1. A. Sufficiency Standards.

   1. (1) Standard and Methodology.

      1. (a) Except as stated in §B of this regulation, each provider panel of a carrier shall have within the geographic area served by the carrier’s network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §A(5) of this regulation for each type of geographic area.

      2. (b) The distances listed in §A(5) of this regulation shall be:

         1. (i) Measured from the enrollee’s place of residence to the practicing location of the provider or facility; and
         2. (ii) Calculated based on road travel distance.

      3. (c) Except for those provider types excluded under §A(3) of this regulation, for each provider type and facility type included on the carrier’s provider panel, the carrier shall:

         1. (i) Map the residences of all Maryland enrollees covered under health benefit plans that use the provider panel;
         2. (ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
         3. (iii) For each zip code, identify the total number of enrollees residing in the zip code and the number of enrollees residing within an area where the applicable distance standard is not met;
         4. (iv) For each zip code, calculate the percentage of enrollees residing within an area where the applicable distance standard is met;
         5. (v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees residing in the zip code;
         6. (vi) For each of the urban, rural, and suburban areas identify the total number of enrollees residing in the geographic area;
         7. (vii) For each of the urban, rural, and suburban areas identify the total number of enrollees residing within an area where the applicable distance standard is not met; and
         8. (viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees residing within an area where the applicable distance standard is met.

      4. (d) Instead of independently calculating the road travel distance for each enrollee as described in §A(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:

         1. (i) Maps the practicing locations of every participating provider within the geographic area served by the carrier’s network or networks;
         2. (ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
         3. (iii) Enables the carrier to accurately identify the information and perform the calculations described in §A(1)(c)(iii)-(viii) of this regulation.

      5. (e) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:

         1. (i) Geo-access maps for each provider type and facility type except for those excluded under §A(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence outside the applicable distance standard;
         2. (ii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide adolescent services; and
         3. (iii) For any facility types listed in §A(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
      6. (f) A carrier shall report each number and percentage described in §A(1)(c)(iii)—(viii) of this regulation as part of the annual access plan filing.
   2. (2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §A(5) of this regulation.

   3. (3) The travel distance standards listed in §A(5) of this regulation do not apply to the following:

      1. (a) Home health care;
      2. (b) Durable medical equipment;
      3. (c) Heart transplant programs;
      4. (d) Heart or lung transplant programs;
      5. (e) Kidney transplant programs;
      6. (f) Liver transplant programs;
      7. (g) Lung transplant programs; or
      8. (h) Pancreas transplant programs.
   4. (4) All other providers and facility types included on the carrier’s provider panel but not listed in the chart in §A(5) of this regulation, including physical therapists and licensed dietitian-nutritionist, shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.

   5. (5) Chart of Travel Distance Standards.

      	Urban Area Maximum Distance (miles)	Suburban Area Maximum Distance (miles)	Rural Area Maximum Distance (miles)
      Provider Type:
      Addiction Medicine	10	25	60
      Allergy and Immunology	15	30	75
      Applied Behavioral Analyst	15	30	60
      Cardiovascular Disease	10	20	60
      Chiropractic	15	30	75
      Dermatology	10	30	60
      Endocrinology	15	40	90
      ENT/Otolaryngology	15	30	75
      Gastroenterology	10	30	60
      General Surgery	10	20	60
      Gynecology, OB/GYN Nurse-Midwifery/Certified Midwifery	5	10	30
      Licensed Clinical Social Worker	10	25	60
      Licensed Professional Counselor	10	25	60
      Nephrology	15	25	75
      Neurology	10	30	60
      Oncology-Medical and Surgical	10	20	60
      Oncology-Radiation/Radiation Oncology	15	40	90
      Ophthalmology	10	20	60
      Pediatrics-Routine/Primary Care	5	10	30
      Physiatry, Rehabilitative Medicine	15	30	75
      Plastic Surgery	15	40	90
      Podiatry	10	30	60
      Primary Care (non-pediatric)	5	10	30
      Psychiatry-Adolescent and Child, Outpatient	10	25	60
      Psychiatry-Geriatric, Outpatient	10	25	60
      Psychiatry-Outpatient	10	25	60
      Psychology	10	25	60
      Pulmonology	10	30	60
      Rheumatology	15	40	90
      Urology	10	30	60
      All Other licensed or certified providers under contract with a carrier not listed	15	40	90
      Facility Type:
      Acute Inpatient Hospitals	10	30	60
      Ambulatory Infusion Therapy Centers	10	30	60
      Critical Care Services — Intensive Care Units	10	30	100
      Diagnostic Radiology	10	30	60
      Inpatient Psychiatric Facility	15	45	75
      Opioid Treatment Services Provider	15	25	60
      Outpatient Dialysis	10	30	50
      Outpatient Mental Health Clinic	15	30	60
      Outpatient Substance Use Disorder Facility	15	30	60
      Pharmacy	5	10	30
      Residential Crisis Services	10	30	60
      Skilled Nursing Facilities	10	30	60
      Substance Use Disorder Residential Treatment Facility	10	25	60
      Surgical Services (Outpatient or Ambulatory Surgical Center)	10	30	60
      All other licensed or certified facilities under contract with a carrier not listed	15	40	90

2. B. Group Model HMO Plans Sufficiency Standards.

   1. (1) Standard and Methodology.

