<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".07" citation="COMAR 14.35.16.07" title_num="14" subtitle_num="35" chapter_num="16" heading="Qualified Health Plan Certification — Essential Community Providers.">
  <paragraph num="A.">
    <text>For each health benefit plan that a carrier seeks to offer through the Exchange, the carrier shall make all good faith efforts to contract with at least 35 percent of available essential community providers in the plan’s service area as part of each plan’s provider network, except as specified in §C of this regulation.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Additional Essential Community Providers.</text>
    <paragraph num="(1)">
      <text>Included with its application for certification and in the form provided by the Exchange, the carrier may write in additional essential community providers that are not included in the definition for essential community provider under Regulation .02B of this chapter.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If available, the carrier shall include the following information when writing in additional essential community health providers:</text>
      <paragraph num="(a)">
        <text>The provider’s zip code reflecting a provider location within a low-income zip code or Health Professional Shortage Areas included on the “Low-Income and Health Professional Shortage Area Zip Code Listing” from CMS;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The provider’s service street address, which may not be a Post Office Box number; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The National Provider Identifier (NPI) number, if the provider has such a number, or an alternate identification, such as a Tax Identification Number, if the provider does not have such a number.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>The authorized carrier shall provide information under this section as part of the application submitted under Regulation .04 of this chapter.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Carriers Who Are Unable to Meet Contracting Requirements.</text>
    <paragraph num="(1)">
      <text>If the authorized carrier cannot meet the standard under this section, the authorized carrier may satisfy this requirement under the alternative standard.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>To meet the alternative standard, the authorized carrier shall provide a narrative explanation of the authorized carrier’s justification that the carrier includes access to sufficient essential community providers within the health benefit plan’s network.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The narrative explanation shall describe the extent to which the authorized carrier’s provider sites are accessible to, and have services that meet the needs of, specific underserved populations, including:</text>
      <paragraph num="(a)">
        <text>Individuals with HIV/AIDS, including those with co-morbid behavioral health conditions;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>American Indians and Alaska Natives;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Low-income and underserved individuals seeking women’s health and reproductive health services; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Other specific populations served by essential community providers in the plan’s service area.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>The narrative explanation shall demonstrate that low-income members receive appropriate access to care and satisfactory service, including performance on provider quality and patient satisfaction metrics, as specified in the Annual Letter to Issuers.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>For each health benefit plan that a carrier seeks to offer through the Exchange, the carrier shall make all good faith efforts to contract with at least one available essential community provider of each essential community provider type, under §E of this regulation, in each county, or partial county, of the plan’s service area as part of each plan’s provider network.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Authorized carriers shall offer the same provider contract terms in good faith to the following essential community providers that a willing, similarly situated, non-essential community provider would accept or has accepted from the authorized carrier to the following provider types:</text>
    <paragraph num="(1)">
      <text>All available Indian Health Care Providers in the plan’s service area;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Willing local health departments under Insurance Article, §15-112(b)(3)(iii), Annotated Code of Maryland, in the plan’s service area; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>For each county in the plan’s service area, at least one provider from the following provider types, if such a provider is available and provides the medical or dental services, as applicable to plan type:</text>
      <paragraph num="(a)">
        <text>A health care provider defined in §340B(a)(4) of the Public Health Services Act;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An outpatient mental health center as described in COMAR 10.21.20;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A substance use disorder treatment provider as described at COMAR 10.09.80.03B(1) and (3);</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A school based-health center;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>A health care provider described in §1927(c)(1)(D)(i)(IV) of the Social Security Act; and</text>
      </paragraph>
      <paragraph num="(f)">
        <text>A State-owned, government-owned, or not-for-profit family planning services site that does not receive federal funding.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>An authorized carrier shall submit verification of essential community provider contract offers to the Exchange upon request.</text>
  </paragraph>
</regulation>