Division of Insurance issues guidance on provider networks

Bulletins detail requirements for insurance companies for their networks

DENVER (April 11, 2016) –The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA), is issuing four bulletins that address the issue of provider networks in health insurance. These bulletins provide clarity regarding requirements for insurance companies in developing adequate provider networks.  

Provider networks are groups of doctors and other healthcare professionals that are contracted with a particular health insurance company to provide health services at negotiated rates.

Throughout 2015, state regulators, stakeholders and advocacy groups from across the nation worked together in the development of the National Association of Insurance Commissioners (NAIC)* model law on network adequacy. The model law was approved by the NAIC in late 2015.  

The DOI held stakeholder meetings with local organizations over the last two months regarding how the model law can be implemented in Colorado, first through the issuance of bulletins, then more formally as regulations.  

Participants in the stakeholder meetings included such organizations as the Colorado Consumer Health Initiative, the Colorado Medical Society, the Colorado Association of Health Plans, the Colorado Center on Law & Policy, the Colorado Hospital Association, and the Chronic Care Collaborative.  

As a result, the DOI has issued two bulletins, with a third due to be issued the week of April 11. The fourth bulletin will likely be issued in mid-April. Each bulletin addresses a different portion of the NAIC model act on network adequacy.

1) Bulletin 4.90, Network Adequacy Standards and Reporting Guidance for Health Benefit Plans - Provides insurance companies with the standards and guidance on network adequacy.  The standards serve as the measurable requirements the Division utilizes to evaluate whether or not a carrier has adequate provider networks. Bulletin 4.90 was issued March 17, 2016.

2) Bulletin 4.91, Network Access Plan Standards and Reporting Guidance for Health Benefit Plans - Establishes the requirements for how carriers file their network access plans with the Division. Network access plans are used by carriers to describe their policies and procedures for maintaining and ensuring that their networks are sufficient and consistent with state and federal requirements.  Bulletin 4.91 was issued March 31, 2016.  

3) Bulletin 4.92, Standard and Reporting Guidance for Provider Directories for Health Benefit Plans - Gives health insurance companies the standards for the provider directories for their health plans.  A provider directory is a comprehensive listing, produced and maintained by the carrier, of a plan's participating providers and facilities in each of the carrier’s networks.  Carriers must file their provider directories with the Division annually and they must be updated at least monthly.  Bulletin 4.92 is expected to be issued the week of April 11.

4) Bulletin 4.93, Continuity of Care Requirements for Health Benefit Plans - Deals with the effects of providers being removed or leaving a company’s network.  In such cases, consumers using that provider must be given notice. In addition, those undergoing active treatment from that provider must be given reasonable steps to transition to an in-network provider.  Bulletin 4.93 is expected to be issued in mid-April.  

Once bulletins are issued, they are available on the DOI’s website for Colorado Insurance Bulletins where visitors can search by name, keyword or bulletin number.  

While bulletins are interpretations of insurance law or statements on DOI policies, they do not carry the weight of law.

Following the bulletins, the next step is for the DOI to draft regulations on these same bulletin topics. Regulations do carry the weight of law, and therefore organizations or individuals who are found not complying with these regulations can face sanctions such as penalties, cease and desist orders and suspension/revocation of licenses.  

The DOI anticipates that the process for drafting regulations will begin summer 2016, with hearings in July and August. January 1, 2017 is the estimated date for these regulations to go into effect.  People and groups interested in this process can sign up to receive electronic notifications of the hearings and requests for stakeholder comments. Go to the Division of Insurance Alert page and enter your email address in the section for “Proposed Regulation Stakeholder Notification.”

* The National Association of Insurance Commissioners (NAIC), to which the DOI belongs, is the U.S. standard-setting and regulatory support organization created and governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories.  NAIC members, together with the central resources of the NAIC, form the national system of state-based insurance regulation in the U.S.

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The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA) regulates the insurance industry and assists consumers and other stakeholders with insurance issues.  Visit dora.colorado.gov/insurance for more information or call 303-894-7499 / toll free 800-930-3745. DORA is dedicated to preserving the integrity of the marketplace and is committed to promoting a fair and competitive business environment in Colorado. Consumer protection is our mission. Visit dora.colorado.gov for more information or call 303-894-7855 / toll free 1-800-886-7675

 


Media Contact:
Vincent Plymell
Division of Insurance
p: 303-894-2261 | c: 303-910-9614