On April 24, 2023, the MIA adopted revised network adequacy regulations for health benefit plans under Code of Maryland Regulations (“COMAR”) 31.10.44. As indicated in COMAR 31.10.44.04H and .08A of the revised regulations, many of the new regulatory requirements apply only to annual access plans submitted on or after July 1, 2024. However, a significant number of the new provisions become effective on May 15, 2023. Please refer to Bulletin 23-8 for additional information.
Current Regulations
Health Benefit Plans COMAR
31.10.44
Dental Plans COMAR 31.10.45
Final Regulation
Title 31 Maryland Insurance Administration
Subtitle 10 Health Insurance - General
Chapter 44 Network Adequacy
View the Final Regulation
Proposed Regulation
Title 31 Maryland Insurance Administration
Subtitle 10 Health Insurance - General
Chapter 44 Network Adequacy
View the Proposed Regulation
Draft Regulation
Title 31 Maryland Insurance Administration
Subtitle 10 Health Insurance - General
Chapter 44 Network Adequacy
View the Draft Regulation: 31.10.44
2019-2022 MIA Questions and Hearings
In preparation for the network adequacy public meeting on June 18, 2021 that will focus on telehealth, MIA staff would appreciate your comments on the following:
1) The MIA acknowledges that consumer choices and preferences between in-person services and telehealth services are critically important considerations when determining whether an individual enrollee has access to needed health care services. However, the existing quantitative network adequacy standards that apply to in-person services and that are measured on an aggregate basis for a carrier’s entire network are based solely on clinical appropriateness, and do not account for individual enrollee preference. When measuring the quantitative network adequacy standards for the entire network, what is the rationale for why enrollee preference must be taken into account for clinically appropriate telehealth services, when this is not taken into account for clinically appropriate in-person services?
2) Carriers have contended that a provision that only allows telehealth services to count toward satisfaction of the network adequacy standards when an individual enrollee elects to use telehealth is unreasonable and extremely difficult to operationalize. If it is not operationally feasible to include enrollee preference with respect to telehealth when measuring compliance with the quantitative network adequacy standards on an aggregate basis, what are suggestions for how the network adequacy standards can otherwise still account for enrollee preference on an individual basis to ensure all enrollees have access to services that meet their needs?
3) Multiple stakeholders have proposed that carriers should be awarded a telehealth credit of up to 10% toward satisfaction of either the wait time standard or the travel distance standard. The Medicare Advantage network adequacy standards have been referenced as a model for this provision. Under the Medicare Advantage standard, a carrier may receive the credit merely by contracting with telehealth providers in particular specialties.
(a) If Maryland considers adopting some form a telehealth credit, what additional or alternative criteria should be required prior to granting the credit to ensure telehealth is available and accessible to enrollees who need it?
(b) If a telehealth credit is applied toward satisfaction of a network adequacy standard, how can the regulations ensure that the credit is only awarded in situations where a telehealth service is clinically appropriate, available, and accessible to enrollees for the particular medical specialty, geographic area, and/or appointment type where the applicable standard is not met? For example, if the travel distance standard is not met for dermatology in the rural geographic areas, it would not appear appropriate to even consider awarding a telehealth credit unless, in the specific rural zip codes where the standard is not met, the carrier offers telehealth services from in-network dermatologists, and the technological infrastructure to support the delivery of telehealth exists in those zip codes. Will carriers be able to gather the data and resources necessary to gauge telehealth accessibility at this level? What standards or criteria can be added to the regulations to address this issue?
While these questions will be discussed at the June 18, 2021 meeting, the MIA will continue to accept written responses to these questions for a 30-day period following the meeting. Please submit your responses to
networkadequacy.mia@maryland.gov.
2019-2021 Hearing Testimony
- View comments submitted by Legal Action Center
July 19, 2021 - View comments submitted by Kaiser Permanente
July 16, 2021 - View comments submitted by Maryland Psychological Association
July 16, 2021 - View comments submitted by Maryland Hospital Association
July 16, 2021 - View comments submitted by CareFirst BlueCross BlueShield
July 16, 2021 - View comments submitted by The League of Life and Health Insurers of Maryland
July 16, 2021 - View comments submitted by Maryland Academy of Nutrition and Dietetics (MAND)
June 25, 2021 - View comments submitted by Maryland Coalition of Families
June 18, 2021 - View comments submitted by APTA.
