Network Adequacy

Filing Requirements for Networks Offered in 2015

All Network filings must be submitted in their entirety by June 27, 2014

The “Minnesota Health Plan Market Rules” (“Market Rules”) outlined in Minnesota Statutes chapter 62K sets forth the requirements applicable to individual and small group health plans offered, sold, issued, or renewed in Minnesota beginning January 1, 2015. Unless otherwise exempted from Minnesota Statutes, chapter 62K, the Market Rules apply to all individual and small group health plans offered either outside or inside of the health insurance exchange.

Minnesota Statutes, Section 62K.10 requires “all health carriers that either require an enrollee to use or that create incentives, including financial incentives, for an enrollee to use, health care providers that are managed, owned, under contract with, or employed by the health carrier” to meet certain network geographic access requirements.

All networks that are offered, sold, issued, or renewed on or after January 1, 2015 and offered either on or off the Health Care Exchange must submit each distinct network for approval. This requirement applies to any “health carrier” as defined under Minnesota Statutes chapter 62A.011 including insurance companies and health maintenance organizations (HMOs).

QHP networks that received approval in 2013 will be required to file additional information related to essential community providers as outlined below.

New Requirements for Networks Offered in 2015

Please note that filings submitted for use in 2015 will have to meet additional requirements for inclusion of Essential Community Providers (ECPs). These requirements were added to address concerns that networks include a broad range of ECPs to serve the unique needs of certain populations. These requirements are based on requirements for federally-facilitated Exchanges. See April 5, 2013 CMS Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF).

  1. Carriers must offer a contract in good faith to all ECPs designated as Indian Health Providers in the network service area. Indian Health Provider ECPs are those providers that may be tribal, urban or other providers that primarily serve American Indian populations, and are state or federally-designated ECPs.   

  2. In addition, each separate network must now include at least one ECP per county in each of the following categories, if such ECP is available:
    1. Primary Care
    2. Family Planning
    3. Mental Health
    4. Chemical Dependency

These categories are based on the list of state-designated ECPs. However, carriers may also use federally-designated ECPs to meet family planning access requirements.

A comprehensive list (Excel format) of state-designated ECPs and identified categories and a list of US Department of Health and Human Services ECPs are located at: Essential Community Providers

Creating an Account under the MDH Network Adequacy System

In order to begin this process you must first submit a binder through the SERFF system and obtain a Network ID. The Network ID is generated in SERFF and can be found in the Network Template in your SERFF Binder.

Once a Network ID is obtained, and an account is created, you will be sent an email containing a password to enable you to upload all necessary documents. In order to create an account, access the Provider Network Adequacy system.

Detailed Network Adequacy Instructions

Detailed instructions for carriers to submit required information can be found at: Provider Network Adequacy Instructions (PDF: 140KB/12 pages)  

A list of provider types is included in the Provider Network Template (Excel).

Documents that are required for Network Adequacy Review include the following:

Information specific to Stand-alone Dental Network Filings – Limited-Scope Pediatric Dental Plans

Dental carriers that wish to be certified as qualified dental plans and offer dental products with any MNSure medical products must submit networks for approval. Documents that are required for network adequacy review for stand-alone dental carriers include the following:

  • Provider File (Excel file) that identifies all providers that provide pediatric dental services
  • Service Area Map identifying all counties in the designated Service Area
  • One Geographic Access Map that identifies all of the providers in the network, shows the Service Area defined by county, and demonstrates that 60 mile/60 minute access requirements for Dental providers are met in the entire service area.
  • Evidence of Contract (Word file)
  • Request for Waiver (Word file) – Required if Geographic Access map indicates gaps in coverage in the designated service area.

Please use the templates provided on this web page to create the Network Provider file, and the Evidence of Contract and Request for Waiver documents. Please see the Detailed Network Adequacy Instructions referenced above for more information.

​The following are the provider types and provider specialties which dental carriers may include in the network adequacy provider file:
Provider Types:
Dentist: 30I
Dental Group: 30F
Allied Dental Professionals: 31 (includes Dental Therapists and Advanced Dental Therapists)
Dental Hygienist: 31

Provider Specialties:
General Practitioner: 62
Pediatrics: 16
Orthodontist (for medically necessary orthodontia): 63
Periodontist (for medically necessary pediatric dental services): 65
Prosthodontist (for medically necessary pediatric dental services): 73
Oral surgeon (for medically necessary pediatric dental services): 61

Recertification Instructions for QHP networks that were approved in 2013

QHPs that received approval for networks last year do not need to resubmit the full networks for recertification. However, in order to re-certify the network for 2015, QHP networks will be required to submit evidence that each network meets new Essential Community Providers (ECP) requirements by submitting:

  • a supplemental list of ECP providers, including the categories, for each network; and
  • a map of the network service area showing ECP locations

The ECP category will be a required field this year (this field was optional last year) and fields were added to allow for identification of ECPs by type. Please submit this information by June 27, 2014 through the Provider Network Adequacy web application system.

If you need a new password, please submit a request to update your password to health.managedcare@state.mn.us.

In addition, all approved networks must continue to submit monthly updates for each provider network through the central provider repository. Detailed instructions for how to complete the monthly updates can be found at: Forms, Templates and Applications.

If you have any questions regarding submitting any information, data and documentation regarding Provider Network Adequacy, please contact MDH network adequacy staff at health.managedcare@state.mn.us.

Adding New Counties to Previously Approved Networks

Carriers wishing to add new counties to previously approved networks must submit a service area expansion to the network adequacy review system. This filing should include:

  • the SERFF network ID;
  • the new counties requested;
  • maps plotting provider locations;
  • provider lists;
  • evidence of contract; and
  • any requested waivers.

In addition, when filing plan binders, the new counties should be added to the service area template.

Service Area Requirements

Under Minnesota Statutes 62K.13, the service area for a health plan must be established without regard to racial, ethnic, language, concentrated poverty or health status-related factors, or other factors that exclude specific high-utilizing, high-cost, or medically underserved populations.

As part of the documentation submitted to determine whether this requirement is met, carriers must submit an attestation describing the process used to designate the service area, demonstrating that the service area has not been designated in consideration of racial, ethnic, language, income or other health status related factors that exclude high utilizing, high cost, or medically underserved populations.

In addition, health carriers “must offer the health plan in a service area that is at least the entire geographic area of a county unless serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of enrollees.” Carriers seeking approval for less than a full county must submit a statement demonstrating that the service area is not discriminatory, is necessary  and in the best interests of enrollees.

Updated Friday, June 13, 2014 at 01:29PM