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Policy QM 10

National Quality Management and Measurement

Issue Date: 12/16/2010 Effective Date: 03/16/2011

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) FOR AETNA USE ONLY

12/16/2010 Practitioner and Provider Availability: Network Composition and Contracting Plan QM 10

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Subject

Originating Dept. National Quality Management and Measurement

Practitioner and Provider Availability: Network Composition and Contracting Plan

Original filed in National Quality Management and Measurement

Signed Date: 12/16/2010

Signature Authority: Andrew Baskin, MD National Medical Director, Quality and Provider Performance Measurement

Applies to:

HMO Products

PPO Products

Medicare Advantage HMO

Medicare Advantage PPO

Aetna Medicare Dual Advantage Plan (SNP)

Medicare Advantage Private Fee For Service

Type: New Revision

Clarification Replacement:

Related Communications: Aetna Credentialing Policy Definitions:

Practitioner Credentialing and Recredentialing, QM 54 Credentialing Allied Health Practitioners QM 53 Assessment/Credentialing Organizational Providers QM 51

For delegated Behavioral Health Contractors: Behavioral Health Contractor Standards Manual HMO Behavioral Health Contractor Standards Manual for PPO-Based Products

Purpose:

Establish a process by which provider and practitioner availability standards are established and periodically assessed by the applicable Quality Oversight Committee and used to improve network adequacy

To define minimum requirements for network composition To ensure compliance with applicable state and federal regulatory

standards To ensure compliance with applicable accreditations standards

Background: Many factors impact the adequacy of the provider network: network composition, geographic distribution of practitioners and members, types and numbers of practitioners and specialties available. A member’s perception of the provider network is a key driver of member satisfaction with the health plan and the member’s

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assessment of health plan quality. Adequacy of the network also impacts marketability of the network and per member per month costs. Additionally, provider network composition and adequacy are determined by state-specific regulatory standards. These standards must be met as a requirement for recertification of the HMOs’ Certificate of Authority in the respective states.

Definitions: Aetna: Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) means: "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefit coverage include Aetna Health Inc., Aetna Health of California Inc, Aetna Life Insurance Company, Aetna Health Insurance Company of New York, and Aetna Health Insurance Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

Availability: “The extent to which an organization geographically distributes practitioners and Organizational/Institutional Providers of the appropriate type and number to meet the needs of its membership.” (Source: NCQA Standards and Guidelines for Accreditation of Health Plans, 2010, Glossary). Note: The NCQA definition was revised by Aetna adding “Organizational/Institutional Providers” so as to meet regulatory standards.

Behavioral Health Participating Practitioner: An independent practitioner who is duly licensed or certified and recognized under state law, and who is contracted to provide mental health or chemical dependency services to Aetna members. This would include psychiatrists (MDs and DOs), psychologists (PH. Ds and PsyDs), social workers and other Master's prepared clinicians who are licensed to practice independently.

Geo-Networks Classification Definitions: Urban: ZIP Code population density is greater than 3,000 persons per square mile Suburban: ZIP Code population density is between 1,000 and 3,000 persons per

square mile Rural: ZIP Code population density is less than 1,000 persons per square mile

High Volume Specialties: In addition to Primary Care Physicians, Obstetricians/Gynecologists and Behavioral Health Practitioners, the top two specialties identified by volume of encounters.

Organizational or Institutional Providers: Institutional providers and suppliers of healthcare services, including behavioral health care organizations. Organizational Providers include, but are not limited to: hospitals, nursing homes; skilled nursing facilities (SNF), home care agencies, free standing surgical centers (including free standing abortion centers). Behavioral health organizations include, but are not limited to: mental health and chemical dependency hospitals, residential treatment facilities, Partial Hospital Programs, Intensive Outpatient Programs, Crises

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Stabilization Centers, clinics, and Community Mental Health Centers. Behavioral Health organizations can be free-standing or hospital-based.

Additionally, in networks where the Medicare product is offered, the organizational providers must include: laboratories, rehabilitation agencies (comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech pathology providers), renal disease services, outpatient diabetes self-management training providers, portable x-ray suppliers, rural health clinics (RHC), and federally qualified health centers (FQHC).

Primary Care Physician: Physician with PCP indicator in Enterprise Provider Database (EPDB). These include Internal Medicine, General Practice, Family Practice, Pediatricians, Nurse Practitioners acting as PCP and Ob/Gyn in states which mandate recognition of Ob/Gyn as PCP who provides the following functions at least fifty (50%) of the time in which he/she engages in the practice of medicine; supervision, coordination and provision of initial and basic medical care to members, as well as referring members for specialist care and maintaining the continuity of their care across providers in the Aetna delivery system.

Policy: Standards

Each region will establish standards for network adequacy for meeting the healthcare needs of current membership.

These standards will include, at a minimum the: number and distribution of practitioners including Primary Care

Physicians, Ob/Gyns, and those identified by the health plan as High Volume Specialties , and

number and distribution of practitioners and Organizational and Institutional Providers in Medicare networks, and

assessment of cultural, ethnic, racial, and linguistic needs and preferences of members.

Each Quality Oversight Committee will establish indicators of network adequacy for numbers of providers and distance and use those indicators to evaluate at least annually network adequacy based on member needs. Examples of network indicators and data to consider when evaluating network adequacy are listed in Attachment B. Information sources are listed in Attachment C. The medical availability indicators and goals adopted by the Quality Oversight Committee (QOC) are listed in Attachments D. Behavioral Health standards are listed in Attachment A.

Medicare Markets Plans with Medicare Contracts must incorporate a standard of 30 minutes drive time modified for longer drive times based on location (such as a rural area) and/or based on routine patterns of care for the geographic area. The evaluation must include at least an assessment of public

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transportation routes and available transportation. The scope of practitioner and provider adequacy analysis must include at least:

Primary care physicians Specialty care practitioners Behavioral health and substance abuse practitioners Behavioral health providers (inpatient, residential, ambulatory) Hospitals Skilled nursing facilities Home health agencies Ambulatory clinics At least two other provider types (i.e.,

mammography/radiology center, freestanding surgical center, rehabilitation center)

Reporting Availability reports will be generated at least annually to evaluate network

adequacy. Results of availability assessments will be used in developing and implementing market contracting plans.

Exception Process: Exceptions to this policy require approval from the Chief Medical Officer. Policy History: Revised: QM 10, issued 03/01/2010 Revised: QM 10, issued 05/29/2009 Revised: QM 10, issued 07/23/2008 Revised: QM 10, issued 03/24/2008 Revised: QM 10, issued 02/19/2007 Revised: QM 10, issued 12/01/2006 Revised: QM 10, issued 10/24/2005 Revised: QM 10, issued 10/11/2004 Revised: QM 10, issued 07/23/2003 Revised: QM 10-0602, issued 07/11/2002 Revised: HDQM Policy 98-01, revised, 09/27/2000 Original Policy: HDQM Policy 98-01, 01/06/1998 Quality Oversight Committee Review/Approval Date: 12/17/2010 _________________________________________ 12/17/2010 Leonard J. Harvey, M.D. Date Quality Oversight Committee Chairperson

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Dr Harvey

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Aetna Behavioral Health Quality Oversight Committee Review/Adoption Date: ___________________________________ Aetna Behavioral Health Date Quality Oversight Committee Chairperson or Designee FOR INFORMATION: Contact Name: Janona Davis Dept. /Unit: National Quality Management and Measurement

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Approval to Implement Review/Approval Date: 12/17/2010 12/17/2010 Grant Tarbox, D.O. Date Oklahoma Medical Director

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Dr Tarbox

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Approval to Implement Review/Approval Date: 12/17/10 12/17/2010 Grant Tarbox, D.O. Date Texas Medical Director

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Dr Tarbox



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Attachment A, Policy QM 10

BEHAVIORAL HEALTH PRACTITIONER AND PROVIDER AVAILABILITY

Commercial HMO and PPO

Practitioner Type

and Providers

Psychiatrist

Psychologist/Other Masters Prepared

Practitioner*

Psychiatrists Treating Children

Facility

Urban 1 in 10 miles 1 in 10 miles 1 in 10 miles 1 in 25 miles Suburban 1 in 10 miles 1 in 10 miles 1 in 10 miles 1 in 25 miles

Geographic Standard

Rural 1 in 40 miles 1 in 40 miles 1 in 40 miles 1 in 45 miles Geographic Goal 90% 85% 90%

Numerical Standard 1 per 2,000 1 per 1,000 1 per 2,000 1 per 40,000 Numeric Goal 100% 100% 100%

* Other Masters Prepared Practitioners Therapist include but are not limited to the following: Addiction medicine specialists, Applied Behavioral Analysts, Clinical social workers, Drug and Alcohol Counselors, Licensed Mental Health Counselors, Licensed Practical Counselors, Pastoral Counselors, Psychiatric clinical nurse specialists and Marriage and family therapists

Geographic standards and goals are noted in the above table according to practitioner type, for providers and according to urban, suburban or rural setting. Numeric standards and goals are also noted by practitioner type and also for facilities. Additional availability analysis parameters include:

Access reports will be generated at least annually to evaluate network adequacy. Additionally markets will assess cultural and linguistic needs and preferences of members on an annual

basis. Results of availability assessments will be used in developing and implementing market contracting plans. A GeoAccess report will be run to the standard of 90% for the presence of both: one psychiatrist and one

Psychologist/Other Masters Prepared Therapist within the required distances. GeoAccess for psychiatrists treating children will be completed against membership 18 and under

with a goal of 85%. Geographic Distribution of Practitioners: There should be 1 MD and 1 non-MD, and 1 psychiatrist treating children within the geographical access standard outlined above. Number of Practitioners: The goal is 100%. Geographic Distribution of Organizational Providers: There should be 1 provider (facility) within the geographic access standard outlined above. Number of Organizational Providers: Unless required for regulatory reasons, the minimum number of providers (facilities) per 40,000 HMO and PPO members: 1.0 with a goal of 100%.



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Medicare Advantage (HMO) and Medicare Advantage (PPO)

Practitioner Type

and Providers

Psychiatrist Psychologist/Other Masters Prepared

Practitioner*

Psychiatrists Treating Children

Facility

Urban 1 in 30 minutes 1 in 30 minutes 1 in 30 minutes 1 in 30 minutes Suburban 1 in 30 minutes 1 in 30 minutes 1 in 30 minutes 1 in 30 minutes

Geographic Standard

Rural 1 in 30 minutes 1 in 30 minutes 1 in 30 minutes 1 in 30 minutes Geographic Goal 90% 85% 90%

Numerical Standard 1 per 2,000 1 per 1,000 2 per 2,000 1 per 40,000 Numeric Goal 100% 100% 100%

* Other Masters Prepared Practitioners Therapist include but are not limited to the following: Addiction medicine specialists, Applied Behavioral Analysts, Clinical social workers, Drug and Alcohol Counselors, Licensed Mental Health Counselors, Licensed Practical Counselors, Pastoral Counselors, Psychiatric clinical nurse specialists and Marriage and family therapists

Geographic standards and goals are noted in the above table according to practitioner type, for providers and according to urban, suburban or rural setting. Numeric standards and goals are also noted by practitioner type and also for facilities. Additional availability analysis parameters include:

Access reports will be generated at least annually to evaluate network adequacy. Additionally markets will assess cultural and linguistic needs and preferences of members on an annual

basis. Results of availability assessments will be used in developing and implementing market contracting plans. A GeoAccess report will be run to the standard of 90% for the presence of both: one psychiatrist and one

Psychologist/Other Masters Prepared Therapist within the required distances. GeoAccess for psychiatrists treating children will be done against membership 18 and under with a

goal of 85%. Geographic Distribution of Practitioners: There should be 1 MD and 1 non-MD, and1 psychiatrist treating children within the geographical access standard outlined above. Number of Practitioners: The goal is 100%. Geographic Distribution of Organizational Providers: There should be 1 provider (facility) within the geographic access standard outlined above. Number of Organizational Providers: Unless required for regulatory reasons, the minimum number of providers (facilities) per 40,000 HMO and PPO members: 1.0 with a goal of 100%.