      1. (a) Each group model HMO’s health benefit plan’s provider panel shall have within the geographic area served by the group model HMO’s network or networks, sufficient primary care providers, specialty providers, mental health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §B(5) of this regulation for each type geographic area.

      2. (b) The distances listed in §B(5) of this regulation shall be:

         1. (i) Measured from the enrollee’s place of residence or, at the option of the carrier, place of employment from which the enrollee gains eligibility for participation in the group model HMO’s health benefit plan to the practicing location of the provider or facility; and
         2. (ii) Calculated based on road travel distance.

      3. (c) Except for those provider types excluded §B(3) of this regulation, for each provider type and facility type included on the group model HMO’s provider panel, the carrier shall:

         1. (i) Map the residences or places of employment of all Maryland enrollees covered under health benefit plans that use the provider panel;
         2. (ii) Calculate the road travel distance for each enrollee to the provider or facility with the closest practicing location;
         3. (iii) For each zip code identify the total number of enrollees with a residence or place of employment in the zip code and the number of enrollees with a residence or a place of employment within an area where the applicable distance standard is not met;
         4. (iv) For each zip code calculate the percentage of enrollees with a residence or place of employment within an area where the applicable distance standard is met;
         5. (v) For each zip code that includes enrollees for whom the applicable travel distance standard is not met, calculate the average distance to the closest provider or facility for all enrollees with a residence or place of employment within the zip code;
         6. (vi) For each of the urban, rural, and suburban areas identify the total number of enrollees with a residence or place of employment in the geographic area;
         7. (vii) For each of the urban, rural, and suburban areas identify the number of enrollees with a residence or place of employment within an area where the applicable distance standard is not met; and
         8. (viii) For each of the urban, rural, and suburban areas identify the percentage of enrollees with a residence or place of employment within an area where the applicable distance standard is met.

      4. (d) Instead of independently calculating the road travel distance for each enrollee as described in §B(1)(c)(i) and (ii) of this regulation, a carrier may use a methodology that:

         1. (i) Maps the practicing locations of every participating provider within the geographic area served by the group model HMO’s network or networks;
         2. (ii) Identifies any geographic areas within each Maryland zip code that fall outside of the applicable distance standard based on road travel distance from the provider locations; and
         3. (iii) Enables the carrier to accurately identify the information and perform the calculations described in §B(1)(c)(iii)—(viii) of this regulation.
      5. (e) When calculating the number or percentage of enrollees with a place of employment within an area or zip code under §B(1)(c)(iii)—(viii) of this regulation, the carrier shall include only those enrollees who gain eligibility for participation in the group model HMO’s health benefit plan from their place of employment.

      6. (f) A carrier shall submit, as part of its documentation justifying to the Commissioner how the access plan meets the network sufficiency standards in this regulation:

         1. (i) Geo-access maps for each provider type and facility type except for those excluded under §B(3) of this regulation showing the practicing locations of participating providers, and identifying either the geographic areas within each zip code where the applicable distance standard is not met, or the locations of enrollees with a residence or place of employment outside the applicable distance standard;
         2. (ii) For any facility types listed in §B(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide adolescent services; and
         3. (iii) For any facility types listed in §B(5) of this regulation that provide services for substance use disorders, the percentage of facilities on the carrier’s provider panel that provide services for alcohol treatment only, drug abuse treatment only, and alcohol and drug abuse treatment.
      7. (g) A carrier shall report each number and percentage described in §B(1)(c)(iii)—(viii) of this regulation as part of the annual access plan filing.
   2. (2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §B(5) of this regulation.

   3. (3) The travel distance standards listed in §B(5) of this regulation do not apply to the following:

      1. (a) Home health care;
      2. (b) Durable medical equipment;
      3. (c) Heart transplant programs;
      4. (d) Heart or lung transplant programs;
      5. (e) Kidney transplant programs;
      6. (f) Liver transplant programs;
      7. (g) Lung transplant programs; or
      8. (h) Pancreas transplant programs.
   4. (4) All other provider and facility types included on the carrier’s provider panel, but not listed in the chart at §B(5) of this regulation, including physical therapists and licensed dietitian-nutritionist, shall individually be required to meet maximum distances standards of 20 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.

   5. (5) Chart of Travel Distance Standards.

