1. (a)

   1. (1) For standalone dental plans offered through the Affordable Care Act-approved marketplace or where a standalone dental plan is offered outside of the Affordable Care Act-approved marketplace for the purpose of providing the essential health benefit category of pediatric oral benefits, all such standalone dental plans must ensure that all covered services to enrollees will be accessible in a timely manner appropriate for the enrollee's conditions.
   2. (2) Dental networks for oral services must be sufficient for the enrollee population in the service area based on potential utilization.

   3. (3) Determination of whether a standalone dental carrier’s network is sufficient will be based on reasonable criteria used by the standalone dental carrier, including, but not limited to:

      1. (A) Provider-to-covered ratios by general dentist;
      2. (B) Typical referral patterns;
      3. (C) Geographic accessibility;
      4. (D) Waiting times for appointments with participating providers;
      5. (E) Hours of operation; and
      6. (F) The volume of technologically advanced or specialty care.

   4. (4) Standalone dental carriers shall strive to meet the following guidelines through geographical access data or other information in a format and with content specified by the State Insurance Department, set forth in 23 CAR § 137-104(f), for the plan year:

      1. (A) In the case of a nonspecialist oral care provider, a covered person will have access to at least one (1) dentist within a thirty-mile radius, or within thirty-minute travel time, whichever is shorter, between the location of the dentist and the residence of the covered person;
      2. (B) In the case of a specialist oral care provider, a covered person will have access to at least one (1) specialist dentist 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;
      3. (C) If an essential community provider that provides oral health services is located 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 a covered person, a standalone dental carrier must make reasonably best efforts to provide the covered person access to that essential community provider;
      4. (D)

2. (i) The health carrier shall provide accurate and up-to-date provider practicing addresses to the department at the time of data submission.

   1. (ii) For purposes of satisfying the requirements of subdivisions (a)(4)(A) – (C) of this section, a standalone dental carrier may submit an accreditation that such requirements are met by a certified accredited entity abiding by the same conditions as described in 23 CAR § 137-104(k); and

      1. (E) Health carriers shall verify practice addresses at least once every ninety (90) days in accordance to requirements of federal law, and the practice addresses reported to the department for plan review should reflect the latest round of such verification.

3. (b)

   1. (1) Standalone dental carriers applying to the Insurance Commissioner to participate in the Affordable Care Act-approved marketplace or offer a standalone dental plan outside of the Affordable Care Act-approved marketplace for the purpose of providing the essential health benefit category of pediatric oral benefits are required to submit metrics demonstrating performance for each of the standards above for each county in the service area and overall service area.
   2. (2) These figures should be provided overall (entire state) for each category as well as stratified by county for each category.
   3. (3) For example, the percent of enrolled members that are within thirty (30) minutes or thirty (30) miles of a general dentist will be submitted with percentages overall and for each county.
   4. (4) The average distance to the first, second, and third closest provider will be submitted overall and for each county.

   5. (5) These include:

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

      3. (C) Standalone dental 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 suitable sampling of United States Census data.

         1. (c) In the event that a standalone dental 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, or shall make other arrangements acceptable to the commissioner that shall include reasonable criteria utilized by the carrier, including, but not limited to:
   6. (1) Provider-to-covered person ratios by dental specialty;
   7. (2) General dentist-to-covered person ratios;
   8. (3) Typical referral patterns;
   9. (4) Geographic accessibility;
   10. (5) Waiting times for appointments with participating providers; and

   11. (6) General hours of operation, including part-time or full-time status and weekend and after-hours availability.

       1. (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 dental providers in the service area under consideration.
4. (e) A standalone dental carrier shall monitor, on an ongoing basis, the ability of its participating providers to furnish all contracted benefits to covered persons.

5. (f) Access plans.

   1. (1) A standalone dental carrier shall file with the commissioner an access plan meeting the requirements of subdivisions (f)(4)(A) – (L) of this section for standalone dental plans issued or renewed in this state on or after January 1, 2015.
   2. (2) The standalone dental carrier shall make the access plans, absent proprietary information, available to its insureds.

   3. (3) The standalone dental carrier shall:

      1. (A) Prepare an access plan prior to offering a new standalone dental plan; and
      2. (B) Update an existing access plan whenever it makes any material change to an existing standalone dental plan, such as the loss of a material provider.

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

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

      4. (D) The standalone dental 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 standalone dental carrier's methods for assessing the healthcare needs of covered persons;
      6. (F) The standalone dental carrier's method of informing covered persons of the plan's services and features, including cost sharing, the plan's grievance procedures, its process for choosing and changing providers, and its procedures for providing and approving emergency and specialty care;
      7. (G) The standalone dental carrier's method for assessing consumer satisfaction;
      8. (H) The standalone dental carrier's method for using assessments of enrollee complaints and satisfaction to improve carrier performance;
      9. (I) The standalone dental 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 standalone dental carrier's process for enabling covered persons to change non-specialist dental providers;

      11. (K)

          1. (i) The standalone dental carrier’s proposed plan for providing continuity of care in the event of:
6. (a) (a) Contract termination between the health carrier and any of its participating providers; or

7. (b) (b) The health carrier’s insolvency or other inability to continue operations.

   1. (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

      1. (L) Any other information required by the commissioner to determine compliance with the provisions of this part.

8. (g) Provider directories.

   1. (1) A standalone dental 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 standalone dental 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) Standalone dental 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, standalone dental 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 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.

Codification Notes: “ECP” means essential community provider.