Filing Requirements for Health Carriers Seeking Approval of Provider Network Adequacy

Filing Requirements for Health Carriers Seeking Approval of Provider Network Adequacy

New for 2017: Lactation Consultants

As required by the 10/23/15 CMS FAQs, QHP issuers are required to provide a list of lactation counseling providers within the network. MDH has received questions from issuers about how to comply with this requirement. It is not necessary to submit geographic access maps for lactation providers. Many different types of providers can perform the services of a lactation consultants, including RN, RDs, DOs, MDs and other professionals. They may also be certified by the International Board of Certified Lactation Consultants, but this is not a requirement. Lactation consultants may work at hospitals, clinics or in private practice. If lactation consultants are hospital or facility-based, it is not necessary to list all providers in the directory, but issuers must clearly disclose the availability of lactation consultant services at the hospital or facility, including the professional certification and/or licensure of the lactation providers available. If lactation consultants are clinic-based or in private practice, issuers must list the individual providers, along with their professional certification and/or licensure. Please direct questions to Patti Fuller at 651-201-5165.

Note regarding networks to be offered in 2017

All network filings must be received by May 11, 2016. The documents may be submitted in the Provider Network Adequacy web application system beginning April 4, 2016.

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.

Under Minnesota Statutes 62K.10 all health carriers that offer health plans that require an enrollee to use or that create incentives, including financial incentives, for an enrollee to use a designated provider network must assure that providers in the designated network are geographically accessible to all potential enrollees within the health plan’s defined service area. Provider networks must be structured so that maximum travel distance or time for an enrollee to the nearest primary care, mental health or general hospital services to be the lesser of 30 miles or 30 minutes. In addition, the maximum travel distance or time for an enrollee to specialty physician services, ancillary services, specialized hospital services, or other types of services must be the lesser of 60 miles or 60 minutes.

All networks that are offered, sold, issued, or renewed 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).

Network adequacy data is nonpublic until the network is both approved by the Minnesota Department of Health (MDH), and the corresponding rates are approved in the plan management binder within the System for Electronic Rate and Form Filing (SERFF). While MDH does not publish lists of providers, if MDH receives a data practices request for this information after the public date, MDH will provide the data. The approved provider network lists are not considered trade secret under Minn. Stat. 13.37.

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 (MNN#). The Network ID is generated in SERFF and can be found in the Network Template in your SERFF Binder. Instructions to create a filing through SERFF can be found on the SERFF website. When creating an account in the PNA System, it must match the same network name as used in SERFF.

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. To create an account, follow the prompts at the following link: Provider Network Adequacy system.

If you intend to submit network information related to a new network during a non-renewal period, please contact network adequacy staff at health.managedcare@state.mn.us or contact the Managed Care Systems Section at 651-201-5100 and request to speak to a Network Adequacy staff person.

Documents Required to be submitted to the Provider Network Adequacy (PNA) System for review for each Network

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

Detailed instructions for all carriers to submit required information can be found at: Provider Network Adequacy Instructions (PDF).

Essential Community Provider (ECP) Requirements for Provider Networks

Filings submitted must meet requirements for inclusion of Essential Community Providers (ECPs). These requirements are intended to ensure that networks include a broad range of ECPs to serve the unique needs of certain populations. Minnesota requirements are based on ECP standards developed for Federally-Facilitated Exchanges. See February 29, 2016 CMS Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF).

The Provider Network Adequacy Instructions (PDF) (page 6) will provide detailed instructions related to this requirement.

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

Dental carriers that wish to be certified as Qualified Dental Plans (QDPs), also known as Stand Alone Dental Plans (SADPs), must submit networks for approval. Specific requirements for QDP’s can be found in the Provider Network Adequacy Detailed Instructions (page 8).

See detailed Provider Network Adequacy Instructions (PDF) for further details and instructions.

Updated Friday, April 29, 2016 at 09:20AM