Filing Requirements for Health Carriers Seeking Approval of Provider Network Adequacy
Note regarding networks to be offered in 2016: All network filings must be received by June 1, 2015. The documents may be submitted in the Provider Network Adequacy web application system beginning May 1, 2015.
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).
Upon review and approval of all networks and corresponding rates contained in a carrier binder, MDH will approve the networks and communicate approval to the carrier. Please note that once the networks are approved in the MDH system, network data is considered public, subject to applicable exceptions under the Minnesota Data Practices Act.
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. Instructions to create a filing through SERFF can be found at http://www.serff.com. When creating an account in the PNA System, please use 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 firstname.lastname@example.org or contact the Managed Care Systems Section at 651-201-5100 and request to speak to a Network Adequacy staff person.
Provider Network Adequacy Recertification Requirements
Health Carriers that previously received approval for networks are not required to resubmit all documentation for recertification during each renewal period; however, it is required that they complete a Provider File (Excel file: 112KB) in Excel format and submit electronically.
If a network expands their service area to include additional counties, the health carrier must resubmit the same required documents it submitted during the initial approval (see “Detailed Network Adequacy Instructions” below). Health carriers will also need to include a map that outlines the counties that are being added to the network service area. When filing SERFF plan binders, health carriers are responsible for ensuring that the correct counties are identified in the service area template.
If a network reduces a service area by removing counties, the health carrier will need to contact MDH network adequacy staff at email@example.com or call 651-201-5100 and ask to speak to a network staff person.
If you have any questions regarding submitting information, data and documentation regarding Provider Network Adequacy, please contact MDH network adequacy staff at firstname.lastname@example.org.
Detailed Network Adequacy Instructions
Detailed instructions for carriers to submit required information can be found at: Provider Network Adequacy Instructions (PDF: 84KB/17 pages)
Documents that are required for Network Adequacy Review include the following:
- Provider File (Excel file: 112KB)
- Geographic Access Maps
- Evidence of Contract (Word file: 33KB/1 page)
- Request for Waiver - Provider type (Word file: 45KB/1 page)
- Request for Waiver - ECP (if needed) (Word file: 45KB/1 page)
Essential Community Provider (ECP) Requirements for Provider Networks
Filings submitted for use in 2015 or later 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 April 5, 2013 CMS Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF).
The Provider Network Adequacy Instructions (PDF: 84KB/17 pages) will provide detailed instructions related to this requirement.
Please ensure that ECP’s are clearly identified in the submitted Excel Provider File. Names and/or addresses of the ECP’s should correspond with the state or Federal ECP list provided at the link above.
Minn. Stat. 62Q.19 Subd.3. and Minn. Rules 4688.0050 require a health plan company to offer a provider contract to any ECP located within the service area of the health plan company (network) if the ECP approaches the health plan. Per 62Q.19 the health plan can require the ECP to meet data requirements, utilization review and quality assurance requirements on the same basis as other health plan network providers. The health plan is only obligated to cover services identified in the health plan company’s certificate of coverage. The health plan company and ECP may negotiate the payment rate, but the health plan company must pay at least the same rate per unit of service that it pays for same or similar services. Please note that Essential Community Providers who request a contract must be included in all networks offered by that carrier. This is consistent with Minnesota Statutes, 62Q.19, which requires a health plan company to offer a contract to any designated ECP located within the area served by the health plan company. A health plan company may not refuse to offer the ECP in some networks and not others because this makes the ECP inaccessible to enrollees in designated networks and thwarts the intent of the statute of making ECPs widely available.
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), and offer dental products with any MNsure medical products must submit networks for approval. Requirements for QDP’s can be found in the Provider Network Adequacy Instructions (PDF: 84KB/17 pages).
Partial County Service Area Requirements
We strongly encourage health carriers to submit service areas that include full counties. However, Minnesota Statutes 62K.13 allows health carriers to submit service areas that are less than the entire geographic area of a county. A service area that includes any partial county 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.
See detailed Provider Network Adequacy Instructions (PDF: 84KB/17 pages) for further details and instructions.