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Attachment B

Examples of network adequacy indicators include, but are not limited to:

PCP to Member ratios Number of providers by type for Urban, Suburban and Rural mileage Practitioner Counts by PCP and each Specialty Practitioner Turnover Rate Practitioner Termination Rates (by Reason Code) Member PCP Change Rates Member PCP Change Requests Tabulated by Reason Code PCP Closed Practice Rates Total Number of Practitioner Initiated Member PCP Change Requests Frequency of Member Complaints Specific to Network Provider Availability

Examples of data include: benefit plans and products offered in the market product/sales targets membership demographic data from CAHPS demographic data from U.S. Census in urban areas, the usual means of transportation used by members, and if the

members primarily rely on public transportation, the location of providers in relation to public transportation

healthcare needs of the membership state legislated mandates regarding provider types for networks CMS guidelines availability of providers in the community occupancy rates PCPs with closed practices member satisfaction data related to network from CAHPS member complaint data related to network disenrollment data related to network mapping of providers to zip code mapping of members to zip code foreign language needs of membership racial and ethnic composition of the community

Attachment C



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QM 10

Information Sources/Reports Available

Report Name Source Cultural & Linguistic Diversity of Population State Health Department, Department of Statistics, or Internet

http://census.gov Number of PCPs with Language in addition to English Sorted by Language Spoken EPDB/RPBD through DAF Number of BH Practitioners with Language in addition to English Sorted by Language Spoken

EPDB/RPBD through DAF

Monthly reports on Frequency and Language Requested of Member Service Use of Contracted Translation Services

AT & T Language Line Reports available through Member Services

Monthly reports on Frequency and Language Requested of Member Service Use of Contracted Translation Services

NCO-Call Operations Solutions

Annual CAHPS Member Satisfaction Survey Eileen Scheye, National QM Annual BH Member Satisfaction Survey Annual Medicare CAHPS Survey National QM Annual Medicare Disenrollment Survey National QM Target Membership by Geography Sales/Marketing Member Complaints and Appeals re: network provider availability (Full to Capacity, Language Assistance Program, Language needed not available at Aetna, Language needed not available in Providers/Practitioner, Network Adequacy, Travel Time)

CATS Reporting Team

Monthly current Member Utilization Reports: Current Member Utilization Reports: Paid Claim and Encounter Data Default view (total dollars and frequency by hospital, diagnosis, service; out-of-network utilization; ER use)

Aetna Integrated Informatics - Managed Care Monitor- Contact local or Regional Medical Director

Number of Providers by Provider Type Marketing Support Unit (MSU) Reporting Services http://aetnet.aetna.com/msu/msu.htm

Number of PCPs (in total and by “closed practice”) NISS Site (requires registered users access) Mapping of Provider Distance/Travel Time MSU Map Facility Services Available by Hospital AHA Guide (Query File Version)

Attachment D Aetna Life Insurance Company

Region

Date of Committee Meeting Confidential of 12

Health Plan Medical and Behavioral Standards and Goals for HMO, PPO, and Medicare [To be completed by Health Plan]

QM 10 Practitioner and Provider Availability: Network Composition and Contracting Plan Attachment D

2011 RegionalQM 10 Provider Availability State Tables

HMO Network Availability StandardsAttachment D: For self and fully insured

West: AZ, CA, CO, NV Mid America: IL, IN, KS, KY, MO, OH, OK, TX,

Northeast: CT, DE, MA, ME, NJ, NY, PASE/SW: DC,FL, GA, MD, NC, TN, VA

Numeric Availability Standards

PHYSICIAN PHYSICIAN PER 1,000 ENROLLEE GOAL

General Practice and Internal Medicine 2:1000 100%Family Practice 2:1000 100%

Pediatric (17 yrs and younger) 2:1000 100%OB/GYN (females 13 yrs and older) 2:1000 100%

Top 2 Specialists .5:1000 100%Closed Practice Rate-General and Internal <15% 100%

Closed Practice Rate-Family Practice <15% 100%

Geographic Availability Standards

TYPE NUMBER OF PROVIDERS PER MILEAGE GOAL

PCP-General Practice and Internal MedicineUrban 2:10 miles 95%

Suburban 2:15 miles 90%Rural 2:40 miles 85%

Family PracticeUrban 2:10 miles 95%


Pediatric (17 yrs and younger)Urban 2:10 miles 95%


OB/GYN (females 13 yrs and older)Urban 2:10 miles 95%


Top 2 Specialists Urban 2:10 miles 90%


12/16/2010Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)

FOR AETNA USE ONLY 1



PPO Network Availability StandardsAttachment D: For self and fully insured

West: AK, AZ, CA, CO, HI, ID, NM, NV, OR, UT, WA

Mid America: IA, IL, IN, KS, KY, MI MN, MT, NE, ND, OH, OK, SD, TX, WI, WY

Northeast: CT, MA, ME, NH, NJ, NY, RI, VTSoutheast: AL, AR, FL, GA, LA, MS, NC, SC, TN





















QM10 Practitioner and Provider Availability: Network Composition and Contracting Plan Attachment D

2011 National QM 10 Provider Avaliablity State Tables National Behaviorial Health HMO & PPO

QM 10 Attachment AFor self and fully insured

Practitioner Type and Providers Psychiatrist Psychologist/Other Masters Prepared TherapistPsychiatrists Treating

Children Facility

Urban 1:10 miles 1:10 miles 1:10 miles 1:25 miles Suburban 1:10 miles 1:10 miles 1:10 miles 1:25 miles

Rural 1:40 miles 1:40 miles 1:40 miles 1:45 miles Goal 90% 90% 85% 90%


Children Facility

Numeric standard 1 per 2,000 1 per 1,000 1 per 2,000 1 per 40,000Numeric goal 100% 100% 100% 100%

Note: Tables reflect Behavioral Health standards and State regulations

* Other Masters Prepared Practitioners Therapist include but are not limited to the following: Addiction medicine specialists, Applied Behavioral Analysts, Clinical social workers, Drug and Alcohol Counselors, Licensed Mental Health Counselors, Licensed Practical Counselors,Pastoral Counselors, Psychiatric clinical nurse specialists and Marriage and family therapists

Geographic standards and goals are noted in the above table according to practitioner type, for providers and according to urban, suburban or rural setting. Numeric standards and goals are also noted by practitioner type and also for facilities. Additional availability analysis parameters include:• Access reports will be generated at least annually to evaluate network adequacy. • Additionally markets will assess cultural and linguistic needs and preferences of members on an annual basis.• Results of availability assessments will be used in developing and implementing market contracting plans.• A GeoAccess report will be run to the standard of 90% for the presence of both: one psychiatrist and one Psychologist/Other Masters Prepared Therapist within the required distances. • GeoAccess for psychiatrists treating children will be completed against membership 18 and under with a goal of 85%.

Geographic Distribution of Practitioners: There should be 1 MD and 1 non-MD, and 1 psychiatrist treating children within the geographical access standard outlined above.

Number of Practitioners: The goal is 100%.

Geographic Distribution of Organizational Providers: There should be 1 provider (facility) within the geographic access standard outlined above.

Number of Organizational Providers: Unless required for regulatory reasons, the minimum number of providers (facilities) per 40,000 HMO and PPO members: 1.0 with a goal of 100%.






PHYSICIAN Standard GOAL

General Practice and Internal Medicine 2:1000 100%

Family Practice 2:1000 100%Pediatric (17 yrs and younger) 2:1000 100%OB/GYN (females 13 yrs and older) 2:1000 100%Top 2 Specialists .5:1000 100%Closed Practice Rate-General and Internal ,<15% 100%Closed Practice Rate-Family Practice ,<15% 100%

Facilities and Ancillary ProvidersHospitals 1:1000 100%Skilled Nursing Facilities 1:1000 100%Home Health Agencies 1:1000 100%Ambulatory Clinics(i.e. Urgent Care Centers) 1:1000 100%Freestanding Surgical Centers 1:1000 100%Radiology Centers 1:1000 100%

Standard / Goal

PRACTITIONER / PROVIDER CATEGORY Urban/Suburban/Rural GOALPrimary Care Practitioners (PCP)*

Urban 1 in 30 Minutes 90%Suburban 1 in 30 Minutes 90%Rural 1 in 45 Minutes 90%


Urban 1 in 30 Minutes 90%Suburban 1 in 30 Minutes 90%Rural 1 in 45 Minutes 90%Specialty Care Practitioners (SCP)**



Urban 1 in 30 Minutes 90%Suburban 1 in 30 Minutes 90%Rural 1 in 45 Minutes 90%#4 - Behavioral Health Practitioners#5 -Substance Abuse PractitionersBehavioral Health Providers/Facilities





#1 - Free Standing Surgical CentersUrban 1 in 30 Minutes 90%Suburban 1 in 30 Minutes 90%Rural 1 in 45 Minutes 90%#2 - Radiology CentersUrban 1 in 30 Minutes 90%Suburban 1 in 30 Minutes 90%Rural 1 in 45 Minutes 90%

Hospitals

Skilled Nursing Facilities

Home Health Agencies

Other Providers

Ambulatory Clinics (i.e. Urgent Care Centers)

2011 National

QM 10 Provider Availability State Tables Medicare Advantage HMO and PPO

HMO & PPO: AZ, CA, CO, CT, DC, DE, FL, GA, IL, KS, KY, MA, MD, ME, MO, NC, NJ, NV, NY, OH, OK, PA, TN, TX, VA***

PPO Only:

IN, MI, MS, NC, NM, RI, WA, WI, WV


Please see Attachment A, Policy QM 10-Behavioral Health Practitioner and Provider Availability

#1 - General Practice and Internal Medicine

#2 - Family Practice

#3 - Pediatrics

#1 - First High Volume Specialty Group

#2- Second High Volume Specialty Group

#3 - Obstetrics and Gynecology




* The groups of General Practice & Internal Medicine combined, Family Practice, & Pediatric practitioners are to be measured for this item. ** The top 2 high volume specialty categories and Obstetrics & Gynecology practitioners are to be measured for this item by the Regional Quality Management Department. Behavioral Health and Substance Abuse practitioners and facilities are to be measured through reports generated by Aetna Behavioral Health.***Resource Document: 2011 MA Detailed Final Service Area, R.Miller, 10/22/2010





ARIZONA HMO and PPOFully Insured




Pediatric (17 yrs and younger) 2:1000 100%OB/GYN (females 13 yrs and older) .5:1000 100%





PCP-General Practice and Internal MedicineUrban 1:10 miles or 30 minutes 95%

Suburban 1:15 miles or 45 minutes 95%Rural 1:30 miles or 90 minutes 95%

Family PracticeUrban 1:10 miles or 30 minutes 95%


Pediatric (17 yrs and younger)Urban 1:10 miles or 30 minutes 95%


OB/GYN (females 13 yrs and older)Urban 1:15 miles or 45 minutes 95%


Top 4 Specialists* Urban 1:15 miles or 45 minutes 95%

Suburban 1:20 miles or 60 minutes 95%Hospitals

Urban 1:25 miles or 75 minutes 95%Suburban 1:30 miles or 90 minutes 95%

*High Profile means one of no fewer than 4 specialties designated by the HCSO and does not include OB. Specialities could include Neurology, Dermatology, Physical Medicine/Rehabilitation, Podiatry, Allergy, Cardiology, Endocrinology, Gastroenterology, Hematology/Onocology, Infectious Disease, Nephrology, Opthamalology, Orthopedics, Otolaryngology, Pulmonary Disease, Rheumatology, Urology and General Surgery.

Note: Tables reflect a combination of regional standards and state requirements




2010 West/North Central QM 10 Provider Availability State Tables

ARIZONA HMO and PPOFully Insured

Aetna will follow Aetna standards for primary care providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07.

Action Required

Arizona Administrative CodeTitle 20 Chapter 6 Article 19R20-6-1916Availability Ratios

A. An HCSO shall maintain a ratio of contracted adult PCPs to adults that is adequate to provide those adults with covered services. An HCSO with a Medicare Advantage (MA) plan may have one ratio that applies to both its insured and MA populations, or a separate ratio for each.B. An HCSO shall maintain a ratio of contracted pediatric PCPs to children that is adequate to provide those children enrollees with covered services.C. An HCSO shall maintain a ratio of contracted high profile SCPs to enrollees that is adequate to provide those enrollees with covered services that include services at contracted facilities. An HCSO with a MA plan may have one ratio that applies to both its insured and MA populations, or a separate ratio for each.Arizona Administrative CodeTitle 20 Chapter 6 Article 19R20-6-1918Geographic Availability in a Urban Area An HCSO shall provide each enrollee living in an urban area of the HCSO's service area the following:1. Primary care services from a contracted PCP located within 10 miles or 30 minutes of the enrollee's home;2. High profile specialty care services from a contracted SCP located within 15 miles or 45 minutes of the enrollee's home; and3. Inpatient care in a contracted general hospital, or contracted special hospital, within 25 miles or 75 minutes of the enrollee's home.

Arizona Administrative CodeTitle 20 Chapter 6 Article 19R20-6-1918Geographic Availability in a Suburban Area

Each HCSO shall provide each enrollee member living in a suburban area within the HCSO's service area the following:1. Primary care from a contracted PCP located within 15 miles or 45 minutes of the enrollee's home;2. High profile specialty care services from a contracted SPC within 20 miles or 60 minutes of the enrollee's home; and3. Inpatient care in a contracted hospital, or a contracted special hospital within 30 miles or 90 minutes of the enrollee's home.

