for providing continuity of care in the event of contract termination between the health carrier and any of its participating providers, or in the event of the health carrier’s insolvency or other inability to continue operations.
          2. (ii) The description shall explain how covered persons will be notified of the contract termination, or the health carrier's insolvency or other cessation of operations, and transferred to other providers in a timely manner; and
      12. (L) Any other information required by the commissioner to determine compliance with the provisions of this part.

10. (j) Provider directories.

    1. (1) A health carrier shall make a provider directory available for online publication by the commissioner and shall also make its provider directory accessible:

       1. (A) By a link to the health carrier’s website; and
       2. (B) To potential enrollees in hardcopy upon request.
    2. (2) The provider directory shall identify providers who are currently accepting new patients.
    3. (3) Health carriers shall update any changes to the provider directory within fourteen (14) days of that change becoming effective.

    4. (4)

       1. (A) If the provider directory must be taken offline for any reason for a period to exceed forty-eight (48) hours, that carrier shall notify the department at least two (2) weeks in advance of the provider directory going offline, or as soon as practically known.

       2. (B) In the department notification, health carriers shall state:

          1. (i) The reason for online unavailability;
          2. (ii) What steps are being taken to get the information back online; and
          3. (iii) The expected online relaunch date.
    5. (5) Online provider directories must be available in Spanish.
    6. (6) The directory search must include the ability to filter by each category of ECP.
    7. (7) The directory search must include an indication of hours of operation, including part-time or full-time as well as after-hours availability as reported by providers.
    8. (8) Providers who participate in the patient-centered medical home program must be indicated in the provider directory.

11. (k) If a health carrier has accreditation that includes an audit of the health carrier's network adequacy, the commissioner will accept that accreditation in lieu of the health carrier demonstrating it has complied with the requirements under subsections (a) – (h) of this section, if the following conditions are met:

    1. (1) A certificate of accreditation must be submitted by the certified accrediting entity that is recognized pursuant to 45 C.F.R. § 156.275, or any other certified entity as recognized by the department;
    2. (2) The certified accrediting entity has submitted information showing that its audit includes a review of all reasonable and/or necessary requirements of state and federal law;
    3. (3) The health carrier agrees to provide to the department any and all material and information submitted to the certified accrediting entity upon the commissioner’s request;
    4. (4) The accredited health carrier has submitted annual geographical access data and performance metrics as required in this section for reporting purposes only;
    5. (5) Nothing in the above conditions shall supersede the federal accreditation requirements of qualified health plans as described in 45 C.F.R. § 156.275; and

    6. (6) The commissioner reserves the right to reverify compliance of network adequacy as a part of any quarterly audit or request for certification of a qualified health plan.

       1. (l) The commissioner will also accept an accreditation of a health carrier’s access plan by a certified accrediting entity that a health carrier has an access plan meeting the requirements of subdivisions (i)(4)(A) – (L) of this section, although such plan must be filed with the commissioner.

          1. (m)
    7. (1) All time and distance guidelines as set forth in this part are minimum standards only.
    8. (2) The commissioner, pursuant to his or her discretion, may publish more detailed and specific network adequacy time/distance standards, as well as guidelines regarding the use of telemedicine to meet network adequacy standards, via SERFF Network Adequacy Data Submission Instructions, and/or annual bulletin for setting forth certification requirements for Affordable Care Act submissions.
    9. (3) Such new standards will become effective for review on January 1 of the following year.

Codification Notes: Section 340B of the Public Health Service Act is codified at 42 U.S.C. § 256b. Section 1927(c)(1)(D)(i)(IV) of the Social Security Act is codified at 42 U.S.C. § 1396r-8(c)(1)(D)(i)(IV). "SERFF" means System for Electronic Rates & Forms Filing. "ECP" means essential community provider.