Network Adequacy FAQ

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 oversight.

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 October 15!
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 mean?
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 could 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%.

If an 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 plan.
  • 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, and 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 plan. 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, then what?
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.
See example
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 Medicaid market.
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 to enrollees?
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 1, 2003.
Our provider license numbers require 10 spaces instead of the prescribed 8 spaces for the provider data file.  Are we permitted to expand this space?
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.