PURPOSE: This rule sets forth standards to ensure that health maintenance organizations maintain a network that is sufficient in number and types of providers to assure that all services to enrollees shall be accessible without unreasonable delay.

1. (1) Definitions.

   1. (A) Categories of counties.

      1. 1. Urban access counties—Counties

with a population of two hundred thousand (200,000) or more persons.

1. 2. Basic access counties—Counties with

a population between fifty thousand (50,000) persons and one hundred ninety-nine thousand nine hundred ninety-nine (199,999) persons.

1. 3. Rural access counties—Counties with

a population of fewer than fifty thousand (50,000) persons.

1. 4. Population figures shall be based on

census data as reported in the latest edition of the Official Manual of the State of Missouri.

1. (B) Closed practice provider—A health care provider who does not accept new or additional patients from the health maintenance organization (HMO) that is reporting the provider as part of the HMO’s network.

2. (C) Hospitals.

   1. 1. Basic—Hospitals with central ser-

vices, dietary services, emergency services, medical records, nursing services, pathology and medical laboratory services, pharmaceutical services, radiology services, social work services and an inpatient care unit.

1. 2. Secondary—Hospitals with all of the

facilities listed under “Basic,” plus one (1) or more operating rooms, obstetrics unit, and intensive care unit; and

1. 3. Tertiary—Hospitals with all of the

facilities listed under “Basic” and “Secondary,” plus Level I trauma unit, neonatal intensive care unit, perinatology unit, comprehensive cancer center, and facilities and personnel for providing cardiac catherization, cardiac surgery, and pediatric subspecialty care.

1. (D) Network—The group of participating providers providing services to a managed care plan or pursuant to a health benefit plan established by an HMO.
2. (E) Pharmacy—Any pharmacy, drug, chemical store, or apothecary shop, conducted for the purpose of compounding, and dispensing and retailing of any drug, medicine, chemical, or poison when used in the compounding of a physician’s prescription, and possessing a valid and current permit issued by the state of Missouri Board of Pharmacy.
3. (F) Primary care provider (PCP)—A participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to an enrollee, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the enrollee.
4. (G) Specialist—A licensed health care provider whose area of specialization is in an area other than general medicine, family medicine, general internal medicine, or general pediatrics. A physician whose area of specialization is obstetrics and/or gynecology may be either a PCP or a specialist within the meaning of this rule.

1. (2) Network Adequacy Standards—Health maintenance organizations shall file with the director of the Department of Insurance an access plan for each county within the state in which the HMO operates one (1) or more managed care plans. The initial access plan shall be filed no later than July 1, 1998. Subsequent access plans shall reflect the status of the HMO’s managed care plans as of December 31 of each year, and shall be filed no later than February 1 of the following year. The access plan shall meet the requirements of sections 354.400–354.636, RSMo, as well as the network adequacy standards set forth herein, and shall demonstrate that the HMO has an adequate network in each Missouri county in which it is licensed to do business. Network adequacy standards shall apply only to those services offered under the terms of a health benefit plan. Except as otherwise provided by law, the HMO submitting an access or deviation plan may request that all or portions of the information submitted be deemed proprietary, pursuant to procedures set forth in 20 CSR 10-3.100.

   1. (A) Access to Primary Care Providers—the access plan must indicate compliance with the distance standards indicated below, as well as the “Access to Care” standards contained in section (4), when applicable.