Title 20 Chapter 6 Article 19R20-6-1919Geographic Availability in a Rural Area

An HCSO shall provide each enrollee living in a rural area with primary care services from a contracted physician or practitioner within 30 miles or 90 minutes of the enrollee's home.

Arizona Administrative Code-State Specific DefinitionsAdult PCP means a primary care provider practicing in any specialty the HCSO designates as adult primary careFacility means an institution that is licensed or authorized to furnish health care services in this state, including general hospitals, special hospitals, residential treatment centers, residential rehabilitation centers, skilled nursing facilities, urgent care centers, and ambulatory surgical treatment centers.

Health care plan means any contractual arrangement whereby any health care services organization undertakes to provide directly or to arrange for all or a portion of contractually covered health care services and to pay or make reimbursement for any remaining portion of the health care services on a prepaid basis through insurance or otherwise. A health care plan shall include those health care services required in this article or in any rule adopted pursuant to this article

Special hospital means a hospital that is licensed to provide hospital services within a specific area ofmedicine, or limits patient admission according to age, gender, type of disease, or medical condition.

Health care services organization means any person that undertakes to conduct one or more health care plans. Unless the context otherwise requires, health care services organization includes a provider sponsored health care services organization.

High Profile means one of no fewer than 4 specialties designated by the HCSO and does not include OB. An HCSO may designate a specialty as high profile on the basis of high volume or other basis theHSCO reasonably determines is directly related to providing covered services to a member

Hospital means a facility that provides inpatient care, medical services, and continuous nursing services for the diagnosis and treatment of patients.

Provider means any physician, hospital or other person that is licensed or otherwise authorized to furnish health care services in this state.





CALIFORNIA HMO and PPOFully Insured



General Practice and Internal Medicine .5:1000 100%

Family Practice .5:1000 100%Pediatric (17 yrs and younger) .5:1000 100%

OB/GYN (females 13 yrs and older) .83:1000 100%Top 2 Specialists .83:1000 100%

Specialist .83:1000 100%Mental Health Professionals see California BH Table

Closed Practice Rate-General and Internal <15% 100%Closed Practice Rate-Family Practice <15% 100%











Top 2 Specialists Urban 2:10 miles or 30 minutes 95%


Specialists (PPO Only) Urban 2:10 miles or 30 minutes 95%


Mental Health Professionals Urban

Suburban Rural

Acute Care Hospitals Urban 1:15 miles or 30 minutes 95%


Full Service Hospital (offers ER, Cardiology and OB Departments) (HMO only)


Rural 1:15 miles or 30 minutes 95%Lab and Pharmacy (HMO Only): To be measured from the PCP offices, not the members' residence.

Urban 1:15 miles or 30 minutes 95%Rural 1:15 miles or 30 minutes 95%

Suburban 1:15 miles or 30 minutes 95%

see California BH Table







Action Required

Aetna will follow Aetna standards for primary care providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07. Legislation allows for measurement from workplace or residence, all measurements listed below is from residence with the exception of Lab and Pharmacy.

California Code of RegulationsTitle 28-Managed Care

Chapter 2-Health Service PlansArticle 7-StandardsSections 1300.67.2

(DMHC)

Within each service area of a plan, basic health care services and specialized health care services shall be readily available and accessible to each of the plan's enrollees;

(a) The location of facilities providing the primary health care services of the plan shall be within reasonable proximity of the business or personal residences of enrollees, and so located as to not result in unreasonable barriers to accessibility.

(d) The ratio of enrollees to staff, including health professionals, administrative and other supporting staff, directly or through referrals, shall be such as to reasonably assure that all services offered by the plan will be accessible to enrollees on an appropriate basis without delays detrimental to the health of the enrollees. There shall be at least one full-time equivalent physician to each one thousand two hundred (1,200) enrollees and there shall be approximately one full-time equivalent primary care physician for each two thousand (2,000) enrollees, or an alternative mechanism shall be provided by the plan to demonstrate an adequate ratio of physicians to enrollees;

(e) A plan shall provide accessibility to medically required specialists who are certified or eligible for cer


Chapter 2-Health Service PlansArticle 7-StandardsSections 1300.67.2.1

(DMHC)

Geographic Accessibility Standards

Subject to subsections (a) and (b) of this section, a plan may rely, for the purposes of satisfying the requirements for geographic accessibility, on the standards of accessibility set forth in Item H of Section 1300.51 and in Section 1300.67.2. (a) If, given the facts and circumstances with regard to any portion of its service area, a plan's standards of accessibility adopted pursuant to Item H of Section 1300.51 and/or Section 1300.67.2 are unreasonably restrictive, or the service area is within a county with a population of 500,000 or fewer, and is within a county that, as of January 1, 2002, has two or fewer full service health care service plans in the commercial market, the plan may propose alternative standards of accessibility for that portion of its service area. The plan shall do so by including such alternative standards in writing in its plan license application or in a notice of material modification. The plan shall also include a description of the reasons justifying the less restrictive standards based on those facts and circumstances. If the Department rejects the plan's proposal, the Department shall inform the plan of the Department's reaso


Chapter 2-Health Service PlansArticle 3-Plan Applications and Amendments

Sections 1300.51HEALTH CARE DELIVERY SYSTEM

H. Geographical Area Served (i) Primary Care Providers. All enrollees have a residence or workplace within 30 minutes or 15 miles of a contracting or plan-operated primary care provider in such numbers and distribution as to accord to all enrollees a ratio of at least one primary care provider (on a full-time equivalent basis) to each 2,000 enrollees.

(ii) Hospitals. In the case of a full-service plan, all enrollees have a residence or workplace within 30 minutes or 15 miles of a contracting or plan operated hospital which has a capacity to serve the entire dependent enrollee population based on normal utilization, and, if separate from such hospital, a contracting or plan-operated provider of all emergency health care services.

(iii) Hospital Staff Privileges. In the case of a full-service plan, there is a complete network of contracting or plan-employed primary care physicians and specialists each of whom has admitting staffprivileges with at least one contracting or plan operated hospital equipped to provide the range of basic health care services the plan has contracted to provide.

(iv) Ancillary Services. Ancillary laboratory, pharmacy and similar services and goods dispensed by ord






California Code of RegulationsTitle 10-Investment

Chapter 5-Insurance CommissionerSubchapter 2-Policy Forms

Article 6-Provider network AccessSections 2240.1.

(c) In arranging for network provider services, insurers shall ensure that:1) There is the equivalent of at least one full-time physician per 1,200 covered persons and at least the equivalent of one full-time primary care physician per 2,000 covered persons2) There are primary care network providers with sufficient capacity to accept covered persons within 30 minutes or 15 miles of each covered person's residence or workplace3) There are medically required network specialists who are certified or eligible for certification by the appropriate specialty board with sufficient capacity to accept covered persons within 60 minutes or 30 miles of a covered person's residence or workplace. Notwithstanding the above, the Commissioner may determine that certain medical needs require network specialty care located closer to covered persons when the nature and frequency of use of such health care services, and the standards of Insurance Code 10133.5(b) (3), support such modification.4) There are mental health professionals with skills appropriate to care for the mental health needs of

5) There is a network hospital with sufficient capacity to accept covered persons for covered services w



Article 6-Provider network AccessSections 2240.5

(DOI) Filing and Reporting Requirements.

(e) Health insurers that contract for alternative rates of payment with providers shall report annually to the Consumer Services Division of the Department of Insurance on complaints received by the insurer regarding timely access to care. This report shall include a summary of receipt and resolution of complaints regarding access to or availability of any of the following services by type of service: primary care services, specialty care services, mental health professional services and hospital services.






CCR 2240 (DOI) Network means all institutions or health care professionals that are utilized to provide medical services to covered persons pursuant to a contract with an insurer to provide such services at alternative rates as described in Insurance Code Section 10133. A network as defined herein can be directly contracted with by an insurer or leased by an insurer.

CCR 2240 (DOI) Basic health care services means any of the following covered health care services provided for in the applicable insurance contract or certificate of coverage:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance services(7) Mental health care services including those intended to meet the requirements of Insurance Code 10144.5(8) Any other health care or supportive services that are covered pursuant to an insurance contract.

CCR 2240 (DOI) Health care professional means a licensee or certificate holder enumerated in Insurance Code 10176 as of the effective date of this Article or as that Section may be amended thereafter

CCR 2240 (DOI) Network provider means an institution or a health care professional which renders health care services to covered persons pursuant to a contract to provide such services at alternative rates.

CCR 2240 (DOI) Insurer means an insurer who provides 'health insurance" as defined in Section 106(b), and includes those who authorize insureds to select providers who have contracted with the insurer for alternative rates of payment as described in Section 10133.

California State Specific Definitions




`

Practitioner Type and Providers PsychiatristPsychologist/Other Masters Prepared

TherapistPsychiatrists Treating

Children Facility

Urban 2:10 miles or 30 minutes 2:10 miles or 30 minutes 2:10 miles or 30 minutes 1:15 miles or 30 minutes

Suburban 2:10 miles or 30 minutes 2:10 miles or 30 minutes 2:10 miles or 30 minutes 1:15 miles or 30 minutes

Rural 1:15 miles or 30 minutes 1:15 miles or 30 minutes 1:15 miles or 30 minutes 1:15 miles or 30 minutes

Goal 95% 95% 95% 95%

Practitioner Type and Providers PsychiatristPsychologist/Other Masters Prepared

TherapistPsychiatrists Treating

Children Facility

Numeric standard .83 per 1,000 1 per 1,000 .83 per 1,000 1 per 40,000

Numeric goal 100% 100% 100% 100%

Action Required

(c) In arranging for network provider services, insurers shall ensure that:1) There is the equivalent of at least one full-time physician per 1,200 covered persons and at least the equivalent of one full-time primary care physician per 2,000 covered persons2) There are primary care network providers with sufficient capacity to accept covered persons within 30 minutes or 15 miles of each covered person's residence or workplace3) There are medically required network specialists who are certified or eligible for certification by the appropriate specialty board with sufficient capacity to accept covered persons within 60 minutes or 30 miles of a covered person's residence or workplace. Notwithstanding the above, the Commissioner may determine that certain medical needs require network specialty care located closer to covered persons when the nature and frequency of use of such health care services, and the standards of Insurance Code 10133.5(b) (3), support such modification.4) There are mental health professionals with skills appropriate to care for the mental health needs of covered persons and with sufficient capacity to accept covered persons w

5) There is a network hospital with sufficient capacity to accept covered persons for cove



Article 6-Provider network AccessSections 2240.5 (DOI)



CCR 2240 (DOI) Network means all institutions or health care professionals that are utilized to provide medical services to covered persons pursuant to a contract with an insurer to provide such services at alternative rates as described in Insurance Code Section 10133. A network as defined herein can be directly contracted with by an insurer or leased by an insurer.

Filing and Reporting Requirements.(e) Health insurers that contract for alternative rates of payment with providers shall report annually to the Consumer Services Division of the Department of Insurance on complaints received by the insurer regarding timely access to care. This report shall include a summary of receipt and resolution of complaints regarding access to or availability of any of the following services by type of service: primary care services, specialty care services, mental health professional services and hospital services.




2011 Regional

QM 10 Provider Availability State Tables

CALIFORNIA Behavorial Health HMO and PPO

Fully Insured


Chapter 2-Health Service PlansArticle 7-Standards

Sections 1300.67.2.1 (DMHC)

Geographic Accessibility StandardsSubject to subsections (a) and (b) of this section, a plan may rely, for the purposes of satisfying the requirements for geographic accessibility, on the standards of accessibility set forth in Item H of Section 1300.51 and in Section 1300.67.2. (a) If, given the facts and circumstances with regard to any portion of its service area, a plan's standards of accessibility adopted pursuant to Item H of Section 1300.51 and/or Section 1300.67.2 are unreasonably restrictive, or the service area is within a county with a population of 500,000 or fewer, and is within a county that, as of January 1, 2002, has two or fewer full service health care service plans in the commercial market, the plan maypropose alternative standards of accessibility for that portion of its service area. The plan shall do so by including such alternative standards in writing in its plan license application or in a notice of material modification. The plan shall also include a description of the reasons justifying the less restrictive standards based on those facts and circumstances. If the Department rejects the plan's proposal, the Department shall in



Article 6-Provider network AccessSections 2240.1. (DOI)






H. Geographical Area Served (DMHC)

(i) Primary Care Providers. All enrollees have a residence or workplace within 30 minutes or 15 miles of a contracting or plan-operated primary care provider in such numbers and distribution as to accord to all enrollees a ratio of at least one primary care provider (on a full-time equivalent basis) to each 2,000 enrollees.


