Amends TCA Title 4; Title 8; Title 33; Title 47; Title 56; Title 63; Title 68 and Title 71.

Present law establishes requirements for health insurers to provide a sufficient network of providers. This bill replaces present law with a version of a model law developed by the National Association of Insurance Commissioners. The stated purposes of this bill are to: (1) Establish standards for the creation and maintenance of networks by health carriers; and (2) Assure the adequacy, accessibility, transparency, and quality of healthcare services offered under a network plan by: establishing requirements for written agreements between health carriers offering network plans and participating providers regarding the standards, terms, and provisions under which the participating provider will provide covered services to covered persons; and requiring health carriers to maintain and follow access plans that consist of policies and procedures for assuring the ongoing sufficiency of provider networks consistent with this bill. This summary provides a broad overview of the Act proposed by this bill. For specific details, please see the bill. PRESENT LAW Present law requires each managed health insurance issuer that offers a plan that limits its enrollees' choice of providers to maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons must have access to health care services 24 hours per day, seven days per week. Sufficiency is to be determined in accordance with the requirements set out in present law and may be established by reference to network adequacy standards established by the managed health insurance issuer, specifically: primary care provider-covered person ratios; and geographic accessibility. In addition to establishing the above-described standards, the managed health insurance issuer's network must demonstrate the following: (1) An adequate number of acute care hospital services, within a reasonable distance or travel time; (2) An adequate number of primary care providers within not more than 30 miles distance or 30 minutes travel time at a reasonable speed; (3) An adequate number of specialists and subspecialists, within a reasonable distance or travel time; (4) A comprehensive listing, updated annually, made available to covered persons and health care providers, of the plan's network participating providers and facilities; (5) The procedures for making referrals within and outside its network that, at a minimum, must include: a process for expediting the referral process when indicated by a medical condition; and a provision that referrals approved by the plan cannot be retrospectively denied except for fraud or abuse, subject to the eligibility and coverage provisions of the contract; (6) The process for monitoring and assuring on an ongoing basis the sufficiency of the network to meet the health care needs of populations that enroll in plans; (7) The quality assurance standards, adequate to identify, evaluate, and remedy problems relating to access, continuity, and quality of care; (8) The system for ensuring the coordination of care for covered persons receiving approved care from specialty providers; and (9) Any other information required by the commissioner. Present law establishes other requirements governing: referrals to nonparticipating providers when the network does not have a provider who can provide a covered benefit; considerations to determine if a health insurance issuer has complied with the sufficient network laws; requirements to provide timely appointments to patients and to see the patients on a timely basis after arrival for an appointment; the obligation of providers who do not participate in a managed health insurance issuer's plan but seek reimbursement through the point of service option mandated in present law obligation to provide appointments and, upon arrival for an appointment, to see patients on a timely basis and, upon arrival for appointments, the provider shall see the patient on a timely basis. THIS BILL Network Adequacy and Other Requirements for a Health Carrier: This bill requires a health carrier providing a network plan to maintain a network that is sufficient in numbers and appropriate types of providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered services to covered persons, including children and adults, will be accessible without unreasonable travel or delay. This bill applies to health carriers that offer network plans; however, certain provisions (as listed in this bill) will not apply to health carriers that offer network plans that consist solely of limited scope dental plans or limited scope vision plans. Like present law, this bill provides that covered persons must have access to emergency services 24 hours per day, seven days per week. The commissioner of commerce and insurance will determine sufficiency in accordance with this bill and may establish sufficiency by reference to reasonable criteria waiting times for an appointment with participating providers and the volume of technological and specialty care services available to serve the needs of covered persons requiring technologically advanced or specialty care services. This bill also requires a health carrier to: (1) Have a process to assure that a covered person obtains a covered benefit at an in-network level of benefits, including an in-network level of cost-sharing, from a non-participating provider, or shall make other arrangements acceptable to the commissioner when: the health carrier has a sufficient network, but does not have a type of participating provider available to provide the covered benefit to the covered person or it does not have a participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay; or the health carrier has an insufficient number or type of participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay; (2) Specify and inform covered persons of the process a covered person may use to request access to obtain a covered benefit from a non-participating provider when: the covered person is diagnosed with a condition or disease that requires specialized healthcare services or medical services; and the health carrier: does not have a participating provider of the required specialty with the professional training and expertise to treat or provide healthcare services for the condition or disease; or cannot provide reasonable access to a participating provider with the required specialty with the professional training and expertise to treat or provide healthcare services for the condition or disease without unreasonable travel or delay. (3) Establish and maintain adequate arrangements to ensure covered persons have reasonable access to participating providers located near their home or business address; (4) File with the commissioner for review and approval prior to or at the time it files a newly offered network, an access plan in compliance with this bill; (5) Prepare an access plan prior to offering a new network plan, and notify the commissioner of a material change to an existing network plan within 15 business days after the change occurs. This bill sets out in detail what the access plan must contain; (6) Establish a mechanism by which participating providers will be notified on an ongoing basis of the specific covered healthcare services for which the provider will be responsible, including limitations or conditions on services. This bill also sets out in detail information that must be included in a contract between a health carrier and a participating provider, and establishes other requirements governing the conduct of participating providers in regard to health carriers and patients (such as providing notice when the provider is removed from or leaves a network); (7) Develop standards for selecting and tiering, as applicable, participating providers for providers and each health care professional specialty; (8) Establish reasonable procedures to transition a covered person who is in an active course of treatment to a participating provider in a manner that provides for continuity of care, if a covered person's provider leaves or is removed from the network, then a health carrier; (9) Establish procedures for resolution of administrative, payment, or other disputes between providers and the health carrier; and (10) Develop a written disclosure or notice to be provided to a covered person or the covered person's authorized representative at the time of pre-certification, if applicable, for a covered benefit to be provided at a facility that is in the covered person's health benefit plan network, or 24 hours before the medical service is rendered, whichever is longer, that there is the possibility that the covered person could be treated by a healthcare professional that is not in the same network. This bill sets out other related notice requirements. This bill also contains provisions governing the following topics: (1) Provider directories. This bill requires a carrier to post provider directories and to update them at least monthly. This bill sets out in detail information to be included in the directory and other requirements regarding the directory; (2) Intermediaries. This bill establishes requirements for intermediaries, which this bill defines as: a person authorized to negotiate and execute provider contracts with health carriers on behalf of healthcare providers or on behalf of a network, including a pharmacy benefits manager. Generally, this bill requires intermediaries to comply with requirements that are applicable to health carriers under 56-7-3506 of this bill, some of which are described above in items (6)-(10); (3) Filing requirements and state administration applicable to sample contract forms and material changes to a contract that would affect a provision required under this bill or implementing rules; (4) Enforcement. This bill provides that if the commissioner determines that a health carrier has not contracted with a sufficient number of participating providers to assure that covered persons have accessible healthcare services in a geographic area, or that a health carrier's network access plan does not assure reasonable access to covered benefits, or that a health carrier has entered into a contract that does not comply with this bill, or that a health carrier has not complied with this bill, then the commissioner must require a modification to the access plan or institute a corrective action plan, as appropriate, that the health carrier must follow, or may use the commissioner's other enforcement powers to obtain the health carrier's compliance with this bill; (5) Penalties. A violation of this bill is a Class A misdemeanor, subject only to a fine not less than $500 nor more than $5,000; and (6) Effective Date. For purposes of rule promulgation and the requirement for a health carrier to file an access plan prior to or at the time it files a newly offered network, this bill will take effect upon becoming law. For all other purposes, this bill will take effect January 1, 2022, and apply to plans and contracts entered into, issued, amended, or renewed on or after that date.