Section 260. Network adequacy

A. The MCHIP licensee shall provide a sufficient number and mix of services, specialists, and practice sites to meet covered persons' health care needs, including providers serving high risk populations or those specializing in the treatment of costly conditions, and its contractual obligations with reasonable promptness.

B. The MCHIP licensee shall ensure covered persons telephone access 24 hours a day, 7 days a week, to responsible and knowledgeable health care practitioners capable of assessing the covered persons' conditions and, as necessary, providing for appropriate services.

C. The MCHIP licensee shall incorporate strategies into its access procedures to facilitate utilization of the licensee's health care services by covered persons with physical, mental, language or cultural barriers.

D. If the MCHIP licensee does not have a health care provider within its network capable of providing care to covered persons, the licensee shall cover such care out of network. The covered person shall not be responsible for any additional costs incurred by the MCHIP as a result of this referral, consistent with the evidence of coverage, other than any applicable copayment, coinsurance or deductible.

E. The MCHIP licensee shall make provisions for affected covered persons to be notified about the termination of a provider as soon as it becomes aware of the termination. The MCHIP shall inform the affected covered persons of other participating providers available to assume their care and facilitate the covered persons' transition from a terminating provider to another provider so that the covered person's continuity of care is not interrupted. Covered persons undergoing an active course of treatment shall have continued access to care during the transition period.

Historical Notes

Derived from Volume 16, Issue 07, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 08, eff. January 30, 2002.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.