(iii) Hospital Staff Privileges. In the case of a full-service plan, there is a complete network of contracting or plan-employed primary care physicians and specialists each of whom has admitting staff privileges with at least one contracting or plan operated hospital equipped to provide the range of basic health care services the plan has contracted to provide.

(iv) Ancillary Services. Ancillary laboratory, pharmacy and similar services and goods dis


Chapter 2-Health Service PlansArticle 7-Standards

Sections 1300.67.2 (DMHC)









CALIFORNIA AVN HMO -PCPs and Specialists Only*Fully Insured



General Practice and Internal Medicine .5:1000 100%

Family Practice .5:1000 100%Pediatric (17 yrs and younger) .5:1000 100%

OB/GYN (females 13 yrs and older) .83:1000 100%Top 2 Specialists .83:1000 100%

All Other Specialist .83:1000 100%Closed Practice Rate-General and Internal <15% 100%














All Other Specialists Urban 1:15 miles or 30 minutes 95%




Action Required


*AVN Member utilize the full CA HMO network for the following services: behavioral health, hospital, ancillary and lab. For all other CA Standards reference the HMO Regional Standards and CA HMO (fully insured) tables.




H. Geographical Area Served

12/16/2010Aenta is the brand name used for products and service provided by one or more of the Aetna group of companies. (Aetna)








Chapter 2-Health Service PlansArticle 7-StandardsSections 1300.67.2

(DMHC)




(e) A plan shall provide accessibility to medically required specialists who are certified or eligible for cert


Chapter 2-Health Service PlansArticle 7-StandardsSections 1300.67.2.1

(DMHC)

Geographic Accessibility Standards

Subject to subsections (a) and (b) of this section, a plan may rely, for the purposes of satisfying the requirements for geographic accessibility, on the standards of accessibility set forth in Item H of Section1300.51 and in Section 1300.67.2. (a) If, given the facts and circumstances with regard to any portion of its service area, a plan's standards of accessibility adopted pursuant to Item H of Section 1300.51 and/or Section 1300.67.2 are unreasonably restrictive, or the service area is within a county with a population of 500,000 or fewer, and is within a county that, as of January 1, 2002, has two or fewer full service health care service plans in the commercial market, the plan may propose alternative standards of accessibility for that portion of its service area. The plan shall do so by including such alternative standards in writing in its plan license application or in a notice of material modification. The plan shall also include a description of the reasons justifying the less restrictive standards based on those facts and circumstances. If the Department rejects the plan's proposal, the Department shall inform the plan of the Department's reason

(i) Primary Care Providers. All enrollees have a residence or workplace within 30 minutes or 15 miles of a contracting or plan-operated primary care provider in such numbers and distribution as to accord toall enrollees a ratio of at least one primary care provider (on a full-time equivalent basis) to each 2,000 enrollees.


(iii) Hospital Staff Privileges. In the case of a full-service plan, there is a complete network of contracting or plan-employed primary care physicians and specialists each of whom has admitting staff privileges with at least one contracting or plan operated hospital equipped to provide the range of basic health care services the plan has contracted to provide.

(iv) Ancillary Services. Ancillary laboratory, pharmacy and similar services and goods dispensed by ord





CCR 2240 (DOI) Network means all institutions or health care professionals that are utilized to providemedical services to covered persons pursuant to a contract with an insurer to provide such services at alternative rates as described in Insurance Code 10133. A network as defined herein can be directly contracted with by an insurer or leased by an insurer.








FLORIDA HMOFully Insured

Numeric Availability Standards PHYSICIAN PHYSICIAN PER 1,000 ENROLLEE GOAL

Family Practice and General Practice 2:1000 100% Internal Medicine 2:1000 100%


Chiropractic .5:1000 100%Podiatry .5:1000 100%

Top 5 Specialists .5:1000 100%Geographic Availability Standards


PCP-Family Practice and General PracticeUrban 1:30 minutes 85%

Suburban 1:30 minutes 85%Rural 1:30 minutes 85%

Internal MedicineUrban 1:30 minutes 85%


Pediatric (17 yrs and younger)Urban 1:30 minutes 85%


OB/GYN (females 13 yrs and older)Urban 1:30 minutes 85%


ChiropracticUrban 1:30 minutes 75%


PodiatryUrban 1:30 minutes 75%


12/16/2010Aetna is the brand name used for products and services provided by one or more of the Aetna group of Companies. (Aetna)



Specialists (report each separately) Allergy/Immunology, Anesthesiology/RN Anesthetist, Cardiology, Certified Nurse

midwife/midwife,Dermatology, Endocrinology,

ENT/Otolaryngology, Gastroenterology, Hematology/Oncology,

Infectious Diseases, Neonatology, Nephrology, Neurology, Oncology,

Opthamology, Optometrist,Orthopedics, Psychology, Psychiatry,

Pulmonary, Radiation Oncology, Rheumatology,

Surgery - cardiovascular, Surgery - colo-rectal, Surgery - general, Surgery - hand, Surgery -

neurological,Surgery - orthopedic, Surgery - oral, Surgery -

plastic/reconstructive, Surgery - thoracic, Urology

Urban 1:60 minutes 75%Suburban 1:60 minutes 75%

Rural 1:60 minutes 75%Hospitals


Rural 1:30 minutes 75%

Ancillary (report each separately)Ancillary Services: Birth Center, Dental,

Diagnostic Radiology, Dialysis, DME/Supplies (include orthotics/prosthetics), Hearing, Home

Health Care, Hospice, Laboratory, Mental Health, Orthotics/Prosthetics, Outpatient

Surgery, Pharmacies, Rehab (I/P and O/P), Physical Therapy, Speech Therapy,

Occupational Therapy, Respiratory Therapy, Skilled Nursing Facility, Vision


Rural 1:60 minutes 75%

Note: Tables reflect state requirements.

Florida Administrative Code 59A-12.006(3)(d)Average travel time from the HMO geographic services area boundary to the nearest primary care delivery site and to the nearest general hospital under arrangement with the HMO to provide health care services of no longer than 30 minutes under normal circumstances. Average travel time from the HMO geographic services area boundary to the nearest provider of specialty physician services, ancillary services, specialty inpatient hospital services and all other health services of no longer than 60 minutes under normal circumstances. AHCA shall waive this requirement if the HMO provides sufficient justification as to why the average travel time requirement is not feasible or necessary in a particular geographic service area.




Health maintenance contracts which provide coverage, benefits, or services for maternity care shall provide, as an option to the subscriber, the services of nurse midwives and midwives, licensed pursuant to chapter 467, and the services of birth centers licensed pursuant to ss. 383.30-383.335, if such services are available within the service area.

s. 641.47(9), F.S.“Geographic area” means the county or counties, or any portion of a county or counties, within which the health maintenance organization provides or arranges for comprehensive health care services to be available to its subscribers.

s. 641.31(18)(a) F.S.





COLORADO HMO and PPOFully Insured



General Practice and Internal Medicine 4:1000 100% Family Practice 4:1000 100%
















HospitalsUrban 1:30 miles 95%


PharmacyUrban 1:30 miles 95%


Action RequiredAetna will follow Aetna standards for primary care providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07.

Gaps in the technological and specialty services available will be evaluated by trending non par requests.

Action Required(a.5) An adequate number of accessible specialists and sub-specialists within a reasonable distance or travel time, or both, or who may be available through the use of telemedicine;

(a.9) If the covered person has a pharmacy benefit, an adequate number of pharmacy providers within a reasonable distance, travel time, delivery time, or all three. Nothing in this paragraph (a.9) shall preclude the use of a retail or mail-order pharmacy provider.


Colorado Revised Statutes 10-16-704(1) A carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have access to health care services twenty-four hours per day, seven days per week. Sufficiency shall be determined in accordance with the requirements of this section and may be established by reference to any reasonable criteria used by the carrier, including but not limited to:(a) Provider-covered person ratios by specialty, which may include the use of providers through telemedicine for services that may appropriately be provided through telemedicine;(c) Geographic accessibility, which in some circumstances may require the crossing of county or state lines;(f) The volume of technological and specialty services available to serve the needs of covered persons requiring covered technologically advanced or specialty care; and(g) An adequate number of accessible acute care hospital services within a reasonable distance, travel time, or both.

Colorado Revised Statutes 10-16-704 Section 9a

Managed care plan means a policy, contract, certificate, or agreement offered by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services through the covered person's use of health care providers managed by, owned by, under contract with, or employed by the carrier because the carrier either requires the use of or creates incentives, including financial incentives, for the covered person's use of those providers

Colorado Statute State Specific Definitions 10-16-102Carrier means any entity that provides health coverage in this state including a franchise insurance plan, a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a sickness and accident insurance company, and any other entity providing a plan of health insurance or health benefits subject to the insurance laws and regulations of Colorado.

Health coverage plan means a policy, contract, certificate, or agreement entered into by, offered to, or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.





ILLINOIS HMO and PPOFully Insured





















Action Required


Gaps in the technological and specialty services available will be evaluated by


ILCS 215 134/40-80Department of Public Health Part 240

andSection 2051.55(e) Preferred Provider Administrator Filing Requirements

2) specific written guidelines for monitoring and evaluating the quality and appropriateness of care andservices provided to enrollees requiring the health care plan to assess;(A) the accessibility to health care providers;

Section 2051.55(e) PPA Filing RequirementsThe number and type of providers necessary to: Meet the health care needs and service demands of the currently enrolled population, including:Hospital Services including 24 hour emergency department services

IL Administrative Code Section 2051.30Administrator means any person, partnership or corporation, other than an insurer or health service corporation or health maintenance organization holding a certificate of authority under the Health Maintenance Organization Act [215 ILCS 125] or self-insured employer, employee benefit trust fund or other ERISA exempt organization, that arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider.

IL Administrative Code Section 5421.20Provider means any physician, hospital facility, or other person which is licensed or otherwise authorized to furnish health care service and also includes any other entity that arranges for the delivery or furnishing of health care services (Section 1-2(12) of the Act).

Illinois State Specific Definitions Insurance Code 215 ILCS 134/10Health care plan means a plan that establishes, operates, or maintains a network of health care providers that has entered into an agreement with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs or dispute resolution.Health care plan does not include the following: indemnity health insurance policies including those using a contracted provider network; health care plans that offer only dental or vision coverage; preferred provider administrators, as defined in section 370g(g);employee or employer self –insured health benefit plans under the federal Employee Retirement Income Security Act of 1974; and not-for-profit voluntary health service plans

Illinois Insurance Code 215 ILCS 5/370g Administrator means any person, partnership or corporation, other than an insurer or health maintenance organization holding a certificate of authority under the "Health Maintenance OrganizationAct", as now or hereafter amended, that arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider.





INDIANA HMOFully Insured



















Physical Therapy, Occupational Therapy, and Rehabilitation services;

Urban 1:50 miles 90%Suburban 1:50 miles 90%

Rural 1:50 miles 90%Hospitals


Rural 1:50 miles 90%Pharmacy


Rural 1:50 miles 90%

Action RequiredAetna will follow Aetna standards for primarycare providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07.

Carrier refers to any of the following: (1) A health maintenance organization (2) An insurer licensed in Indiana to write Class 1(B) or Class 2(A) lines of insurance (3) Any other entity responsible for the payment of benefits or provision of services under a group contract

Health maintenance organization means a person that undertakes to provide or arrange for the delivery of health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles.

Provider means a physician, a hospital, or any other person licensed or authorized to furnish health care services.(b) The term includes an entity that: (1) is owned in whole or in part by one (1) or more physicians, hospitals, or other persons licensed or authorized to furnish health care services; and (2) was established for purposes of furnishing health care services through: (A) contracts; or (B) employment agreements; with one (1) or more physicians, hospitals, or other persons licensed or authorized to furnish health care services.


Indiana Code 27-13-36-3Each health maintenance organization shall demonstrate to the department that the health maintenance organization offers an adequate number of: (1) acute care hospital services; (2) primary care providers; and (3) other appropriate providers;that are located within a reasonable proximity of subscribers of the health maintenance organization.

Compliance with the most current standards or guidelines developed by the National Committee on Quality Assurance or a successor organization is sufficient to meet the requirements of this subsection

Indiana State Specific Definitions IC 27-13-1-6, IC 27-13-1-19, IC 27-13-1-28

(c) If a health maintenance organization provides coverage for: (1) specialty medical services, including physical therapy, occupational therapy, and rehabilitation services; (2) mental and behavioral care services; or (3) pharmacy services;

the health maintenance organization shall demonstrate to the department that the offered services are located within a reasonable proximity of subscribers of the health maintenance organization. Compliance with the most current standards or guidelines developed by the National Committee on Quality Assurance or a successor organization.





