Network Adequacy Requirements, Standards, and Submission Instructions

I.  INTRODUCTION AND PURPOSE

Insurance Law § 3241(a) requires insurers, corporations organized pursuant to Article 43 of the Insurance Law, municipal cooperative health benefit plans certified pursuant to Article 47 of the Insurance Law, and student health plans (collectively “insurers”) established or maintained pursuant to Insurance Law § 1124 that issue a health insurance policy or contract or a dental or vision policy or contract with a network of providers to ensure that the network is adequate to meet the health needs of insureds and provide an appropriate choice of providers sufficient to render the services covered under the policy or contract.  The Insurance Law § 3241(a) network adequacy requirements apply to health insurance policies and contacts, including stand-alone vision and stand-alone dental insurance policies or contracts, with a network of health care providers upon issuance or renewal on and after March 31, 2015, and upon application for the expansion of any service area associated with the policy or contract.  Any health insurance policy, contract, or rider submitted to the Department of Financial Services (DFS) for approval must include network adequacy information.

This document provides general information and guidance about the network adequacy requirements and standards for medical, stand-alone dental, and stand-alone vision insurers, as well as instructions about the submission of provider networks to DFS through the Provider Network Data System (PNDS) and System for Electronic Rate and Form Filing (SERFF).

II.  NETWORK ADEQUACY REQUIREMENTS AND STANDARDS

A. Applicability

• DFS will review provider networks that will be used with a medical, stand-alone dental, or stand-alone vision insurance policy or contract for a commercial non-managed care (non-MCO) product.  A stand-alone dental policy or contract is not limited to those dental policies or contracts that are New York State of Health (NYSOH) certified, but instead includes all dental policies or contracts that are sold off the NYSOH.
  • “Commercial non-MCO medical” refers to a comprehensive hospital, surgical and medical product that is not a government program and not a HMO.
  • “Commercial non-MCO dental” refers to a stand-alone dental product that is not a government program. 
  • “Commercial non-MCO vision” refers to a stand-alone vision product that is not a government program.
• If a network used with a commercial non-MCO product has already been approved by DOH, then for network adequacy submissions made on or after January 1, 2024, the following requirements apply:
  • Same or Similar Network as NYSOH or HMO.  If an insurer’s commercial non-MCO medical, stand-alone dental, or stand-alone vision product uses a network that been approved by DOH for a NYSOH or a HMO product, whether in the same counties or in fewer or more counties, or with the same number of providers or with fewer or more providers than approved for the NYSOH or a HMO product, then the insurer must still make a commercial non-MCO network submission in PNDS for DFS review.
  • See Section III “PNDS Network Submission Requirements” for instructions on submitting a network for DFS review.

B. Frequency of Submissions and Review of Provider Networks

• Insurers that issue commercial non-MCO medical, stand-alone dental, or stand-alone vision products should submit their networks to DFS for quarterly review through PNDS.  DFS will review network submissions at least annually.

C.  Standards for Review of Provider Networks

• When establishing a network, an insurer must consider the following: anticipated enrollment; expected utilization of services by the population to be enrolled; the number and types of providers necessary to furnish the services covered in each product; the number of providers who are not accepting new patients; and the geographic location of the providers and enrollees.
• To be considered accessible, the network should contain a sufficient number and array of providers to meet the diverse needs of the insured population and to ensure that all services will be accessible without undue delay.  This includes being geographically accessible (i.e., meeting time/distance standards) and being accessible for people with disabilities.
• DFS uses the same standards as DOH uses to determine network adequacy.  Each county in the network must include the commercial non-MCO required core provider and service types listed in Tables 1 and 2 of the PNDS Data Dictionary, available on the DOH website.  In rural counties, this may not be possible due to lack of available providers.  In counties where this is evident, commercial non-MCOs may contract with providers in adjacent counties (see section D. “Service Area & Expanded County Border” below) to fulfill the network requirements.  In general, these standards include the following for medical coverage:
  • At least one (1) hospital in each county; however, for Bronx, Erie, Kings, Monroe, Nassau, New York, Queens, Suffolk, and Westchester counties the network should include at least 3 hospitals;
  • A choice of at least three (3) primary care providers in each county, and potentially more based on enrollment and geographic accessibility; and
  • At least two (2) of all other required specialist provider types, and potentially more based on enrollment and geographic accessibility.

D.  Service Area & Expanded County Border

A “service area” refers to the complete list of counties in a network.  The service area should be submitted and approved by DFS through the SERFF form and rate filing process.  For PNDS network adequacy review purposes, and for counties other than Bronx, Kings, New York, Queens, and Richmond, a county will be “extended” to include portions of adjacent counties because of health care resources and the utilization patterns of consumers (“expanded county border”).  This extension will expand the county border approximately 10 miles into contiguous counties.

E.  Network Composition

The insurer’s network should contain all provider types necessary to provide services under the insurance product, including with respect to medical coverage:  hospitals; physicians (primary care and specialists); mental health and substance use disorder treatment providers; allied health professionals; ancillary providers; durable medical equipment providers; home health providers; and pharmacies.  DFS may ask for further explanations and/or details in the event PNDS is not able to capture or accurately identify particular service providers.