      1. 1. Distance standards—Compliance with

the following distance standards will be achieved if ninety-five percent (95%) of the population of the county (or, at the HMO’s option, ninety-five percent (95%) of the enrollees residing or working in the county) is within the distance standard of the providers with whom the HMO contracts:

1. A. Urban access counties—10 miles;
2. B. Basic access counties—20 miles;

and

1. C. Rural access counties—30 miles.
2. (B) Access to Specialists in Basic Access Counties.

Service/ Basic Distance Specialty Standard (in miles) Obstetrics/gynecology Neurology Dermatology Physical medicine/ rehabilitation Podiatry Vision care/primary eye care 30

Medical Subspecialties Allergy Cardiology Endocrinology Gastroenterology Hematology/oncology Infectious disease Nephrology Opthalmology Orthopedics Otolaryngology Pediatric Pulmonary disease Rheumatology Urology

General Surgery

Surgical Subspecialties Neurosurgery Plastic Surgery Thoracic Surgery

Hospital Specialties Radiology Anesthesiology Pathology Emergency medicine

Pediatric Subspecialties Cardiology Endocrinology Gastroenterology Hematology/oncology Infectious disease Nephrology Pulmonary disease Rheumatology

1. (C) Access to Specialists in Urban and Rural Access Counties.

   1. 1. Urban access counties—The access

plan must indicate that ninety-five percent (95%) of a county’s population (or, at the HMO’s option, ninety-five percent (95%) of the enrollees residing or working in the county) have access to participating providers within one-half (1/2) of the distance standard indicated for specialists under the basic access standard.

1. 2. Rural access counties—The access

plan must indicate that ninety-five percent (95%) of a county’s population (or, at the HMO’s option, ninety-five percent (95%) of the enrollees residing or working in the county) have access to participating providers within twice the distance standard for specialists in basic access counties, or the distance standard for a tertiary hospital, whichever is less.

1. (D) Hospitals—The following distance standards apply to participating hospitals. In order to achieve compliance, ninety-five percent (95%) of a county’s population (or, at the HMO’s option, ninety-five percent (95%) of the enrollees residing or working in the county) must live within the distance indicated of a participating facility of each type, regardless of whether the geographical access area is basic, urban, or rural:

   1. 1. Basic hospital—30 miles; 20 CSR 400-7

50 2. Secondary hospital—50 miles; and

1. 3. Tertiary hospital—75 miles.
2. (E) Pharmacies—The distance standards

50 for participating pharmacies are the same as 50 those for primary care providers, as indicated in paragraph (2)(A)1.

1. (F) Emergency Medical Services—The HMO will have in place and monitor a written triage, treatment and transfer protocol for all ambulance services and acute care hospitals. This document must be available for review by current or prospective enrollees.

2. (G) Mental Health Providers—The following distance standards shall apply to participating psychiatrists, psychologists, and other licensed mental health care providers located in basic access counties. Distance standards for mental health providers in urban and rural access counties shall be adjusted in accordance with the provisions contained in subsection (2)(C):

   Basic

   Distance Standard

Provider (in miles) Psychiatrists Adult, general 30 Child/adolescent 30 Psychologists/other therapists 20

1. 1. Telephone access to a licensed thera-

pist should be available twenty-four (24) hours per day, seven (7) days per week.

1. 2. Mental/behavioral health facilities—

Distance standards for mental/behavioral health facilities in basic access counties are as follows, subject to adjustment for facilities in urban and rural access counties according to the provisions of subsection (2)(C):

1. A. Outpatient facilities.

   1. (I) Adult—within 20 miles.
   2. (II) Child/adolescent—within 30

miles.

1. (III) Geriatric—within 30 miles;

and

1. B. Inpatient/intensive treatment facili-

ties.

1. (I) Adult—within 30 miles.
2. (II) Child/adolescent—within 50

miles.

1. (III) Geriatric—within 75 miles.
2. (IV) Alcohol/chemical dependen-

cy—within 75 miles.