KENTUCKY HMO and PPO

Fully InsuredNumeric Availability Standards


General Practice and Internal Medicine 4:1000 100% Family Practice 4:1000 100%



Closed Practice Rate-Family Practice <10% 100%Geographic Availability Standards
















Action Required Aetna will follow Aetna standards for primary care providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07.

Note: Tables reflect a combination of regional standards and state requirements Note: In Kentucky all other providers shall be available within 50 miles to the extent those services are available

Kentucky Revised Statutes 304.17A-515A managed care plan shall arrange for a sufficient number and type of primary care providers and specialists throughout the plan's service area to meet the needs of enrollees. Each managed care plan shall demonstrate that it offers:

(a) An adequate number of accessible acute care hospital services, where available;

(c) An adequate number of accessible specialists and subspecialists, and when the specialist needed for a specific condition is not represented on the plan's list of participating specialists, enrollees have access to nonparticipating health care providers with prior plan approval.

(d) The availability of specialty services; and

(e) A pr provider network that meets the following accessibility requirements:

For urban areas, a provider network that is available to all persons enrolled in the plan within thirty (30) miles or thirty (30) minutes of each person's place of residence or work, to the extent that services are available; or

2. For areas other than urban areas, a provider network that makes available primary care physician services, hospital services, and pharmacy services within thirty (30) minutes or thirty (30) miles of each enthe plan within fifty (50) minutes or fifty (50) miles of each enrollee's place of residence or work, to the exte

Kentucky State Specific Definitions 304.17A-005 & 304.17A-500 Health benefit plan means any hospital or medical expense policy or certificate; nonprofit hospital, medical-surgical, and health service corporation contract or Page 4 of 8 certificate; provider sponsored integrated health delivery network; a self-insured plan or a plan provided by a multiple employer welfare arrangement, to the extent permitted by ERISA; health maintenance organization contract; or any health benefit plan that affects the rights of a Kentucky insured and bears a reasonable relation to Kentucky, whether delivered or issued for delivery in Kentucky, anddoes not include policies covering only accident, credit, dental, disability income, fixed indemnity medical expense reimbursement policy, long-term care, Medicare supplement, specified disease, vision care, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical-payment insurance, insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, short-term coverage, studenthealth insurance offered by a Kentucky-licensed insurer under written contract with a university or college

Managed care plan means a health insurance policy that integrates the financing and delivery of appropriate health care services to enrollees by arrangements with participating providers who are selected to participate on the basis of explicit standards to furnish a comprehensive set of health care services and financial incentives for enrollees to use the participating providers and procedures provided for in the plan

Participating health care provider means a health care provider that has entered into an agreement with an insurer to provide health care services




2011 Regional QM 10 Provider Avaliablity State Tables Maryland Behaviorial Health HMO & PPO

Fully Insured


Children Facility

Urban 1:10 miles 1:10 miles 1:10 miles 1:25 miles Suburban 1:10 miles 1:10 miles 1:10 miles 1:25 miles

Rural 1:40 miles 1:40 miles 1:40 miles 1:45 miles Goal 90% 90% 85% 90%


Children Facility

Numeric standard 1 per 2,000 1 per 1,000 1 per 2,000 1 per 40,000Numeric goal 100% 100% 100% 100%




Maryland Title 31 Section 10 31.10.34.04 Provider Panel SufficiencyA. A carrier shall maintain a provider panel that is sufficient in numbers and types of available providers to meet the health care needs of enrollees. B. Standards to meet the health care needs of enrollees shall be determined in accordance with the requirements of this chapter, and may be established by reference to any reasonable criteria used by the carrier, including but not limited to: (1) Provider-enrollee ratios by specialty; (2) Primary care provider-enrollee ratios; (3) Geographic accessibility; (4) Waiting times for appointments with providers; (5) Hours of operation; and (6) The volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.

Maryland Ttile 31 Section 10 31.10.34.05 Availability PlanA. A carrier shall implement an availability plan describing: (1) If the carrier is aa insurer or nonprofit health service plan, the quantifiable and measurable standards for the number and geographic distribution of: (a) General and internal medicine providers; (b) Family practitioners; (c) Pediatricians; (d) Obstetricians and gynecologists; (e) High-volume specialty behavioral health care providers, including psychiatrists, psychologists, clinical social workers, and any other behavioral health care providers identified by the carrier; and (f) High-volume specialty health care providers, identified by the carrier.


FOR AETNA UE ONLY 1



Maine HMO & PPOFully Insured






TYPENUMBER OF PROVIDERS PER MILEAGE

GOAL

PCP-General Practice and Internal Medicine

Urban 1:15 or 30 minutes 90%Suburban 1:20 or 30 minutes 90%

Rural 1:25 or 30 minutes 90%Family Practice


Rural 1:25 or 30 minutes 90%Pediatric (17 yrs and younger)


Rural 1:25 or 30 minutes 90%OB/GYN (females 13 yrs and older)


Rural 1:50 or 60 minutes 90%Top 2 Specialists


Rural 1:50 or 60 minutes 90%

HospitalsUrban 1:30 or 60 minutes 90%

Suburban 1:40 or 60 minutes 90%Rural 1:50 or 60 minutes 90%

Note: Tables reflect a combination of regional standards and state requirements Maine Department of Professional and Financial Regulation

Bureau of Insurance Chapter 850: Health Plan Accountability Section 7 Subsections B (1) and C (1) (2)

12/16/2010Aetna is the brand name used for products and services provided by one or more of the Aenta group of companies. (Aetna)



To the extent reasonably possible, carriers that offer managed care plans utilizing primary care providers shall maintain a minimum ratio of one full-time equivalent primary care provider to 2000 enrollees. Primary care services shall be available within 30 minutes travel time by automobile of each enrollee's residence. The following distances shall be used as guidelines in determining distances corresponding to 30 minutes travel time under normal conditions: a) Areas with primary road available: 20 miles. b) Areas with only secondary roads available: 15 miles. c) Areas connected by interstate highways: 25 miles. Specialty care and hospital services shall be available within 60 minutes travel time by automobile of each enrollee's residence. The following distances will be used as guidelines in determining distances corresponding to 60 minutes travel time under normal conditions: a) Areas with primary road available: 40 miles. b) Areas with only secondary roads available: 30 miles. c) Areas connected by interstate highways: 50 miles.

Note: The finacial incentives may not require a member to travel a distance that exceeds the standards established in subsection 7(C)(2)(Specialty care and hospital services) for mileage and travel time by 100%. DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION Chapter 850 Sec (C)(30(d).

12/16/2010Aetna is the brand name used for products and services provided by one or more of the Aenta group of companies. (Aetna)




MISSOURI HMOFully Insured

















12/16/2010Aetna is the brand name for products and services provided by one or more of the Aetna group of companies. (Aetna)



NEUROLOGY, DERMATOLOGY, PHYSICAL MEDICINE/REHABILITATION, PODIATRY,

ALLERGY,CARDIOLOGY, ENDOCRINOLOGY,

GASTROENTEROLGY, HEMATOLOGY/ONCOLOGY,

INFECTIOUS DISEASE, NEPHROLOGY, OPHTHALMOLOGY, ORTHOPEDICS,

OTOLARYNGOLOGY, PULMONARY DISEASE, RHEUMATOLOGY, UROLOGY AND GENERAL

SURGERYUrban 1:25 miles 90%


Vision Care/Primary Eye CareUrban 1:15 miles 90%


Physical and Occupational TherapyUrban 1:30 miles 90%


Speech Therapy and AudiologyUrban 1:50 miles 90%


Chiropractic CareUrban 1:15 miles 90%




Hospitals-Basic and SecondaryUrban 1:30 miles 90%


Hospitals-Tertiary Services: Level 1or 2 Trauma, Neonatal Intesive Care, Gerontology Services, Comprehenisve Cancer Services, Comprehensive Cardiac Services, Pediatric

Subspecialty CareUrban 1:100 miles 90%






MISSOURI HMOAction Required

Note: Tables reflect a combination of regional standards and state requirements Note: In Missouri for those providers not addressed in the table, access to a provider shall be reasonable and not exceed 100 miles

Missouri Revised Statutes 354.603 A health carrier shall 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. In the case of emergency services, enrollees shall have access twenty-four hours per day, seven days per week. The health carrier's medical director shall be responsible for the sufficiency and supervision of the health carrier's network. Sufficiency shall be determined by the director in accordance with the requirements of this section and by reference to any reasonable criteria, including but not limited to provider-enrollee ratios by specialty, primary care provider-enrollee ratios, geographic accessibility, reasonable distance accessibility criteria for pharmacy and other services, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care

Aetna will follow Aetna standards for primary care providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07.Gaps in the technological and specialty services available will be evaluated by trending non-par requests

20 CSR 400-7.095- HMO Access Plans The plan is required to be filed with the Department of Insurance pursuant to section 354.603, RSMo, and in accordance with the requirements of this regulation.

(B) Categories of counties1. Urban access counties-Counties with a population of two hundred thousand (200,000) or more persons.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.3. Rural access counties-Counties with a population of fewer than fifty thousand (50,000) persons.4. Population figures shall be based on census data as reported in the latest edition of the Official Manual of the State of Missouri.

Missouri State Specific Definitions 20 CSR 400-7.095 Health Benefit Plan means a policy, contract , certificate or agreement entered into, offered or issued by an HMO to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services and identified by the form number or numbers used by the HMO when the health benefit plan was filed.

354.600 Health care provider or provider is a health care professional or a facility

354.600 Health carrier is a health maintenance organization established pursuant to sections 354.400 to 354.636




2011 Regional QM 10 Provider Avaliablity State Tables Missouri Behaviorial Health HMO

Fully Insured


Children FacilityAmbulatory Mental Health

Treatment ProviderResidential Mental Health

Treatment Provider

Urban 1:10 miles 1:10 miles 1:10 miles 1:25 miles 1:15 miles 1:20 miles Suburban 1:10 miles 1:10 miles 1:10 miles 1:25 miles 1:25 miles 1:25 miles

Rural 1:40 miles 1:40 miles 1:40 miles 1:45 miles 1:45 miles 1:45 miles Goal 90% 90% 85% 90% 90% 90%


Children Facility Facility Facility

Numeric standard 1 per 2,000 1 per 1,000 1 per 2,000 1 per 40,000 1 per 40,000 1 per 40,000Numeric goal 100% 100% 100% 90% 90% 90%


Action RequiredGaps in the technological and specialty services available will be evaluated by trending non-par requests

Action RequiredExhibit A is found on the DOI webite and includes specific standards listed in table above for InpatientMental Health Treatment Facilities, Ambulatory Mental Health Treatment Providers and ResidentialMental Health Treatment Providers

Health Benefit Plan means a policy, contract , certificate or agreement entered into, offered or issued by an HMO to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services and identified by the form number or numbers used by the HMO when the health benefit plan was filed.

