The Exchange established the following network adequacy, provider directory, and essential community provider standards in October 2012 to meet noted federal regulatory requirements for purposes of the 2013 Exchange certification process.
QHP issuers, with respect to their portfolio of business with the Exchange, must ensure that QHP provider networks are sufficient in number and types of providers, including mental health and substance abuse providers, to assure that all services are accessible without unreasonable delay. 45 C.F.R. § 156.230.
Minnesota Statutes, sections 62D.124 and Minnesota Rules, 4685.3300, Subpart 9 will function as network adequacy certification standards for Minnesota insurers, service plan corporations, and HMOs. The Department of Health will perform network adequacy review for QHPs.
QHP issuers are required to make a provider directory for a QHP available to the Exchange for publication online in accordance with guidance from the Exchange and to potential enrollees in hard copy upon request. 45 C.F.R. § 156.230(b).
QHP issuers will be required to file a provider network at the time of QHP filing, update it shortly before the open enrollment period begins, and update it on a regular interval (monthly or quarterly) throughout a benefit year. The provider network information filed by QHP issuers will form the basis of an Exchange consolidated provider directory. The Exchange is working with the Departments of Health and Human Services to build a unified provider information data collection system and will consult with issuers as we move forward with system development.
Essential Community Providers
A QHP issuer, with respect to its portfolio of business with the Exchange, must have a sufficient number and geographic distribution of essential community providers, where available, that serve predominantly low income, medically underserved individuals. A staff model health plan or integrated delivery system plan that contracts with a single medical group must have a sufficient distribution of providers to ensure reasonable and timely access for low‐income, medically underserved individuals in its service area. 45 C.F.R. § 156.235.
Minnesota Statutes, section 62Q.19 will function as the certification standard related to essential community providers for qualified health plans sold on the Exchange. Minnesota Statutes, section 62Q.19 requires all health plans to offer contracts to state designated essential community providers within their service areas.
To begin your Network Adequacy review:
- Please create an account here.
- Once account is created, you will be sent an email containing the link to the site to upload all documents and a pass code, this code will be used along with your SERFF ID to submit all documents.
These are the detailed instructions (PDF) for submitting for a Network Adequacy review.
Please submit the following for your Network Adequacy Review:
- Provider File (Excel file)
- Geo Access Maps (xml,xls,xlsx,doc,pdf,docx,rtf,txt,csv,zip,jpg,img,tif)
- Evidence of Contract (Word file)
- Request for Waiver (Word file) (if needed)
Q&A for Stand-alone Dental Network Adequacy Filings
Q: What do carriers of stand-alone dental plans need to submit for network adequacy certification?
- Maps demonstrating 60 mile access to dental providers providing pediatric dental services.
- The list of dental providers in the excel provider template.
- Evidence of contracts.
- Waivers, if requested.
Q: What kinds of dental providers should be included in the dental network?
A: The following are the provider types and provider specialties to include in the network adequacy provider file:
Dental Group: 30F
Allied Dental Professionals: 31 (includes Dental Therapists and Advanced Dental Therapists)
Dental Hygienist: 31
General Practitioner: 62
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