NAC695C.200. List of providers: Submission; changes; extension of submission date; excessive reduction.

     1. Each applicant for a certificate of authority shall:

     (a) Submit a list of the providers in its health care plan and a description of the type of providers based upon a projected number of enrollees;

     (b) Sufficiently describe its list of providers to demonstrate the accessibility and availability of health care to its enrollees; and

     (c) Describe a plan for increasing the number of providers based upon increased enrollment.

     2. The organization shall notify:

     (a) For a health maintenance organization, the Division and the State Board of Health in writing not later than 14 days after the end of each quarter of each calendar year of any changes in its list of providers unless an extension is granted pursuant to this paragraph. On or before the date on which the notification is due, the health maintenance organization may submit a request to the Commissioner for an extension of time in which to provide the notification of not more than 30 days after the date on which the notification is due.

     (b) For a provider-sponsored organization, the Division in writing not later than 14 days after the end of each quarter of each calendar year of any changes in its list of providers unless an extension is granted pursuant to this paragraph. On or before the date on which the notification is due, the provider-sponsored organization may submit a request to the Commissioner for an extension of time in which to provide the notification of not more than 30 days after the date on which the notification is due.

     (c) An enrollee in writing of the disassociation of his or her primary physician from the organization not later than 30 working days after such disassociation.

     3. Based upon the current list of providers of an organization, an overall reduction of more than 30 percent in the number of primary physicians in a geographic area of service or a material change in the panel of specialists shall be deemed by the Division to jeopardize the ability of the organization to meet its obligations to its enrollees, and the Division will so notify the organization, and for a health maintenance organization, the Division will also notify the State Board of Health. The organization may rebut this presumption by providing written information to the Division within 14 days after the notice is sent to the organization.

     4. The provisions of subsection 3 do not apply if the organization:

     (a) Notifies the Division in writing;

     (b) Submits information concerning the number of persons enrolled in the organization and the reasons for any reductions; and

     (c) Obtains the approval of the Division in advance for the reduction.

     (Added to NAC by Comm’r of Insurance, eff. 6-11-86; A 5-27-92; R082-98 & R148-99, 1-27-2000)