1. (H) Dental Health Care—The following distance standards apply only to dental health care providers and facilities whose services are offered to enrollees as part of a major medical HMO plan, and not to prepaid dental plans. The distance standards listed in this section are for those providers and facilities located in basic access counties, subject to adjustment for providers and facilities located

in urban and rural access counties, as provided in section (2)(C): Basic Distance Standard Provider (in miles) General dentists 30

1. (I) Chiropractic Care—The following distance standards apply to chiropractic care providers and facilities located in basic access counties, subject to adjustment for providers and facilities located in urban and rural access counties, as provided in subsection (2)(C):

   Basic

   Distance Standard

Provider (in miles)

Chiropractors 30

1. (J) Ancillary Health Care Services—The following standards shall apply for providers of ancillary health care services:

   1. 1. Physical therapy—within 30 miles;
   2. 2. Occupational therapy—within 30

miles;

1. 3. Speech therapy—within 50 miles;
2. 4. Audiology—within 50 miles;
3. 5. Intermediate care facility (ICF) nurs-

ing home—within 50 miles;

1. 6. Skilled nursing facility (SNF) nurs-

ing home—within 50 miles;

1. 7. Home health services—must be avail-

able in all counties in which plan operates; and

1. 8. Hospice—must be available in all

counties in which plan operates.

1. (3) Network Adequacy Evaluation—In addition to complying with the distance standards contained in section (2) and the “Access to Care” standards contained in section (4), the access plan shall include a section in which the HMO sets forth those standards by which it determines the adequacy of its network, including documentation or evidence that the HMO’s managed care network meets or exceeds those standards.

2. (4) Access to Care Standards (Primary Care Providers)—A managed care plan which has been doing business in a county for more than one (1) year must show that the plan has implemented administrative measures which would ensure enrollees in that county timely access to appointments, based on the following guidelines:

   1. (A) Routine care, without symptoms— within thirty (30) days from the time the enrollee contacts the provider;
   2. (B) Routine care, with symptoms—within one (1) week or five (5) business days from the time the enrollee contacts the provider;
   3. (C) Urgent care for serious, but nonlifethreatening illnesses/injuries—within twentyfour (24) hours from the time the enrollee contacts the provider;
   4. (D) Emergency care for serious and/or life-threatening illnesses or injuries—a provider or emergency care facility shall be available twenty-four (24) hours per day, seven (7) days per week for enrollees who require emergency care; and
   5. (E) Obstetrical care—within one (1) week for enrollees in the first or second trimester of pregnancy; within three (3) days for enrollees in the third trimester. Emergency obstetrical care is subject to the same standards as emergency care, except that an obstetrician must be available twenty-four
3. (24) hours per day, seven (7) days per week for enrollees who require emergency obstetrical care.

4. (5) Alternative Compliance Mechanisms— Alternatives to the network adequacy standards set forth in section (2) may be submitted to the department for approval under certain conditions, as further described herein.

   1. (A) Different/Reduced Network—An alternative compliance method may be requested by an HMO in those instances where an employer that has contracted with the HMO to provide medical services to its employees pursuant to a managed care plan has requested a different or reduced provider network from the HMO, provided the HMO can demonstrate the adequacy of the different or reduced network with respect to the provision of services to employees enrolled in the plan.
   2. (B) Other Network Adequacy Standards— Health plans offered to enrollees which are subject to other network adequacy standards established by a governmental or quasi-governmental agency may be allowed to demonstrate the adequacy of their network with reference to those standards in lieu of the network adequacy standards contained in section (2). Examples include plans subject to Medicare risk standards, Medicaid standards, and Missouri Consolidated Health Care Plan (MCHCP) standards.
   3. (C) Quality of Care—An HMO may request an alternative compliance method to the distance standards contained in section

5. (2) by submitting an access plan which is designed to significantly enhance the quality of care to enrollees, and which does in fact enhance the quality of care. Alternative compliance methods based on this section must impose no greater cost on enrollees than would be incurred if they had access to an innetwork provider meeting the distance standards contained in section (2).