Missouri State Specific Definitions 20 CSR 400-7.095

354.600 Health care provider or provider is a health care professional or a facility

354.600 Health carrier is a health maintenance organization established pursuant to sections 354.400 to 354.636

20 CSR 400-7.095- HMO Access Plans The plan is required to be filed with the Department of Insurance pursuant to section 354.603, RSMo, and in accordance with the requirements of this regulation.(B) Categories of counties1. Urban access counties-Counties with a population of two hundred thousand (200,000) or more persons.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.3. Rural access counties-Counties with a population of fewer than fifty thousand (50,000) persons.4. Population figures shall be based on census data as reported in the latest edition of the Official Manual of the State of Missouri.(G) Enrollee access rate-The percentage of a managed care plans enrollees living or working within a county who are able to access a participating provider within the travel distance standards set forth in Exhibit A



Missouri Revised Statutes 354.603 A health carrier shall maintain a network that is sufficient in number and types of providersto assure that all services to enrollees shall be accessible without unreasonable delay. In the case of emergency services, enrollees shall have access twenty-four hours per day, seven days per week. The health carrier's medical director shall be responsible for the sufficiency and supervision of the health carrier's network. Sufficiency shall be determined by the director in accordance with the requirements of this section and by reference to any reasonable criteria, including but not limited to provider-enrollee ratios by specialty, primary care provider-enrollee ratios, geographic accessibility, reasonable distance accessibility criteria for pharmacy and other services, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care





NORTH CAROLINA HMO and PPOFully Insured


Family Practice, General Practice, Internal Medicine 2:1000 100%


Top 5 Specialists .2:1000 100%Chiropractic .2:1000 100%

Podiatry .2:1000 100%Optometrists .2:1000 100%

Inpatient Facilities .2:1000 100%Outpatient Facilities (defined as

Ambulatory/Outpatient Surgery Centers) .2:1000 100%

Geographic Availability Standards TYPE NUMBER OF PROVIDERS PER MILEAGE GOAL

Family Practice,General Practice and Internal Medicine


Rural 2:30 miles 90%Pediatric (17 yrs and younger)


Rural 2:30 miles 90%OB/GYN (females 13 yrs and older)


Rural 2:30 miles 90%Chiropractic


Rural 2:45 miles 90%Podiatry


Rural 2:45 miles 90%Optometrists


Rural 2:45 miles 90%Top 5 Specialists


Rural 2:45 miles 90%Inpatient Facilities





Rural 2:45 miles 90%Outpatient Facilities (defined as

Ambulatory/Outpatient Surgery Centers)Urban 2:10 miles 95%



N.C.G.S. § 58 3 191. (a) Each health benefit plan shall annually, on or before the first day of March of each year, file in the office of the Commissioner the following information for the previous calendar year: (4) Data relating to the utilization, quality, availability, and accessibility of services. The report shall include the following: a. Information on the health benefit plan's program to determine the level of network availability, as measured by the numbers and types of network providers, required to provide covered services to covered persons. This information shall include the plan's methodology for: 1. Establishing performance targets for the numbers and types of providers by specialty, area of practice, or facility type, for each of the following categories: primary care physicians, specialty care physicians, nonphysician health care providers, hospitals, and non-hospital health care facilities. 2. Determining when changes in plan membership will necessitate changes in the provider network. The report shall also include: the availability performance targets for the previous and current years; the numbers and types of providers currently participating in the health benefit plan's provider network; and an evaluation of actual plan performance against performance targets. c. Information on the health benefit plan's program to determine the level of provider network accessibility necessary to serve its membership. This information shall include the health benefit plan's methodology for establishing performance targets for member access to covered services from primary care physicians, specialty care physicians, nonphysician health care providers, hospitals, and non-hospital health care facilities. The methodology shall establish targets for: 1. The proximity of network providers to members, as measured by member driving distance, to access primary care, specialty care, hospital based services, and services of non-hospital facilities. 2. Expected waiting time for appointments for urgent care, acute care, specialty care, and routine services for prevention and wellness. The report shall also include: the accessibility performance targets for the previous and current years; data on actual overall accessibility as measured by driving distance and average appointment waiting time; and an evaluation of actual plan performance against performance targets. Measures of actual accessibility may be developed using scientifically valid random sample techniques. d. A statement of the health benefit plan's methods and standards for determining whether in network services are reasonably available and accessible to a covered person, for the purpose of determining whether a covered person should receive the in network level of coverage for services received from a non-network provider. e. A description of the health benefit plan's program to monitor the adequacy of its network availability and accessibility methodologies and performance targets, plan performance, and network provider performance.





NORTH CAROLINA Behavioral Health HMO and PPOFully Insured

Numeric Availability Standards PHYSICIAN PHYSICIAN PER 1,000 ENROLLEE GOALPsychiatrists 1:2000 100%

Psychologists / Other Masters Prepared Practitioner 1:1000 100%

MH/CD Inpatient Facilities 1:40000 100%Geographic Availability Standards

TYPE NUMBER OF PROVIDERS PER MILEAGE GOALPsychiatrists

Urban 1:10 miles 90% Suburban 1:10 miles 90%

Rural 1:40 miles 90%Psychologists / Other Masters Prepared

Practitioner (non-MD)Urban 1:10 miles 90%


MD/CD Inpatient FacilitiesUrban 1:25 miles 90%


Action Required


N.C.G.S. § 58 3 191.





(a) Each health benefit plan shall annually, on or before the first day of March of each year, file in the office of the Commissioner the following information for the previous calendar year: (4) Data relating to the utilization, quality, availability, and accessibility of services. The report shall include the following: a. Information on the health benefit plan's program to determine the level of network availability, as measured by the numbers and types of network providers, required to provide covered services to covered persons. This information shall include the plan's methodology for: 1. Establishing performance targets for the numbers and types of providers by specialty, area of practice, or facility type, for each of the following categories: primary care physicians, specialty care physicians, nonphysician health care providers, hospitals, and non-hospital health care facilities. 2. Determining when changes in plan membership will necessitate changes in the provider network. The report shall also include: the availability performance targets for the previous and current years; the numbers and types of providers currently participating in the health benefit plan's provider network; and an evaluation of actual plan performance against performance targets. c. Information on the health benefit plan's program to determine the level of provider network accessibility necessary to serve its membership. This information shall include the health benefit plan's methodology for establishing performance targets for member access to covered services from primary care physicians, specialty care physicians, nonphysician health care providers, hospitals, and non-hospital health care facilities. The methodology shall establish targets for: 1. The proximity of network providers to members, as measured by member driving distance, to access primary care, specialty care, hospital based services, and services of non-hospital facilities. 2. Expected waiting time for appointments for urgent care, acute care, specialty care, and routine services for prevention and wellness. The report shall also include: the accessibility performance targets for the previous and current years; data on actual overall accessibility as measured by driving distance and average appointment waiting time; and an evaluation of actual plan performance against performance targets. Measures of actual accessibility may be developed using scientifically valid random sample techniques. d. A statement of the health benefit plan's methods and standards for determining whether in network services are reasonably available and accessible to a covered person, for the purpose of determining whether a covered person should receive the in network level of coverage for services received from a non-network provider. e. A description of the health benefit plan's program to monitor the adequacy of its network availability and accessibility methodologies and performance targets, plan performance, and network provider performance.





NEBRASKA PPO









PCP-General Practice and Internal Medicine Urban 1:10 miles 95%













Action Required

Aetna will follow Aetna standards for primary care providers and other appropriate providers including behavioral health practitioners and facilities as defined in QM 10 and QM 07. Gaps in the technological and specialty services available will be evaluated by trending non-par requests

Managed care plan means a health benefit plan, including closed plans and open plans, that either requires a covered person to use or creates financial incentives by providing a more favorable deductible, coinsurance, or copayment level for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier;

Health benefit plan means a policy, contract, certificate, or agreement entered into, offered, or issued by any person to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. Health benefit plan does not include workers' compensation insurance coverage;

Nebraska Statutes 44-7105Managed Care Plan Network Adequacy

A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all health care services to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have access twenty-four hours per day, seven days per week. Sufficiency shall be determined in accordance with the requirements of this section and may be established by reference to any reasonable criteria used by the health carrier, including, but not limited to: Provider-covered person ratios by specialty; primary care provider-covered person ratios; geographic accessibility; waiting times for appointments with participating providers; hours of operation; and the volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

Nebraska State Specific Defintions Nebraska Century Code 44-7105

Health carrier means an entity that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a prepaid limited healthservice organization, a prepaid dental service corporation, or any other entity providing a plan of healthinsurance, health benefits, or health care services. Health carrier does not include a workers' compensation insurer, risk management pool, or self-insured employer who contracts for services to be provided through a managed care plan certified pursuant to section 48-120.02;



QM 10 Practitioner and Provider Availability: Network Composition and Contracting Attachment D


NEW JERSEY HMO & PPOFully Insured






Home Health AgencyOne state-licensed agency in each county where 1000 or more

members reside 100%

Hospice ProgramOne Medicare-certified program in any county where 1000 or more

members reside 100%Geographic Availability Standards


PCP-General Practice and Internal Medicine New Jersey has no urban, suburban or rural requirement

Urban 2:10 or 30 minutes avg driving time or public transit which ever is

less 90%Suburban 2:10 or 30 minutes 90%

Rural 2:10 or 30 minutes 90%Family Practice


Rural 2:10 or 30 minutes 90%Pediatric (17 yrs and younger)


Rural 2:10 or 30 minutes 90%OB/GYN (females 13 yrs and older)


Rural 2:10 or 30 minutes 90%HMO ONLY

Cardiology, Dermatology, Endocrinology, General Surgery, Neurology, OB/GYN,

Onocology, Opthamology, Orthopedics, Oral Surgery, Otolaryngology, Psychiatrists and Urology (for SCPs not identifed as one of

these 13 the requirement is the same)


Rural 1:45 or 60 minutes 90%Vision Care/Primary Eye Care

Optometry HMO & PPOUrban 1:45 or 60 minutes 90%

Suburban 1:45 or 60 minutes 90%




Rural 1:45 or 60 minutes 90%Acute Care Hospital: One licensed acute care

hospital including one licensed medical surgical, pediatiric, obstetrical and critical

care services in any county or service area.

1:20 miles or 30 minutes

90%Surgical Facilities including acute care hospitals, licensed ambulatory surgical

facilities, and/or Medicare certified physician's surgical practices available in each county or

service area.

1:20 miles or 30 minutes

90%One hospital providing regional perinatal

services1:45 miles or 60 minutes

90%Therapeutic Radiation Provider 1:20 miles or 30 minutes 90%

MRI Center 1:20 miles or 30 minutes 90%Diagnostic Radiology Provider including X-ray,

Ultrasound, and CAT Scan1:20 miles or 30 minutes

90%Licensed Renal Dialysis Provider 1:20 miles or 30 minutes 90%

Specialty Outpatient Centers for HIV/AIDS, Sickle Cell Disease, Hemophilia, and

Craniofacial and Congentinal anomolies 1:45 or 60 minutes 90%Comprehensive Rehab Services 1:45 or 60 minutes 90%

Hospital Offering Tertiary Pediatric Services 1:45 or 60 minutes 90%Licensed Long Term Care Facility with Medicare certified skilled nursing beds

1:20 miles or 30 minutes90%

Hospital Offering Diagnostic Cardiac Catherterization Services 1:45 or 60 minutes 90%


New Jersey Adminstrative Code 11:24-6.2 (a) (i-v)

(a)The HMO shall maintain an adequate number of primary care providers, specialists, and other ancillary health care personnel to serve the enrolled population. i) There shall be a sufficient number of licensed primary care providers (PCPs) under contract with the HMO to provide basic comprehensive health care services; ii) There shall be a sufficient number of licensed medical specialists available to HMO members to provide medically necessary specialty care. The HMO shall have a policy assuring access to the specialists identified in (a)1ii(1) through (13) below within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area: (1) Cardiologist; (2) Dermatologist; (3) Endocrinologist; (4) ENT; (5) General surgeon; (6) Neurologist; (7) Obstetrician/gynecologist; (8) Oncologist; (9) Ophthalmologist; (10) Orthopedist; (11) Oral surgeon; (12) Psychiatrist; and (13) Urologist;

New Jersey Adminstrative Code 11:24-6.3 (a) (1-5)

iii. For specialists not identified in (a)1ii above, the HMO shall have a policy assuring access to such specialists within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area; iv. There shall be a sufficent number of other health professional staff including but not limited to licensed nurses and other professionals available to the HMO members to provide basic health services; v. There shall be sufficient licensed optometrists associated with or available to the HMO to assure that, unless referral to an ophthalmologist is determined by the PCP to be medically required and outside the scope and practice of an optometrist, the member can choose to have vision care services provided by a licensed optometrist, the HMO shall have a policy assuring access to these providers, as set forth above in N.J.A.C. 11:24-6.2(a)1ii.




(a) The HMO shall maintain contracts or other arrangements acceptable to the Department with institutional providers which have the capability to meet the medical needs of members and are geographically accessible. The network of providers shall include: 1. At least one licensed acute care hospital including at least licensed medical-surgical, pediatric, obstretrical, and critical care services in any county or service area no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of mebers within the county or service area; 2. Surgical facilities including acute care hospitals, licensed ambulatory surgical facilities, and/or Medicare-certified physician surgical practices available in each county or service area no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of mebers within the county or service area; 3. Tertiary and specialized services as follows:

ii. The HMO must have a policy assuring access, as evidenced by contract or other agreement acceptable to the Department, to the following specialized services, as determined to be medically necessary. Such services will be available within 45 miles or 60 minutes average driving time, whichever is less, of 90 percent of members within each countty or approved sub-county area: (1) At least one hospital providing regional perinatal services; (2) A hospital offering tertiary pediatric services; (3) In-patient psychistric services for adults, adolescents and children; (4) Residential substance abuse treatment center; (5) Diagnostic cardiac actheterization services in a hospital; (6) Specialty out-patient centers for HIV/AIDS, sickle cell disease, hemophilia, and craniofacial and congenital abnormalities; and (7) Comprehensive rehabilitation services.

iii. The HMO shall have a policy assuring access, as evidenced by contract or other agreement acceptable to the Department, to the following specialized services, as determined to be medically necessary. Such services will be available within 20 miles or 30 minutes average driving time, whichever is less, of 90 percent of members within each county or approved sub-county area: (1) A licensed long term care facility with Medicare-certified skilled nursing beds; (2) Therapeutic radition provider; (3) Magnetic resonance imaging center; (4)Diagnostic radiology provider, including x-ray, ultrasound, and CAT scan; (5) Emergency mental health service, including a short term care facility for involuntary psychiatric admissions; (6) Out-patient therapy providers for mental health and substance abuse conditions; and (7) Licensed renal dialysis provider. 4. At least one home health agency licensed by the Deaprtment to serve each county where 1,000 or more members reside; and

5. At least one hospice program certified by Medicare in any county where 1,000 or more members reside.

New Jersey Adminstrative Code 11:24A-4.10 (b)(2)(i) Health Care Quality Act applicable to HMO and PPO

The carrier shall meet the following requirements for network adequacy: The carrier shall contract with a sufficient number of optometrists to assure access to an optometrist consistent with the requirements of (b)2 above, and the carrier shall not require that covered persons use the services of an ophthalmologist rather than an optometrist in order to obtain benefits, unless referral by a PCP is determined to be medically required, and the care outside the scope of practice of an optometrist.