      	Urban Area Maximum Distance (miles)	Suburban Area Maximum Distance (miles)	Rural Area Maximum Distance (miles)
      Provider Type:
      Addiction Medicine	15	30	75
      Allergy and Immunology	20	30	75
      Applied Behavioral Analyst	15	20	60
      Cardiovascular Disease	15	25	60
      Chiropractic	20	30	75
      Dermatology	20	30	60
      Endocrinology	20	40	90
      ENT/Otolaryngology	20	30	75
      Gastroenterology	20	30	60
      General Surgery	20	30	60
      Gynecology, OB/GYN Nurse-Midwifery/Certified Midwifery	15	20	45
      Licensed Clinical Social Worker	15	30	75
      Licensed Professional Counselor	15	30	75
      Nephrology	15	30	75
      Neurology	15	30	60
      Oncology-Medical, Surgical	15	30	60
      Oncology-Radiation/Radiation Oncology	15	40	90
      Ophthalmology	15	20	60
      Pediatrics-Routine/Primary Care	15	20	45
      Physiatry, Rehabilitative Medicine	15	30	75
      Plastic Surgery	15	40	90
      Podiatry	15	30	90
      Primary Care (non-pediatric)	15	20	45
      Psychiatry-Adolescent and Child, Outpatient	15	30	60
      Psychiatry-Geriatric, Outpatient	15	30	60
      Psychiatry-Outpatient	15	30	60
      Psychology	15	30	60
      Pulmonology	15	30	60
      Rheumatology	15	40	90
      Urology	15	30	60
      All Other licensed or certified providers under contract with a carrier not listed	20	40	90
      Facility Type:	15	30	60
      Acute Inpatient Hospitals	15	30	60
      Ambulatory Infusion Therapy Center	15	30	60
      Critical Care Services-Intensive Care Units	15	30	120
      Diagnostic Radiology	15	30	60
      Inpatient Psychiatric Facility	15	45	75
      Opioid Treatment Services Provider	15	30	60
      Outpatient Dialysis	15	30	60
      Outpatient Mental Health Clinic	15	30	60
      Outpatient Substance Use Disorder Facility	15	30	60
      Pharmacy	5	10	30
      Residential Crisis Services	15	30	60
      Skilled Nursing Facilities	15	30	60
      Substance Use Disorder Residential Treatment Facility	15	30	60
      Surgical Services (Outpatient or Ambulatory Surgical Center)	10	30	60
      All other licensed or certified facilities under contract with a carrier not listed	15	40	120

3. C. Essential Community Providers.

   1. (1) Each provider panel of a carrier, that is not a group model HMO provider panel, shall include:

      1. (a) At least 30 percent of the available essential community providers providing medical services in each of the urban, rural, and suburban areas;
      2. (b) At least 30 percent of the available essential community providers providing mental health services in each of the urban, rural, and suburban areas; and
      3. (c) At least 30 percent of the available essential community providers providing substance use disorder services in each of the urban, rural, and suburban areas.

   2. (2) Methodology for calculating essential community provider inclusion standard.

      1. (a) Except as provided in §§C(2)(b) and (c) of this regulation, a carrier shall use the MHBE ECP Network Inclusion Calculation Methodology that is described in the Instructions on Meeting the Essential Community Provider Plan Certification Standard guidance provided by the Maryland Health Benefit Exchange, which is current as of the date 3 months prior to the due date of the annual access plan.
      2. (b) The calculation described in §C(2)(a) of this regulation shall be performed separately for essential community providers providing medical services, mental health services, and substance use disorder services in each of the urban, rural, and suburban areas.
      3. (c) If the Maryland Health Benefit Exchange changes the MHBE ECP Network Inclusion Calculation Methodology after the effective date of this regulation, a carrier may not use the revised methodology to calculate the essential community provider inclusion standard in §C(1) of this regulation unless the Commissioner has approved the revised methodology for this purpose.

   3. (3) Each group model HMO plan shall demonstrate that its own providers located in Health Professional Shortage Areas or low-income zip codes within its service area perform at or above the 50th percentile on the following two HEDIS measures:

      1. (a) Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment; and
      2. (b) Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults.
   4. (4) Each group model HMO plan shall demonstrate that it has alternative standards for addressing the needs of low income, medically underserved individuals. One manner in which a group model HMO may demonstrate this is by providing the Maryland Insurance Administration with its narrative or alternate standard justification to the essential community provider requirement, which was submitted to and accepted by the Maryland Health Benefit Exchange for certification as a qualified health planstandards of practice as determined by the treating provider acting within the scope of the provider’s license, certification, or other authorization.

Authority: Insurance Article, §§2-109(a)(1) and 15-112(a)—(d), Annotated Code of Maryland

Effective date: December 31, 2017 (44:25 Md. R. 1180)

Chapter revised effective May 15, 2023 (50:9 Md. R. 379)