   1. (D) Noncompetitive Market Exception for PCPs and Pharmacies—In the event an HMO can demonstrate to the department that there is not a competitive market among PCPs and/or pharmacies who meet the HMO’s credentialing standards, and who are qualified within the scope of their professional license to provide appropriate care and services to enrollees, the department may approve an alternative compliance method to double the distance standard indicated in section (2) for the type of provider or pharmacy.
   2. (E) Noncompetitive Market Exception for Hospitals and Specialists—If no hospital or specialist of the appropriate type provides services to enrollees of an HMO in a county within the distance standards indicated in section (2), the HMO may submit an alternative compliance method request to the department. The request shall demonstrate that no fewer than ninety-five percent (95%) of the population of that county (or, at the HMO’s discretion, ninety-five percent (95%) of the enrollees residing or working in the county) have access to a participating hospital or specialist of the appropriate type, which hospital or specialist is located no more than twentyfive (25) miles further than the hospital or specialist closest to that county.
   3. (F) The department may approve an exception to geographic network adequacy requirements for those health care services provided to enrollees by an HMO if substantially all of those services are provided by the HMO to its enrollees through qualified full-time employees of the HMO or qualified full-time employees of a medical group that does not provide substantial health care services other than on behalf of such HMO. In order to qualify for the exception provided for in this section, an HMO must demonstrate that all or substantially all of the type of health care services in question are provided by full-time employees, that enrollees have adequate access to such health care services, and that the contract holder was made aware of the circumstances under which such services were to be provided prior to the decision to contract with the HMO.
   4. (G) The standard by which the department will review alternative compliance method requests is whether or not the alternative compliance method, taken as a whole, is to the benefit of the enrollee.

6. (6) Reporting Identity and Number of Providers—For primary care providers, physician assistants, advanced nurse practitioners, residents, interns, chiropractors, and those specialists and facilities listed in subsections (2)(B), (E), (F), (G), (H), and (J), the access plan shall report the following information:

   1. (A) The name, business address, zip code, professional license number, and specialty or degree of each provider;
   2. (B) The number of other practice affiliations reported by each provider on the provider’s standardized credentialing form; and
   3. (C) Whether or not the provider is a closed practice provider, as defined in subsection (1)(B).

7. (7) Enforcement of Standards. The network adequacy standards set forth herein are minimum standards designed to assure that all services provided to enrollees shall be available without delay. HMOs must demonstrate compliance with these standards, or an alternative compliance method, at the time of issuance and renewal of their certificate of authority.

   1. (A) HMOs which fail to demonstrate compliance with network adequacy standards or an alternative compliance method at the time of their initial and/or renewal application may have their application denied or their certificate non-renewed until such time as they demonstrate compliance or obtain approval of an alternative compliance method.
   2. (B) HMOs which fail to maintain network adequacy standards while possessing a certificate of authority, unless an alternative compliance method has been approved, shall be placed on probationary status by the department for a period not to exceed ninety

8. (90) days, during which time the HMO shall take appropriate measures to achieve compliance. If compliance is achieved prior to the expiration of the probationary period, the HMO will be removed from probationary status.

   1. (C) If an HMO which is on probation for noncompliance fails to achieve compliance by the end of the probationary period, the department may order the HMO to refrain from writing new business for a period of up to ninety (90) days following the expiration of the probationary period in those counties in which the HMO is operating one (1) or more noncompliant plans.
   2. (D) If an HMO fails to achieve compliance within the ninety (90)-day period following the expiration of the probationary period, the HMO may be ordered to refrain from writing new business within the state of Missouri until such time as compliance has been achieved and verified by the Department of Insurance.
   3. (E) HMOs must report changes in their network or number of enrollees to the director of insurance if and when such changes cause one (1) or more of the HMO’s managed care plans to be in non-compliance with any of the applicable network adequacy standards contained herein.

AUTHORITY: sections 354.405, 354.603 and 354.615, RSMo Supp. 1997.* Original rule filed Nov. 3, 1997, effective May 30, 1998.

*Original authority: 354.405, RSMo 1983, amended 1997; 354.603, RSMo 1997; and 354.615, RSMo 1997.