Sec. 31.10.44.04. Travel Distance Standards

A. Sufficiency Standards.

(1) Except as stated in §B of this regulation, each provider panel of a carrier shall have within the geographic area served by the carrier’s network or networks, sufficient primary care physicians, specialty providers, behavioral health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §A(5) of this regulation for each type of geographic area. The distances listed in §A(5) of this regulation shall be measured from the enrollee’s place of residence.

(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §A(5) of this regulation.

(3) The travel distance standards listed in §A(5) of this regulation do not apply to the following:

(a) Home health care;

(b) Durable medical equipment;

(c) Heart transplant programs;

(d) Heart or lung transplant programs;

(e) Kidney transplant programs;

(f) Liver transplant programs;

(g) Lung transplant programs; or

(h) Pancreas transplant programs.

(4) All other providers and facility types not listed in the chart in §A(5) of this regulation shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.

(5) Chart of Travel Distance Standards.

	Urban Area Maximum Distance (miles)	Suburban Area Maximum Distance (miles)	Rural Area Maximum Distance (miles)
Provider Type:
Allergy and Immunology	15	30	75
Applied Behavioral Analyst	15	30	60
Cardiovascular Disease	10	20	60
Chiropractic	15	30	75
Dermatology	10	30	60
Endocrinology	15	40	90
ENT/Otolaryngology	15	30	75
Gastroenterology	10	30	60
General Surgery	10	20	60
Gynecology, OB/GYN	5	10	30
Gynecology Only	15	30	75
Licensed Clinical Social Worker	10	25	60
Nephrology	15	25	75
Neurology	10	30	60
Oncology-Medical and Surgical	10	20	60
Oncology-Radiation/Radiation Oncology	15	40	90
Ophthalmology	10	20	60
Pediatrics-Routine/Primary Care	5	10	30
Physiatry, Rehabilitative Medicine	15	30	75
Plastic Surgery	15	40	90
Podiatry	10	30	60
Primary Care Physician	5	10	30
Psychiatry	10	25	60
Psychology	10	25	60
Pulmonology	10	30	60
Rheumatology	15	40	90
Urology	10	30	60
All Other licensed or certified providers under contract with a carrier not listed	15	40	90
Facility Type:
Acute Inpatient Hospitals	10	30	60
Critical Care Services - Intensive Care Units	10	30	100
Diagnostic Radiology	10	30	60
Inpatient Psychiatric Facility	15	45	75
Outpatient Dialysis	10	30	50
Outpatient Infusion/Chemotherapy	10	30	60
Pharmacy	5	10	30
Skilled Nursing Facilities	10	30	60
Surgical Services (Outpatient or Ambulatory Surgical Center)	10	30	60
Other Behavioral Health/Substance Abuse Facilities	10	25	60
All other licensed or certified facilities under contract with a carrier not listed	15	40	90

B. Group Model HMO Plans Sufficiency Standards.

(1) Each group model HMO’s health benefit plan’s provider panel shall have within the geographic area served by the group model HMO’s network or networks, sufficient primary care physicians, specialty providers, behavioral health and substance use disorder providers, hospitals, and health care facilities to meet the maximum travel distance standards listed in the chart in §B(5) of this regulation for each type geographic area. The distances listed in §B(5) of this regulation shall be measured from the enrollee’s place of residence or place of employment from which the enrollee gains eligibility for participation in the group model HMO’s health benefit plan.

(2) When an enrollee elects to utilize a gynecologist, pediatrician, or certified registered nurse practitioner for primary care, a carrier may consider that utilization as a part of its meeting the primary care provider standards listed in §B(5) of this regulation.

(3) The travel distance standards listed in §B(5) of this regulation do not apply to the following:

(a) Home health care;

(b) Durable medical equipment;

(c) Heart transplant programs;

(d) Heart or lung transplant programs;

(e) Kidney transplant programs;

(f) Liver transplant programs;

(g) Lung transplant programs; or

(h) Pancreas transplant programs.

(4) All other provider and facility types not listed in the chart at §B(5) of this regulation shall individually be required to meet maximum distances standards of 15 miles for Urban Areas, 40 miles for Suburban Areas, and 90 miles for Rural Areas.

(5) Chart of Travel Distance Standards.

	Urban Area Maximum Distance (miles)	Suburban Area Maximum Distance (miles)	Rural Area Maximum Distance (miles)
Provider Type:
Allergy and Immunology	20	30	75
Applied Behavioral Analyst	15	20	60
Cardiovascular Disease	15	25	60
Chiropractic	20	30	75
Dermatology	20	30	60
Endocrinology	20	40	90
ENT/Otolaryngology	20	30	75
Gastroenterology	20	30	60
General Surgery	20	30	60
Gynecology, OB/GYN	15	20	45
Gynecology Only	15	30	60
Licensed Clinical Social Worker	15	30	75
Nephrology	15	30	75
Neurology	15	30	60
Oncology-Medical, Surgical	15	30	60
Oncology-Radiation/Radiation Oncology	15	40	90
Ophthalmology	15	20	60
Pediatrics-Routine/Primary Care	15	20	45
Physiatry, Rehabilitative Medicine	15	30	75
Plastic Surgery	15	40	90
Podiatry	15	30	90
Primary Care Physician	15	20	45
Psychiatry	15	30	60
Psychology	15	30	60
Pulmonology	15	30	60
Rheumatology	15	40	90
Urology	15	30	60
All Other licensed or certified providers under contract with a carrier not listed	20	40	90
Facility Type:
Acute Inpatient Hospitals	15	30	60
Critical Care Services-Intensive Care Units	15	30	120
Diagnostic Radiology	15	30	60
Inpatient Psychiatric Facility	15	45	75
Outpatient Dialysis	15	30	60
Outpatient Infusion/Chemotherapy	15	30	60
Pharmacy	5	10	30
Skilled Nursing Facilities	15	30	60
Surgical Services (Outpatient or Ambulatory Surgical Center)	10	30	60
Other Behavioral Health/Substance Abuse Facilities	15	30	60
All other licensed or sertified facilities under contract with a carrier not listed	15	40	120

C. Essential Community Providers.

(1) Each provider panel of a carrier, that is not a group model HMO provider panel, shall include at least 30 percent of the available essential community providers in each of the urban, rural, and suburban areas.

(2) Each group model HMO plan shall demonstrate that its own providers located in Health Professional Shortage Areas or low-income zip codes within its service area perform at or above the 50th percentile on the following two HEDIS measures:

(a) Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment; and

(b) Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults.

(3) Each group model HMO plan shall demonstrate that it has alternative standards for addressing the needs of low income, medically underserved individuals. One manner in which a group model HMO may demonstrate this is by providing the Maryland Insurance Administration with its narrative or alternate standard justification to the essential community provider requirement, which was submitted to and accepted by the Maryland Health Benefit Exchange for certification as a qualified health plan.