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.  Any health insurance policy, contract, or rider submitted to DFS for approval must include network adequacy information.

Health plans should submit their networks to DFS for quarterly review through the Provider Network Data System (“PNDS”).  PNDS is an online portal used by DOH to collect health plan network information and track and manage network adequacy for each health plan.

The network adequacy standards do not include specific exceptions to allow for circumstances when service areas do not have the required number of providers or where usage patterns are distinct.  DFS follows the same standards that DOH currently uses in these circumstances. 

DFS follows the same standards that DOH uses to determine which providers may be considered PCPs.  For purposes of network adequacy requirements, PCPs can typically be in one of four primary care provider categories:  Family Practice, General Practice, Internal Medicine, and Pediatrics.  Nurse Practitioners that specialize in Family Practice, General Practice, or Internal Medicine may also satisfy the PCP requirement count.  While Physician Assistants may serve as PCPs, Physician’s Assistants are not counted in the primary care provider categories in PNDS and are not counted toward satisfying the minimum network adequacy requirements for PCPs. 

The network adequacy standards do not include a process to request an exception.  DFS follows the same standards that DOH uses in these circumstances.   

DOH’s Guidelines for Reviewing MCO Service Delivery Networks do not allow for exceptions to time and distance standards for urban areas.  DFS follows the same standards that DOH uses.   

When a health plan attests that its network has been approved by DOH, the health plan should use the date of the statement of agreement with DOH.  

Yes, if a policy form is approved before the network is approved, the policy form may be used and the health plan’s marketing materials should indicate that the network is pending DFS approval.  Any network used in connection with an approved policy form must be submitted to DFS for review within 60 days of the date of approval of the policy form. 

Health plans are required to submit a network filing for each unique network.

DFS does not distinguish between tiered and non-tiered networks.  As such, health plans should follow the same process for submitting a tiered network as they would for a non-tiered network. 

No.  The requirement to file a network used with a stand-alone dental insurance policy or contract is not limited to those dental insurance policies or contracts that are NYSOH-certified, but includes all stand-alone dental insurance policies or contracts that use a network of providers.

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.