1. In order for the Commissioner to determine that a network plan made available for sale in this State is adequate, the network plan must contain, at a minimum:
(a) Evidence that the network plan provides reasonable access to at least one provider in the specialty area listed in the following table for at least 90 percent of enrollees by complying with the area designations for the maximum time and distance standards in the following table:
|
Specialty Area
|
Maximum Time and Distance Standards (Minutes/Miles)
|
|
Metro
|
Micro
|
Rural
|
Counties with Extreme Access Considerations (CEAC)
|
|
Primary Care
|
15/10
|
30/20
|
40/30
|
70/60
|
|
Endocrinology
|
60/40
|
100/75
|
110/90
|
145/130
|
|
Infectious Diseases
|
60/40
|
100/75
|
110/90
|
145/130
|
|
Oncology - Medical/Surgery
|
45/30
|
60/45
|
75/60
|
110/100
|
|
Oncology - Radiation/Radiology
|
60/40
|
100/75
|
110/90
|
145/130
|
|
Psychiatrist
|
45/30
|
60/45
|
75/60
|
110/100
|
|
Psychologist
|
45/30
|
60/45
|
75/60
|
110/100
|
|
Licensed Clinical Social Workers (LCSW)
|
45/30
|
60/45
|
75/60
|
110/100
|
|
Pediatrics
|
25/15
|
30/20
|
40/30
|
105/90
|
|
Rheumatology
|
60/40
|
100/75
|
110/90
|
145/130
|
|
Hospitals
|
45/30
|
80/60
|
75/60
|
110/100
|
|
Outpatient Dialysis
|
45/30
|
80/60
|
90/75
|
125/110
|
(b) Evidence that the network plan:
(1) Contracts with at least 35 percent of the:
(I) Essential community providers in the service area of the network plan that are available to participate in the provider network of the network plan.
(II) Federally-qualified health centers in the service area of the network plan that are available to participate in the provider network of the network plan.
(III) Family planning providers in the service area of the network plan that are available to participate in the provider network of the network plan.
(2) Offers contracts in good faith to all available Indian health care providers in the service area of the network plan, including, without limitation, the Indian Health Service established pursuant to 25 U.S.C. §
1661, Indian Tribes, tribal organizations and urban Indian organizations, as defined in 25 U.S.C. §
1603, which apply the special terms and conditions necessitated by federal statutes and regulations as referenced in the
Model Qualified Health Plan Addendum for Indian Health Care Providers. A copy of the
Model Qualified Health Plan Addendum for Indian Health Care Providers may be obtained free of charge at the Internet address
https://www.qhpcertification.cms.gov/s/ECP%20and%20Network%20Adequacy.
(3) Offers contracts in good faith to all available essential community providers in all counties in the service area of the network plan that are designated pursuant to subsection 3 as Counties with Extreme Access Considerations.
(4) Offers contracts in good faith to at least one essential community provider in each category of essential community provider in the following table, in each county in the service area of the network plan, where an essential community provider in that category is available and provides medical or dental services that are covered by the network plan:
|
Major ECP Category
|
ECP Provider Types
|
|
Family Planning Providers
|
Title X Family Planning Clinics and Title X "Look-Alike" Family Planning Clinics
|
|
Federally Qualified Health Centers (FQHCs)
|
Federally Qualified Health Centers and Federally Qualified Health Center "Look Alike" Clinics, Outpatient health programs/facilities operated by Indian tribes, tribal organizations, programs operated by Urban Indian Organizations
|
|
Hospitals
|
Disproportionate Share Hospitals (DSH) and DSH-eligible Hospitals, Children's Hospitals, Rural Referral Centers, Sole Community Hospital, Freestanding Cancer Centers, Critical Access Hospitals
|
|
Indian Health Care Providers
|
Indian Health Service providers, Indian Tribes, Tribal organizations, and urban Indian Organizations
|
|
Ryan White Providers
|
Ryan White HIV/AIDS Program Providers
|
|
Other ECP Providers
|
STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics, Community Mental Health Centers, Rural Health Clinics, Substance Use Disorder Treatment Centers, Health centers providing dental services, Rural Emergency Hospitals and other entities that serve predominantly low-income, medically underserved individuals
|
2. To offer a contract in good faith pursuant to paragraph (b) of subsection 1, a network plan must offer contract terms comparable to the terms that a carrier or other person or entity which issues a network plan would offer to a similarly situated provider that is not an essential community provider, except for terms that would not be applicable to an essential community provider, including, without limitation, because of the type of services provided by an essential community provider. A network plan must be able to provide verification of such offers if the Commissioner requests to verify compliance with this policy.
3. For the purposes of this section, the area designations for the maximum time and distance standards are based upon the population size and density parameters of individual counties within the plan's service area. The population and density parameters applied to determine county type designations are listed in the following table:
|
County Type
|
Population
|
Density
|
|
Metro
|
>= 1,000,000
|
10 - 999.9/mi2
|
|
500,000 - 999,999
|
10 - 1,499.9/mi2
|
|
200,000 - 499,999
|
10 - 4,999.9/mi2
|
|
50,000 - 199,999
|
100 - 4,999.9/mi2
|
|
10,000 - 49,999
|
1,000 - 4,999.9/mi2
|
|
Micro
|
50,000 - 199,999
|
10 - 49.9/mi2
|
|
10,000 - 49,999
|
50 - 999.9/mi2
|
|
Rural
|
10,000 - 49,999
|
10 - 49.9/mi2
|
|
< 10,000
|
10 - 4,999.9/mi2
|
|
Counties with Extreme Access Considerations or CEAC
|
Any
|
< 10/mi2
|
4. As used in this section:
(a) "Essential community provider" or "ECP" means a provider of healthcare that serves predominantly low-income, medically underserved individuals. The term includes, without limitation:
(1) Health care providers described in section 340B(a)(4) of the Public Health Service Act, 42 U.S.C. §
256b(a)(4), as amended;
(2) Entities described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act, 42 U.S.C. §
1396r-8(c)(1)(D)(i)(IV), as amended, including, without limitation, state-owned family planning service sites, governmental family planning service sites or not-for-profit family planning service sites that do not receive funding that qualifies the service for the drug pricing program established pursuant to section 340B of the Public Health Service Act, 42 U.S.C. §
256b, as amended, without limitation, funding pursuant to Title X of the Public Health Service Act, 42 U.S.C. §
300 et seq., as amended; or
(3) Indian health care providers, unless any of the providers or entities listed in subparagraphs (1), (2) and (3) has lost its status as a provider described in section 340B(a)(4) of the Public Health Service Act, 42 U.S.C. §
256(b)(a)(4), as amended, or as an entity described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act, 42 U.S.C. §
1396r-8(c)(1)(D)(i)(IV), as amended, as a result of violating Federal law.
(b) "Maximum time and distance standards" means the maximum time and distance an individual should have to travel to see a provider of health care based on the area designation determined pursuant to subsection 3.
Notes
Nev. Admin. Code §
687B.768
Added to NAC by Comm'r of Insurance, by R049-14, eff. 4/4/2016; A by R002-18A, eff. 4/30/2018; A by R002-18AP, eff. 1/1/2019; A by R067-19A, eff. 12/17/2019; A by R024-23A, eff. 1/5/2024; A by R118-24A, eff. 1/1/2025