F.  Time and Distance Standards For Primary Care Providers

• Metropolitan Areas:  30 minutes by public transportation.
• Non-Metropolitan Areas:  30 minutes or 30 miles by public transportation or by car.
• In rural areas, transportation may exceed these standards if justified.

G.  Time and Distance Standards For Providers That Are Not Primary Care Providers

• It is preferred that an insurer meet the 30 minute or 30-mile standard for other providers that are not primary care providers.

H.  Providers That Should Not Be Included in an Insurer’s Network

An insurer should not include in its network any provider who:

• Has been sanctioned or prohibited from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act;
• Is deceased; or
• Had their license suspended or revoked by the New York State Education Department or the NYSDOH Office of Professional Medical Conduct.

I.  Behavioral Health Providers For Medical Coverage  

• An insurer should include individual providers, outpatient facilities, and inpatient facilities in its behavioral health network.  The network should include facilities that provide inpatient and outpatient mental health and inpatient and outpatient substance use disorder treatment services.  Facilities providing inpatient substance use disorder treatment services should be capable of providing detoxification and rehabilitation services.
• An insurer should advise participating providers that conversion therapy should not be provided to an insured and that the insurer will not provide reimbursement for such services.  As part of the insurer’s provider credentialing or application and re-credentialing processes, insurers should require behavioral health providers to certify that they will not provide conversion therapy to an insured or seek reimbursement from the insurer for such services.  Conversion therapy means any practice by a mental health professional that seeks to change an individual’s sexual orientation or gender identity, including efforts to change behaviors, gender expressions, or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same sex.  Conversion therapy does not include counseling or therapy for an individual who is seeking to undergo a gender transition or who is in the process of undergoing a gender transition, that provides acceptance, support, and understanding of an individual or the facilitation of an individual’s coping, social support, and identity exploration and development, including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices, provided that the counseling or therapy does not seek to change sexual orientation or gender identity.

J. Telehealth Network Adequacy Requirements

The telehealth network adequacy requirements in Insurance Law §§ 3217-h(a)(3) and 4306-g(a)(3) apply to health insurance policies and contracts with a network of health care providers upon issuance or renewal on or after April 1, 2022.  Insurers that provide comprehensive health insurance must ensure that the network is adequate to meet the telehealth needs of insureds for services covered under the policy or contract.

K.  Dental Coverage

• An insurer’s dental network should include geographically accessible general dentists sufficient to offer insureds a choice of 2 primary dentists within each county in the network and to achieve a ratio of at least 1 primary care dentist for each 2,000 insureds.
• Networks should include at least the following providers:  2 orthodontists (unless the network is used only with products that do not contain an orthodontic benefit), 1 pedodontist, and 1 oral surgeon.  A general dentist who is willing and able to treat children may be designated as a pedodontist for network adequacy purposes.
• Orthognathic surgery, temporal mandibular disorders (TMD), and oral/maxillofacial prosthodontics should be provided through any qualified dentist, either in-network or by referral. 
• Periodontists and endodontists should be available by referral. 
• The network should include dentists with expertise serving special needs populations (e.g., HIV+ and developmentally disabled patients).
• A time and distance standard of 45 minutes/45 miles may be used for the following rural counties for the following provider types:
  • Pedodontist: Allegany, Cayuga, Chemung, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis, Montgomery, Oneida, Otsego, Schoharie, Schuyler, St. Lawrence, Steuben, and Tompkins.
  • Oral Surgery: Essex, Franklin, Lewis, Schoharie, and Steuben.
  • Orthodontics: Broome, Cayuga, Chemung, Clinton, Essex, Franklin, Jefferson, Lewis, Madison, Oneida, Otsego, Schoharie, Schuyler, St. Lawrence, and Tompkins.

L.  Stand-Alone Vision Coverage

• A stand-alone vision network should include the following provider types in each county (or expanded county border): 2 ophthalmologists, 2 optometrists, or 1 ophthalmologist and 1 optometrist.  The network should include a minimum of two unique providers in each county, each with their own NPI number.

M.  Provider Standards

In general, the network should have the following minimum numbers of providers for each provider type per county in order be considered adequate.  Refer to Tables 1 and 2 of the PNDS Data Dictionary, available on the DOH website, for more precise submission requirements.

Medical Providers

STAND-ALONE Dental Providers

STAND-ALONE Vision Providers

Note: 2 ophthalmologists, 2 optometrists, or 1 ophthalmologist and 1 optometrist can satisfy network adequacy requirements. The network must include a minimum of two unique providers in each county, each with their own NPI number.

III.  NETWORK ADEQUACY SUBMISSION INSTRUCTIONS

The following provides instructions about the submission of provider networks to DFS through PNDS and SERFF. 