New Jersey Behavioral Health HMO & PPOFully Insured


PsychiatristsUrban 1:45 or 60 minutes 90%

Suburban 1:45 or 60 minutes 90%Rural 1:45 or 60 minutes 90%

Inpatient Psychiatric Services for Adults, Adolescents and Children

1:45 or 60 minutes 90%

Residential Substance Abuse Treatment Center


Emergency Mental Health Service including short term care facility for involuntary psychiatric admissions


Out-patient therapy providers for mental health and substance abuse

conditions


(6) Out-patient therapy providers for mental health and substance abuse conditions.

New Jersey Adminstrative Code 11:24-6.2 (a) (ii)ii) There shall be a sufficient number of licensed medical specialists available to HMO members to provide medically necessary specialty care. The HMO shall have a policy assuring access to the specialists identified in (a)1ii (1) through (13) below within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved sub-county service area: (12) Psychiatrist.

New Jersey Adminstrative Code 11:24-6.3 (a) (ii) (3) (4) & (iii) (5) (6)ii. The HMO must have a policy assuring access, as evidenced by contract or other agreement acceptable to the Department, to the following specialized services, as determined to be medically necessary. Such services will be available within 45 miles or 60 minutesaverage driving time, whichever is less. of 90 percent of members within each county or approved sub-county area: (3) In-patient psychiatric services for adults, adolescents and children; (4) Residential substance abuse treatment center. iii. The HMO must have a policy assuring access, as evidenced by contract or other agreement acceptable to the Department, to the following specialized services, as determined to be medically necessary. Such services will be available within 20 miles or 30 minutesaverage driving time, whichever is less. of 90 percent of members within each county or approved sub-county area: (5) Emergency mental health service, including a short term facility for involuntary psychiatric admissions;




2011 Regional QM 10 Provider Availability State Tables

NEVADA HMO & PPO Fully Insured





















Action Required


Organization (NRS 679B.130) means a health maintenance organization or a provider-sponsored organization

Health care services means any services included in the furnishing to any natural person of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness or injury.

Provider means any physician, hospital or other person who is licensed or otherwise authorized in thisstate to furnish health care services


Nevada Administrative Code 695C.160

Geographic area of service: Definition. (NRS 679B.130, 695C.275) An organization shall clearly define the geographic area it intends to serve, which: 1. In a county having a population of 30,000 or more, must have a radius of not more than 25 miles between the subscriber or individual enrollee and a primary physician and the hospital used by the organization. 2. In any other county, must be defined by the organization under a plan for the provision of health care services if the organization receives the written approval of the Division for such a geographic area by: (a) Demonstrating the availability and accessibility of services to its enrollees, including reasonable access to primary physicians, a hospital and to medically necessary services or services in an emergency; and (b) Submitting a statement concerning the standards within that community regarding the availability and accessibility of other health care services and demonstrating that the organization will meet the community’s standards for such services. (Added to NAC by Comm’r of Insurance, eff. 6-11-86; A 5-27-92)

Nevada State Specific Definitions NevadaAdministrative Code 695C.060 & Nevada Revised Statutes 695C.030





New York HMO






Closed Practice Rate-Family Practice <18% 100%Geographic Availability Standards*


PCP-General Practice and Internal Medicine 3:30 miles or 30 minutes 90% Family Practice 3:30 miles or 30 minutes 90%

Pediatric (17 yrs and younger) 3:30 miles or 30 minutes 90%OB/GYN (females 13 yrs and older) 3:30 miles or 30 minutes 90%

Nurse Practitioners (Note: Nurse Practitioners may be primary or specialty care providers.

3:30 miles or 30 minutes 90%




Allergy/Immunology, Anesthesiology, Cardiology, Chiropractic, Colon Rectal

Surgery, Dermatology, Endocrinology and Metabolism, Gastroenterology, General

Surgery, Geriatrics, Hematology/Oncology, Infectious Disease, Neonatal-Perinatal

Medicine, Nephrology, Neurology, Neurological Surgery, Nurse Midwives, Nurse

Practitioners (Nurse Practitioners can be primary or specialty care providers),

Oncology, Ophthamology, Optometry, Oral surgery, Orthopedics, Otolaryngology, Pediatric Surgery, Physical Medicine &

Rehabilitation, Plastic Surgery, Podiatry, Pulmonary Medicine, Rheumatology, Thoracic Surgery, Urology, Audiology, Durable Medical

Equipment, Hospice, Home Health Care, I/P Hospital, Medical Laboratory, Pathology,

Pharmacy, Radiology, Residential Health Care Facility, Physical Therapy, Occupational

Therapy, Speech Therapy

2:30 miles or 30 minutes and 2 Specialists per County

90%

Note: Tables reflect a combination of regional standards and state requirements *Note: NY State does not break down mileage standards into urban, suburban and rural for Commercial Networks

New York Public Health Law §4403 5(a)(ii)(ii) & (iii) The commissioner, at the time of initial licensure, at least every three years thereafter, and upon application for expansion of service area, shall ensure that the health mainteneance organization maintains a network of health care providers adequate to meet the comprehensive health needs of its enrollees and to provide an appropriate choice of providers sufficient to provide the services covered under its enrollee's contracts by determining that (i) there are a sufficient number of geographically accessible participating providers; (ii) there are opportunities to select from at least three primary care providers pursuant to travel and distance time standards, providing that such standards account for conditions of accessing providers in rural areas; (iii) there are sufficient providers in each area of specialty practice to meet the needs of the enrollment population.

New York State Department of Health PHL §4403 IL §4303 Capacity Requirements




In addition to the full array of required health care providers, the network must include sufficient numbers of each provider type, be geographically distributed and ensure choice of primary and specialty care providers. The Public Health Law requires the member be allowed a choice of at least three geographically accessible primary care providers. With regard to specialty care providers, MCOs are required to contract minimally with two of each required specialist provider types in each county. However, additional providers may be required based on enrollment and to ensure geographic accessibility. For commercial networks, the time and distance standards are as follows: - 30 minutes or 30 miles for primary care providers - for all other providers it is preferred that they satisfy 30 minute or 30 mile standard.



QM 10 Practitoner and Provider Availability: Network Composition and Contracting Plan Attachment D


New York Behavioral Health HMOFully Insured


Psychiatrist 1 per 2,000 100%Therapist 1 per 1,000 100%Children 1 per 2,000 100%

Psychology 1 per 1,000 100%Social Work 1 per 1,000 100%

Facility 1 per 40,000 100%Geographic Availability Standards*


Child Psychiatry 3:30 miles or 30 minutes 90%Psychiatry 3:30 miles or 30 minutes 90%

Psychology 3:30 miles or 30 minutes 90%Social Work 3:30 miles or 30 minutes 90%

I/P Chemical Dependency/Detoxification Services

3:30 miles or 30 minutes 90%

O/P Chemical Dependency 2:30 miles or 30 minutes and 2 Specialists per County

90%

I/P Mental Health 2:30 miles or 30 minutes and 2 Specialists per County

90%

O/P Mental Health 2:30 miles or 30 minutes and 2 Specialists per County

90%

*Note: NY State does not break down mileage standards into urban, suburban and rural for Commercial Networks

New York State Department of Health PHL §4403 IL §4303 Capacity Requirements

The commissioner, at the time of initial licensure, at least every three years thereafter, and upon application for expansion of service area, shall ensure that the health mainteneance organization maintains a network of health care providers adequate to meet the comprehensive health needs of its enrollees and to provide an appropriate choice of providers sufficient to provide the services covered under its enrollee's contracts by determining that (i) there are a sufficient number of geographically accessible participating providers; (ii) there are opportunities to select from at least three primary care providers pursuant to travel and distance time standards, providing that such standards account for conditions of accessing providers in rural areas; (iii) there are sufficient providers in each area of specialty practice to meet the needs of the enrollment population.

New York Public Health Law §4403 5 (a)(ii)(ii) & (iii)

12/16/2010Aetna is the brand name used for products and servies provided by one or more of the Aetna group of companies. (Aetna)

FOR AETNA UE ONLY Attachment D


In addition to the full array of required health care providers, the network must include sufficient numbers of each provider type, be geographically distributed and ensure choice of primary and specialty care providers. The Public Health Law requires the member be allowed a choice of at least three geographically accessible primary care providers. With regard to specialty care providers, MCOs are required to contract minimally with two of each required specialist provider types in each county. However, additional providers may be required based on enrollment and to ensure geographic accessibility. For commercial networks, the time and distance standards are as follows: - 30 minutes or 30 miles for primary care providers - for all other providers it is preferred that they satisfy 30 minute or 30 mile standard.

12/16/2010Aetna is the brand name used for products and servies provided by one or more of the Aetna group of companies. (Aetna)

FOR AETNA UE ONLY Attachment D

QM 10 Practitioner and Provider Availability: Network Compositon and Contracting Plan Attachment D


Pennsylvania HMO & PPOFully Insured




Top 2 Specialists .5:1000 100%General Surgery, Orthopedic Surgery,

Ophthalmology, Allergy and Immunology, Anesthesiology, Otolaryngology, Physical

Medicine and Rehabilitation, Psychiatry and Neurology, Neurological Surgery, and Urology

.5:1000 100%

Closed Practice Rate-General and Internal <18% 100%Closed Practice Rate-Family Practice <18% 100%

Geographic Availability Standards* TYPE NUMBER OF PROVIDERS PER MILEAGE GOAL














General Surgery, Orthopedic Surgery, Ophthalmology, Allergy and Immunology, Anesthesiology, Otolaryngology, Physical

Medicine and Rehabilitation, Psychiatry and Neurology, Neurological Surgery, and Urology


Rural 1:45 miles or 60 minutes 90%General acute inpatient hospital services


Rural 1:45 miles or 60 minutes 90%Laboratory


Rural 1:45 miles or 60 minutes 90%Diagnostic Radiology Provider including X-ray,

Ultrasound, and CAT ScanUrban 1:20 miles or 30 minutes 90%


Note: Tables reflect a combination of regional standards and state requirements 28 PA Code § 9.679 (d) (e)




(d) A plan shall provide for at least 90% of its enrollees in each county in its service area, access to covered services that are within 20 miles or 30 minutes travel from an enrollee's residence or work in a county designated as a metropolitan statistical area (MSA) by the Federal Census Bureau, and within 45 miles or 60 minutes travel from an enrollee's residence or work in any other county. (e) A plan shall at all times assure enrollee access to primary care providers, specialty care providers and other health care facilities and services necessary to provide covered benefits. At a minumum, the following health care services must be available in accordance with the standards in subsection (d): (1) General acute inpatient hospital services (2) Common laboratory and diagnostic services (3) Primary care (4) General surgery (5) Orthopedic surgery (6) Obstetrical and gynecological services (7) Ophthalmology (8) Allergy and immunology (9) Anesthesiology (10) Otolaryngology (11) Physical medicine and rehabilitation (12) Psychiatry and neurology

(13) Neurological surgery (14) Urology.