August 19, 2020 - View comments submitted by CareFirst.
August 19, 2020 - View comments submitted by Kaiser Permanente.
August 19, 2020 - View comments submitted by the League of Life.
August 19, 2020 - View comments submitted by the Legal Action Centers.
August 19, 2020. - View comments submitted by MD Coalition of Families.
August 19, 2020 - View comments submitted by MDDCSAM.
August 19, 2020 - View comments submitted by MedChi.
August 19, 2020 - View comments submitted by the Maryland Academy of Nutrition and Dietetics
August 4, 2020 - View comments submitted by the Maryland Psychiatric Society January 22, 2020.
- View comments submitted by the Maryland Assembly on School-
Based Health Care January 19, 2020 - View comments submitted by American Psychiatric Association January 13, 2020.
- View comments submitted by Maryland Academy of Nutrition and Dietetics December 18, 2019.
- View comments submitted by Legal Action Center December 19, 2019.
- View comments submitted by Community Behavioral Health Association of Maryland December 12, 2019.
- View comments submitted by Maryland Assembly on School-Based Health Care November 12, 2019.
- View comments submitted by Maryland Society of Pathologists November 4, 2019.
2019-2020 MIA Staff Questions to Interested Parties
The Maryland Insurance Administration is accepting comments on all aspects of the network adequacy regulations in COMAR 31.10.44. In addition to the questions posed in the October 23, 2019 meeting agenda, MIA staff would appreciate comments on the following:
In the definitions section in COMAR 31.10.44.02, should a definition for any of the provider types listed in the travel distance standards be included?
Do the charts of travel distance standards in COMAR 31.10.44.04 include the appropriate mix of providers? Should any providers be added (e.g. child psychiatrist) or removed, and why?
Are the current mileage metrics for the travel distance standards in COMAR 31.10.44.04 appropriate?
Should carriers be required to comply with the travel distance standards for 100% of enrollees, or should the threshold be 95% to be consistent with the appointment waiting time standards, and why?
Should the regulations be revised to require that travel distance standards are based on “road travel distance”? Why or why not?
For enrollees covered under student health plans, should the regulations mandate or allow that the school’s address be used for determining travel distance standards?
For the essential community provider standard, COMAR 31.10.44.04C requires that a provider panel “shall include 30 percent of the available essential community providers in each of the urban, rural, and suburban areas.”
Should the regulation be revised to require a standardized methodology for calculating the 30% inclusion standard by geographic region?
Should carriers be required to provide a list of all contracted ECPs within their network for each provider panel?
Should the regulations require a standardized methodology to measure wait time standards, and if so, what methodology?
Are the current time period metrics for the waiting time standards in COMAR 31.10.44.05 appropriate based on the availability of healthcare providers in Maryland?
The Following Two Questions have been Added Effective December 3, 2019
House Bill 599 of the 2019 legislative session, effective January 1, 2020, requires carriers to use the most recent edition of the American Society of Addiction Medicine treatment criteria (“ASAM criteria”) for all medical necessity and utilization management determinations for substance use disorder benefits. Are revisions to the network adequacy regulations in COMAR 31.10.44 necessary to ensure that a carrier’s network is sufficient to provide coverage at all levels of care indicated by the ASAM criteria? If so, what specific standards or metrics should be established based on the ASAM criteria?
It has been noted that the definition of “essential community provider” in the plan certification regulations for the Maryland Health Benefit Exchange expressly includes school-based health centers, but the corresponding definition in the network adequacy regulations for the Maryland Insurance Administration does not. Are there any potential adverse consequences for consumers or significant carrier concerns with revising the essential community provider definition in COMAR 31.10.44.02B(6) to expressly include school-based health centers?
Please note that the deadline for the submission of written comments is August 19, 2020.