A.  PNDS NETWORK SUBMISSION REQUIREMENTS

The primary purpose of PNDS is to collect the data needed to evaluate provider networks, including physicians, hospitals, labs, home health agencies, durable medical equipment providers, etc., for all health plans in New York State.  DFS network adequacy reviews will be conducted for all commercial non-MCO medical, stand-alone dental, and stand-alone vision networks.  Plans must submit provider network information electronically to PNDS on a quarterly basis (at a minimum).  This data will be used for network adequacy reviews by DFS and will also be made available through a public facing provider lookup tool on the DOH website.  

Review of commercial non-MCO medical, stand-alone dental, and stand-alone vision networks will be performed at least annually, but quarterly submissions are required even if there are no changes to the network.  Please note that the commercial non-MCO network adequacy reviews may be staggered across different quarters or may all be performed during the same quarter.  Therefore, plans should continue to submit their commercial non-MCO networks to PNDS on a quarterly basis (at a minimum).  DFS reserves the right to conduct network adequacy reviews of all commercial non-MCO networks on a more frequent basis.

In addition to the quarterly submissions for network adequacy analysis, plans should update their network submission in PNDS within 15 days of any change to the network.  If no network changes occur, then a quarterly submission in accordance with the data submission schedule will be sufficient.  However, significant changes to the network, such as the loss of a hospital system, may require a network adequacy submission for analysis in between quarters.  The data reported in the submission must comply with the PNDS submission requirements listed in the PNDS Data Dictionary, available on the DOH website. 

1. Accessing PNDS

   Connection to PNDS is through a secure connection via a web portal, available at https://pnds.health.ny.gov.  Each plan should have self-designated at least 2 Coordinators.  Coordinators can log into PNDS to create additional accounts for Plan Submitters.  A Plan Submitter is responsible for the submission and maintenance of data into PNDS.  Please contact [email protected] with any questions relating to accessing PNDS.

2. Data Submission Schedule

   Insurers should refer to the PNDS Data Dictionary, available on the DOH website, for the timeline for submission of networks.  Other submissions, including corrections and service area expansions, are submitted on an as needed basis.

3. Submitting a New Network

   When an issuer seeks to establish a new network that would be subject to DFS review, certain information needs to be collected and entered in PNDS before network data can be submitted.  Please submit a “PNDS Commercial non-MCO New Plan Request Form” to the Health Bureau by email to [email protected].  DFS will not proceed with setting up a new network in PNDS until the associated form(s) and rates have been submitted for approval in SERFF.

4. Commercial non-MCO networks that are the same or similar as NYSOH or HMO networks.

   Beginning January 1, 2024, DFS will no longer accept network adequacy attestations made through SERFF.  Instead, all issuers must make a commercial non-MCO network submission in PNDS and use a positive indicator for the commercial non-MCO line of business.  Please see the most updated version of the PNDS Data Dictionary, available on the DOH website, for additional information.  Please contact [email protected] with any questions relating to accessing PNDS.

5. Deficiency Reports
   1. Upon completion of review of a network, DFS will issue a final deficiency report in PNDS.  For those deficiencies on the final report the insurer must permit insureds to access non-participating providers at the in-network cost-share for the provider types in the counties listed on the deficiency report until an adequate network is established.  This obligation continues in-between review periods if there are changes to an issuer’s network that affects the availability of participating providers.
   2. DFS will provide deficiency reports for all commercial non-MCO medical, stand-alone dental, and stand-alone vision networks at least annually.

B.  SERFF NETWORK SUBMISSION REQUIREMENTS

While networks will be submitted to PNDS, submission of other documents related to network adequacy must be submitted in SERFF in certain instances.  These filings should be submitted as Form Only filings that are Filed for Reference.  The filing type of insurance (TOI) is “H21 Health – Other” and the filing type is “Network Adequacy.”  These submissions should be submitted upon initial submission of the network in PNDS and annually thereafter. 

These submissions should include:

• For a pharmacy only network, a Network Adequacy Attestation for Certification of Adequacy should be submitted in SERFF in PDF format.
• For all network submissions, whether submitted through PNDS for review by DFS or submitted by attestation prior to January 1, 2024, the following network adequacy supporting documents should be submitted in SERFF annually:
  • The provider selection criteria in PDF format;
  • The quality assurance procedures in PDF format;
  • A sample provider agreement; and
  • Any additional attestations or affirmations as applicable.

Significant changes to the supporting documents may require a new submission more frequent than annually.

C.  PNDS NETWORK INFORMATION FOR SERFF FORM FILINGS.

Issuers filing a contract or policy form for approval in SERFF should identify the corresponding network by including the four-digit PNDS ID and corresponding Network ID in the appropriate field on the State Specific tab in SERFF.   This SERFF requirement applies for networks reviewed by DFS and DOH.  Alternatively, the insurer may indicate in the Filing Description under the General Information tab in SERFF that the corresponding network has not yet been submitted to PNDS for DFS review or has not yet been approved by DOH.  Insurers have 60 days from the approval of a contract or policy form to submit the corresponding network for review in PNDS.