Pennsylvania Behavioral Health HMO & PPOFully Insured

Numeric Availability Standards PHYSICIAN PHYSICIAN PER 1,000 ENROLLEE GOALPsychiatry .5:1000 100%

Geographic Availability Standards* TYPE NUMBER OF PROVIDERS PER MILEAGE GOAL

PsychiatryUrban 1:20 miles or 30 minutes 90%



28 PA Code § 9.679 (d) (e) (d) A plan shall provide for at least 90% of its enrollees in each county in its service area, access to covered services that are within 20 miles or 30 minutes travel from an enrollee's residence or work in a county designated as a metropolitan statistical area (MSA) by the Federal Census Bureau, and within 45 miles or 60 minutes travel from an enrollee's residence or work in any other county. (e) A plan shall at all times assure enrollee access to primary care providers, specialty care providers and other health care facilities and services necessary to provide covered benefits. At a minumum, the following health care services must be available in accordance with the standards in subsection (d): (1) General acute inpatient hospital services (2) Common laboratory and diagnostic services (3) Primary care (4) General surgery (5) Orthopedic surgery (6) Obstetrical and gynecological services (7) Ophthalmology (8) Allergy and immunology (9) Anesthesiology (10) Otolaryngology (11) Physicalmedicine and rehabilitation (12) Psychiatry and neurology (13) Neurological surgery (14) Urology.



QM 10 Practitoner and Provider Availability: Network Composition and Contracting Attachment D]


TEXAS HMOFully Insured


Family Practice, General Practice, Internal Medicine 1:250 100%


Top 5 Specialists 1:5000 100%Closed Practice Rate-General and Internal <10% 100%

Closed Practice Rate-Family Practice <10% 100%Closed Practice Rate-Pediatrics <10% 100%


Family Practice,General Practice and Internal Medicine

Urban/Suburban/Rural 1:30 miles * 100% Pediatric (17 yrs and younger)

Urban/Suburban/Rural 1:30 miles * 100% OB/GYN (females 13 yrs and older)

Urban/Suburban/Rural 1:30 miles * 100% General Hospitals

Urban/Suburban/Rural 1:30 miles * 100%

Specialists (report each separately)Allergy & Immunology; Cardiovascular Services, Chiropractors, Dermatology, Endocrinology Diabetes & Metabolism,

Gastroenterology, General Surgery, Hematology/Oncology, Infectious Disease, Nephrology, Neurology , Nutrition/Dietary

Services, Ophthalmology, Optometry, Orthopedic Surgery, Otolaryngology, Podiatry,

Pulmonary/Critical Care, Rheumatology, Urology




QM 10 Practitoner and Provider Availability: Network Composition and Contracting Attachment D]

Diagnostic & Therapeutic Services(report each separately)

Ambulatory Surgical Center, Chiropractic, Diagnostic Imaging Centers, Dialysis, DME

Orthotic and Prosthetics, Home and Community Support Services (Free Standing

Hospice), Home Health Care Agencies, Nutrition/Dietary, Lab, Occupational Therapy,

Outpatient Reference Labs, Pharmacy, Physical Therapy, Podiatry, Rehabilitation

Facilities, Skilled Nursing Facilities, Specialty Hospitals, Speech Therapy, Therapeutic

Oncologic Radiation Facilities, Urgent Care Centers and Vision Centers


Hospital-Based Physicians(report each separately)

Anesthesiology, Emergency Room Physicians, Neonatology, Radiology, Pathology


Texas Admin Code 28 TAC §11.1902 (2) (B) (i)The QI program for basic and limited services HMOs shall be continuous and comprehensive, addressing both the quality of clinical care and the quality of services. The HMO shall dedicate adequate resources, such as personnel and information systems, to the QI program. (2) Work plan. The QI program shall include an annual QI work plan designed to reflect the type of services and the population served by the HMO in terms of age groups, disease categories, and special risk status. The work plan shall include: (B) The work plan shall address each program area, including: (i) Network adequacy, which includes availability and accessibility of care, including assessment of open/closed physician and individual provider panels

Note: Tables reflect state requirements

* In addition to member access mileage, maps for each provider type must contain radii mapping to ensure that providers are geographically distributed so all portions of the service area meet the required distance - 30 miles for PCP, Pediatric, OB/GYN, Hospitals and 75 miles for all others.

Texas Admin Code 28 TAC §11.1607 (h) An HMO is required to provide an adequate network for its entire service area. All covered services must be accessible and available so that travel distances from any point in its service area to a point of service are no greater than: (1) 30 miles for primary care and general hospital care; and (2) 75 miles for specialty care, specialty hospitals, and single healthcare service plan physicians or providers.





TEXAS Behavioral Health HMOFully Insured


PsychiatristsUrban/Suburban/Rural 1:75 miles * 100%

PhD PsychologistsUrban/Suburban/Rural 1:75 miles * 100%

Other Behavioral Health (BH) PractitionersUrban/Suburban/Rural 1:75 miles * 100%

Acute Psychiatric FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

CD IOP FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

MH IOP FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

CD Partial Hospitalization FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

MH Partial Hospitalization FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

CD Residential Treatment FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

MH Residential Treatment FacilitiesUrban/Suburban/Rural 1:75 miles * 100%

An HMO is required to provide an adequate network for its entire service area. All covered services must be accessible and available so that travel distances from any point in its service area to a point of service are no greater than: (1) 30 miles for primary care and general hospital care; and (2) 75 miles for specialty care, specialty hospitals, and single healthcare service plan physicians or providers.

Note: Tables reflect state requirements

* In addition to member access mileage, maps for each provider type must contain radii mapping to ensure that providers are geographically distributed so all portions of the service area meet the required distance - 30 miles for PCP, Pediatric, OB/GYN, Hospitals and 75 miles for all others.

Texas Admin Code 28 TAC §11.1607 (h)





Vermont HMO & PPOHMO, POS, PPO, Fully-Insured & Self-Insured (Non-ERISA)





Closed Practice Rate-Family Practice <18% 100%Geographic Availability Standards*

TYPE

NUMBER OF PROVIDERS PER MILEAGE VT does not break mileage requirements into urban, suburban &

ruralGOAL

PCP-General Practice and Internal Medicine 1 in 30 minutes 90%

Family Practice 1 in 30 minutes 90%Pediatric (17 yrs and younger) 1 in 30 minutes 90%

OB/GYN (females 13 yrs and older) 1 in 30 minutes 90%Top 2 Specialists 1 in 60 minutes 90%

Outpatient Physician Specialty Care; Laboratory; Pharmacy; General Optometry;

Inpatient; Imaging; and Inpatient Medical Rehabilitation Services

1 in 60 minutes 90%

Kidney Transplantation; Major Trauma Treatment; Neonatal Intensive Care; Tertiary-

Level Cardiac Services (including procedures such as Cardiac Catheterization

and Cardiac Surgery)

1 in 90 minutes 90%

Other Specialty Care (including Major Burn Care, Organ Transplants (other than

kidneys), and Specialty Pediatric Care

1 in 90 minutes 90%

Note: Tables reflect a combination of regional standards and state requirements State of Vermont Division of Health Care Administration Rule H-2009-03 Part 5 Section 5.1 Adequacy of

Access to Providers and Continuity of Services




Each managed care organization, either directly or through its provider contracts, shall ensure that covered health services are accessible to members on a timely basis, as follows. Each managed care organization shall contract with sufficient numbers and types of providers to ensure that all covered services for which there are restrictions or incentives for members to use contracted or certain other providers will beprovided without unreasonable delay. This requirement must be met in all service areas where the managed care organiztion has members. Travel time standards. Travel times for members of a mangaed care organization to contracted providers, under normal conditions from their residence or place of business, generally should not exceed the following: 1. Thirty (30) minutes to a primary care provider; 2. Thirty (30) minutes to routine, office-based mental health and substance abuse services; 3. Sixty (60) minutes for outpatient physician specialty care; intensive outpatient, partial hospital, residential or inpatient mental health and substance abuse services; laboratory; pharmacy; general optometry; inpatient; imaging; and inpatient medical rehabilitation services; 4. Ninety (90) minutes for kidney transplantation, major trauma treatment; neonatal in





Vermont Behavioral Health HMO & PPOHMO, POS, PPO, Fully-Insured & Self-Insured (Non-ERISA)

Geographic Availability Standards*

TYPE

NUMBER OF PROVIDERS PER MILEAGE *VT does not break mileage requirements

into urban, suburban & ruralGOAL

Office-based Mental Health and Substance Abuse Services

1 in 30 minutes 90%

Intensive Outpatient 1 in 60 minutes 90%Partial Hospital 1 in 60 minutes 90%

Inpatient Mental Health and Substance Abuse Services

1 in 60 minutes 90%

State of Vermont Division of Health Care Administration Rule H-2009-03 Part 5 Section 5.1 Adequacy of Access to Providers and Continuity of Services

Each managed care organization, either directly or through its provider contracts, shall ensure that covered health services are accessible to members on a timely basis, as follows. Each managed care organization shall contract with sufficient numbers and types of providers to ensure that all covered services for which there are restrictions or incentives for members to use contracted or certain other providers will beprovided without unreasonable delay. This requirement must be met in all service areas where the managed care organization has members. Travel time standards. Travel times for members of a mangaed care organization to contracted providers, under normal conditions from their residence or place of business, generally should not exceed the following: 1. Thirty (30) minutes to a primary care provider; 2. Thirty (30) minutes to routine, office-based mental health and substance abuse services;

3. Sixty (60) minutes for outpatient physician specialty care; intensive outpatient, partial hospital, residential or inpatient mental health and substance abuse services; laboratory; pharmacy; general optometry; inpatient; imaging; and inpatient medical rehabilitation services; 4. Ninety (90) minutes for kidney transplantation, major trauma treatment; neonatalintensive care; and tertiary-level cardiac services, including procedures such as cardiac catheterization and cardiac surgery; and 5. Reasonable accessibility for other specialty services, including major burn care, organ transplantation (other than kidneys), and specialty pediatric care.

12/16/2010



WASHINGTON PPO



















Note: Tables reflect regional standards, as there are no state requirements

Action Required


Gaps in the technological and specialty services available will be evaluated by trending non par requests.

Participating provider and participating facility means a facility or provider who, under a contract with the health carrier or with the carrier's contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, from the health carrier rather than from the covered person.

Primary care provider means a participating provider who supervises, coordinates, or provides initial care or continuing care to a covered person, 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 covered person.

Health care provider or provider means: (a) A person regulated under Title 18 RCW or chapter 70.127 RCW, to practice health or health-related services or otherwise practicing health care services in this state consistent with state law; or (b) An employee or agent of a person described in (a) of this subsection, acting in the course and scope of his or her employment.

Health carrier or carrier means a disability insurance company regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as defined in RCW 48.44.010, and a health maintenance organization as defined in RCW 48.46.020

Health plan or plan means any individual or group policy, contract, or agreement offered by a health carrier to provide, arrange, reimburse, or pay for health care service except the following: (a) Long-term care insurance governed by chapter 48.84 RCW; (b) Medicare supplemental health insurance governed by chapter 48.66 RCW; (c) Limited health care service offered by limited health care service contractors in accordance with RCW 48.44.035;

Managed care plan means a health plan that coordinates the provision of covered health care services to a covered person through the use of a primary care provider and a network.

Washington Administrative CodeTitle 284 Chapter 43

284-43-200Network Adequacy

(2) Sufficiency and adequacy of choice may be established by the carrier with reference to any reasonable criteria used by the carrier, including but not limited to: Provider-covered person ratios by specialty, primary care provider-covered person ratios, geographic accessibility, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care. Evidence of carrier compliance with network adequacy standards that are substantially similar to those standards established by state agency health care purchasers (e.g., the state health care authority and the department of social and health services) and by private managed care accreditation organizations may be used to demonstrate sufficiency. At a minimum, a carrier will be held accountable for meeting those standards described under WAC 284-43-220 (5) A health carrier shall monitor, on an ongoing basis, the ability and clinical capacity of its network providers and facilities to furnish health plan services to covered persons

Washington State Specific Definitions - WAC 284-43-130 Facility means an institution providing health care services, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic settings.





WISCONSIN PPOFully Insured






















Action Required


628.36(2)(a)1 Health care plan means an insurance contract providing coverage of health care expenses.

609.01(5m) Provider means a health care professional, a health care facility or a health care service or organization.

Wisconsin Statutes 609.22 Defined Network Plans

1) PROVIDERS. A defined network plan shall include a sufficient number, and sufficient types, of qualified providers to meet the anticipated needs of its enrollees, with respect to covered benefits, as appropriate to the type of plan and consistent with normal practices and standards in the geographic area.(1) An insurer offering a defined network plan that is not a preferred provider plan shall do all of the following:(a) Provide covered benefits by plan providers with reasonable promptness with respect to geographic location, hours of operation, waiting times for appointments in provider offices and after hours care. The hours of operation, waiting times, and availability of after hours care shall reflect the usual practicein the local area. Geographic availability shall reflect the usual medical travel times within the community

Wisconsin State Specific Definitions 609.01(1b) Defined Network Plan means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan.



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