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<regulation prefix="Regulation" num=".03" citation="COMAR 31.10.44.03" title_num="31" subtitle_num="10" chapter_num="44" heading="Network Adequacy Standards.">
  <paragraph num="A.">
    <text>Sufficiency Standards.</text>
    <paragraph num="(1)">
      <text>A carrier shall develop and maintain a network of providers in sufficient numbers, geographic locations, and practicing specialties to ensure enrollees have access to participating providers for the full scope of benefits and services covered under the carrier’s health benefit plan.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A carrier shall establish written policies and procedures to implement a process for addressing network deficiencies that result in an enrollee lacking access to any providers with the professional training and expertise necessary to deliver a covered service without unreasonable travel or delay.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A carrier shall clearly define and specify referral requirements, if any, to specialty and other providers.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>A carrier shall take reasonable steps to ensure that participating providers provide physical access, reasonable accommodations, and accessible equipment for enrollees with physical or mental disabilities.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>A carrier’s written policies and procedures to monitor availability of services shall include how the carrier will monitor the availability of services for:</text>
      <paragraph num="(a)">
        <text>Continuing care patients;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Individuals with physical or mental disabilities, including individuals who have disabilities that limit their physical ability to access services; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Individuals with limited English proficiency, including diverse cultural and ethnic backgrounds.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>A carrier shall take reasonable steps to ensure services are delivered in a culturally competent manner to all enrollees, including enrollees:</text>
      <paragraph num="(a)">
        <text>With limited English proficiency;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>With diverse cultural, racial, and ethnic backgrounds; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Of all genders, sexual orientations, and gender identities.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(7)">
      <text>A carrier must have the ability to identify, by county and for the City of Baltimore, the number of participating providers for each facility type listed in the charts in Regulation .05A(5) and B(5) of this chapter and each provider type code and specialty code listed on the uniform credentialing form described in Insurance Article, §15-112.1, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(8)">
      <text>The identification of the number of participating providers described in §A(7) of this regulation:</text>
      <paragraph num="(a)">
        <text>Shall include either:</text>
        <paragraph num="(i)">
          <text>All participating providers who were credentialed for a specific provider type or specialty code listed in the uniform credentialing form described in Insurance Article, §15-112.1, Annotated Code of Maryland; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>All participating providers who reported a specific provider type or specialty code when completing the uniform credentialing form described in Insurance Article, §15-112.1, Annotated Code of Maryland; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>May include additional participating providers identified by the carrier through other documented means.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(9)">
      <text>A carrier shall retain copies of its policies and procedures required by this chapter for a period of 3 years following the date the policies and procedures were last effective.</text>
    </paragraph>
    <paragraph num="(10)">
      <text>At the request of the Commissioner, a carrier shall file with the Commissioner a copy of its current and retained past policies and procedures required by this chapter. A carrier may request a finding by the Commissioner that its policies and procedures are considered confidential commercial information.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Monitoring Sufficiency Standards.</text>
    <paragraph num="(1)">
      <text>A carrier shall continuously monitor its provider network for compliance with this chapter and shall conduct internal compliance audits for the standards listed in Regulations .05, .06, and .07 of this chapter on at least a quarterly basis; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A carrier shall continuously verify and update its network directory consistent with Insurance Article, §15-112, Annotated Code of Maryland and §2799A-5of the Public Health Service Act, enacted by 116 of the federal No Surprises Act.</text>
    </paragraph>
  </paragraph>
</regulation>