Network Adequacy FAQs
- What other accreditation organizations would Insurance consider other than NCQA,
JCAHO or URAC?
- Currently, Insurance has no knowledge of other accrediting organizations. We
would rely on a plan that had accreditation from another organization, or
was aware of another accrediting organization. If a plan wished to provide
us with information about that organization, we could research what the accrediting
organization offers, it's history, whether or not it offers partnership arrangements
with government, what its standards are, how accreditation is maintained
over time, and/or other issues that might be pertinent. We would try to make
an educated and fair determination of whether or not another accreditation
organization could reasonably and credibly serve as a proxy for direct government
We would try to figure all this out in time for the plan to know
whether or not the accreditation would matter for purposes of filing provider
data with the next access plan. The sooner we had a request to investigate
another accrediting organization, the more likely we are to be able to come
up with an answer in time. Therefore, no one should feel they have to wait
until October 15 of each year to bring another accrediting organization to
our attention. We would be happy to consider such a request any time before
- I received a letter regarding my access plan, and it says something about
a portion of the access plan being 'conditionally approved'. What does this
- The outcome of an HMO access plan filing could take many final forms.
There are two components to every access plan: the network component, which
be represented by data or by an affidavit of accreditation; and the written
component, which is the documentation addressing requirements from sections
(2)(A)2 and (2)(A)3 of 20 CSR 400-7.095. Either component can affect whether
or not an access plan meets the requirements for approval. In addition, an
access plan could be approved, or it could be 'conditionally approved'. Conditional
approval will be granted if a network earns an enrollee access score of 90%
on average, but a few counties in the service area fall below 90%.
access plan was consolidated to represent two or more managed care plans,
such as an MC+ managed care plan and a commercial managed care plan,
it may be that the MC+ portion of the consolidated access plan meets all
the requirements for approval, but the commercial portion doesn't. Rather
than withholding approval entirely, Insurance is required to approve as much of
a consolidated access plan as can be approved. Finally, a portion of an access
plan might be conditionally approved, just like a portion of an access plan
might be approved. So:
- If your letter specifies that your access plan is approved, no further
action is required unless there is a change in your accreditation
status or your network.
- If your letter specifies that only a portion of your access plan is
approved, there is still work to be done on the remainder of the access
- If your letter specifies that your access plan, or a portion of your
access plan, is conditionally approved, there is still work to be done,
Insurance provided 30 days for you to specifically respond to the areas
of your network
that fall below 90%.
If your letter specifies neither approval nor conditional approval, this
means there are outstanding issues in the written component of the access
You will need to address those. In addition, if your enrollee access scores
are less than 90% in any county in your service area, you have 30 days
to specifically respond to this.
If my access plan was conditionally approved, and I sent a response as required,
- It's possible that the final status of an access plan could change from 'conditionally
approved' to 'approved'. For example, if you discover that the provider data
you filed contained errors that might affect the enrollee access score in
a particular county, corrected provider data should be filed. It's also possible
for 'conditional approval' to remain as the final status of the access plan.
The final status depends on how you respond to the areas of your network
that have enrollee access rates of less than 90%. Once we receive your response
and all outstanding issues with the access plan are settled, a final status
letter will be issued."
- Regarding the standards for getting an appointment with a participating
provider, what does Insurance want to see in the access plan?
- It's very important to note that the regulation states the minimum standards
for getting an appointment with ALL PROVIDERS listed in Exhibit A, including
facilities. Access plans that only reflect appointment standards for PCPs
and OB/GYN, without incorporating all providers listed in Exhibit A, are
no longer acceptable. Many HMOs simply provide a grid showing the level of
need (routine care with no symptoms, routine care with symptoms, urgent care
and emergency care) and the time frame for getting an appointment that applies
at each level. Grids are an effective and acceptable way to address this
issue in the access plan. However, grids should clearly apply to ALL PROVIDERS
listed in Exhibit A, and should also indicate compliance with the specific
OB/GYN appointment standards. Grids that appear to apply to PCPs and OB/GYNs
only are not sufficient. The HMO should either add a grid for the rest of
the providers listed in Exhibit A, or should otherwise incorporate ALL PROVIDERS
listed in Exhibit A. HMOs that apply stricter standards than the regulation
requires are encouraged to show specific providers for which stricter standards
are applied, as long as the minimum standards expressed in the regulation
are clearly applied to ALL PROVIDERS listed in Exhibit A.
- I have questions related to the completion of the affidavits, as we are
both URAC and Medicare +Choice approved.
- The regulation requires an affidavit for each managed care plan. Insurance will
accept a consolidated affidavit. One affidavit may be completed for multiple
managed care plans as long as each managed care plan is adequately identified
by the network, product name and policy/certificate form(s) with amendments
applicable. The accreditation information applicable to each plan must be
clearly stated. A managed care plan is made up of the network the enrollee
has access to and the policy/certificate form which outlines his benefits
and restrictions to benefits. It is important to identify which accreditation
applies to a particular managed care plan or product name. The Affidavit
may be expanded as necessary if extra space is needed.
- I want to be clear on what we are required to submit if our organization
is NCQA accredited. It was my understanding that if an organization is NCQA
accredited, submitting the affidavit is in lieu of the raw data files. I
want to know if we are responsible for sending in the written component of
the access plan if no changes occurred since last year's submission. I want
to be assured that I am providing all required information.
- If an organization is accredited by any of the permitted organizations,
it is necessary to send the written information, accreditation affidavit,
all provider directories utilized, along with any additional information
requested by the Director.
If an HMO offers more than one managed care plan, one written component may
be submitted as long as the information submitted clearly identifies the
managed care plan to which it applies.
- May the affidavit be used for Missouri's Medicaid Plans?
- No. Missouri MC+ organizations may not utilize the affidavit for
their Medicaid market. Data must be submitted in the format outlined
in the Network Adequacy Instructions for 2003. If an HMO has both Commercial
and Medicaid markets, the affidavit may be used if the Commercial market
is accredited. However, the network data must be submitted for the
- A number of subspecialists and services are no longer required to be reported
for network adequacy in 2003. Do we still need to provide these services
- Yes, HMO's are required to provide medically necessary basic healthcare
services to their enrollees. The elimination of these specialists from the
regulation only means there are no prescribed distance standards with which
the HMO must comply. HMOs remain obligated to provide reasonable access
to participating medical providers for all covered benefits.
- We are no longer marketing one of our commercial managed care products
and only have a small number of enrollees. Must we still submit the
data for this product?
- You are permitted to request a waiver from filing the annual access plan
if you have complied with the provisions of 20 CSR 400-7.095(2)(D). The
HMO must certify that it has notified all enrollees and producers with whom
they do business that the HMO ceased writing new contracts. In addition,
the HMO must have also informed enrollees of this managed care plan that
they may access any provider at no greater cost than if that provider was
a participating provider, in the event the managed care plan cannot provide
access to providers as required in the regulation. This request must
normally be received by January 15th of the year the filing would
be required. For 2003 only, this deadline has been extended to March
- Our provider license numbers require 10 spaces instead of the prescribed
8 spaces for the provider data file. Are we permitted to expand this
- Yes, in this situation, you may expand the field to 10 characters or more. Please
state that this has been done in your cover letter to avoid loss of data
when the files are imported and cleaned.