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Rev. 08/21/2018 Kaiser Permanente Insurance Company 2019 Access Plan

KAISER PERMANENTE INSURANCE COMPANY

2019 COLORADO ACCESS PLAN


TABLE OF CONTENTS

I. INTRODUCTION ..................................................................................................................................... 1

II. NETWORK ADEQUACY AND CORRECTIVE ACTION PROCESS ................................................................ 2

A. Summary of the carrier’s network adequacy standards measured and results of measurements . 2

B. Carrier’s quantifiable and measurable process for monitoring and assuring the sufficiency of the network ................................................................................................................................................... 22

C. Carrier’s description of all applicable standards used for selecting and tiering providers............. 23

D. Carrier’s quality assurance standards ............................................................................................. 23

E. Carrier’s description of corrective actions process that will be used to remedy networks found to be inadequate. ........................................................................................................................................ 24

F. If a network is found to be inadequate, the carrier will explain/describe specific actions to be taken, including remedies, timeframes, schedule for implementation, and proposed notifications & communications with the Division, providers and policyholders. .......................................................... 25

1. General Colorado Access and Availability Corrective Action Plan .............................................. 25

2. Essential Community Provider Colorado Corrective Action Plan ............................................... 25

3. Colorado Directory Corrective Action Plan ................................................................................. 25

G. The carrier’s process to assure that a covered person is able to obtain a covered benefit, at the in-network level of benefit, from a non-participating provider should the carrier’s network prove to not be sufficient. ..................................................................................................................................... 26

H. The carrier’s process for monitoring access to [in-network] physician specialist services for emergency room care, anesthesiology, radiology, hospitalist care and pathology/laboratory services at its participating facilities. .................................................................................................................... 27

III. NETWORK ACCESS PLAN PROCEDURES FOR REFERRALS .................................................................... 28

A. Location(s)/availability of provider directory(ies), how often it is updated, and availability in other languages. ............................................................................................................................................... 28

B. Full description of the referral process, including at a minimum: .................................................. 29

1. A provision that referral options cannot be restricted to less than all providers in the network that are qualified to provide covered specialty services; except that a health benefit plan may offer variable deductibles, coinsurance and/or copayments to encourage the selection of certain providers. ............................................................................................................................................ 29

2. A process for timely referrals for access to specialty care ......................................................... 29

3. A process for expediting the referral process when indicated by medical condition. ............... 29

4. A provision that referrals approved by the carrier cannot be retrospectively denied except for fraud or abuse. .................................................................................................................................... 29


5. A provision that referrals approved by the carrier cannot be changed after the preauthorization is provided unless there is evidence of fraud or abuse. ......................................... 29

6. A health benefit plan that offers variable deductibles, coinsurance, and/or copayments shall provide adequate and clear disclosure, as required by law, of variable deductibles and copayments to enrollees, and the amount of any deductible or copayment shall be reflected on the benefit card provided to the enrollees; .................................................................................................................. 30

C. The carrier’s process allowing enrollees to access services outside the network when necessary. 30

IV. NETWORK ACCESS PLAN DISCLOSURES AND NOTICES ....................................................................... 31

A. Method for informing covered persons of the plan’s services and features through disclosures and notices to policyholders. .................................................................................................................. 31

B. Required disclosures, pursuant to CRS §10-16-704(9). .................................................................. 31

1. Carrier’s grievance procedures, which shall be in conformance with Division regulations concerning prompt investigation of health claims involving utilization review and grievance procedures .......................................................................................................................................... 31

2. The extent to which specialty medical services, including but not limited to physical therapy, occupational therapy, and rehabilitation services are available; ....................................................... 32

3. The carrier’s procedures for providing and approving emergency and non-emergency medical care 32

4. The carrier’s process for choosing and changing network providers ......................................... 33

5. The carrier’s documented process to address the needs, including access and accessibility of services, of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with physical or mental disabilities ............................................................ 33

6. The carrier’s documented process to identify the potential needs of special populations ....... 33

7. The carrier’s methods for assessing the health care needs of covered persons, tracking and assessing clinical outcomes from network services, assessing needs on an on-going basis, assessing the needs of diverse populations, and evaluating consumer satisfaction with services provided .... 34

V. PLANS FOR COORDINATION AND CONTINUITY OF CARE ................................................................... 34

A. The carrier’s documented process for ensuring the coordination and continuity of care for covered persons referred to specialty providers .................................................................................... 34

B. The carrier’s documented process for ensuring the coordination and continuity of care for covered persons using ancillary services, including social services and other community resources ... 34

C. The carrier’s documented process for ensuring appropriate discharge planning. ......................... 35

D. The carrier’s process for enabling covered persons to change primary care providers ................ 35

E. The carrier’s proposed plan and process for providing continuity of care in the event of contract termination between the carrier and any of its participating providers or in the event of the carrier’s


insolvency or other inability to continue operations. The proposed plan and process must include an explanation of how covered persons shall be notified in the case of a provider contract termination, the carrier’s insolvency, or of any other cessation of operations, as well as how policyholders impacted by such events will be transferred to other providers in a timely manner. ........................... 35

F. A carrier must file and make available upon request the fact that the carrier has a “hold harmless” provision in its provider contracts, prohibiting contracted providers from balance-billing covered persons in the event of the carrier’s insolvency or other inability to continue operations in compliance with CRS § 10-16-705(3) Network access plan requirements and demonstrations. .......... 37

Rev. 08/21/2018 Page 1 of 37 Kaiser Permanente Insurance Company 2019 Access Plan

I. INTRODUCTION

Carrier Name: Kaiser Permanente Insurance Company (“KPIC”)

Network Name: Private Healthcare Systems, Inc. (“PHCS”)

Carrier’s Network ID Number: CON001

Type of Network and General Description:

KPIC’s Participating Provider Network consists of the Private Healthcare Systems, Inc. (“PHCS”), Network Providers (hereafter referred to as the “PHCS Network”) and the direct contracted providers to enhance KPIC’s primary network, the PHCS Network. Private Healthcare Systems, Inc. (“PHCS”), a wholly owned subsidiary of MultiPlan, Inc., develops and manages a primary network of health care providers and hospitals that are utilized by insurance carriers in the provision of preferred provider organization (“PPO”) and 3-Tiered Point-of-Service (“POS”) health benefit plans. KPIC also directly contracts with providers (referred to as “direct contracted providers”) for primary care, specialty care and hospital services. With PPO health benefit plans, covered persons are encouraged to utilize the services of PHCS providers through the provision of financial incentives such as lower coinsurance payments and deductibles. The 3-Tiered POS health benefit plans provide coverage under three (3) Tiers –Tier 1 or the HMO Tier, underwritten by the Kaiser Foundation Health Plan; and Tier 2 or the Participating Provider Tier and Tier 3 (Non-Participating Provider Tier), underwritten by Kaiser Permanente Insurance Company (KPIC). Covered persons with the POS Plans are encouraged to utilize the HMO Tier (Tier 1) which will result to lower cost share but are allowed to obtain services from the Participating Provider Tier (Tier 2). Please note neither PHCS nor the insurance carrier provides health care services.

Specific Geographic Area(s) covered by the network:

The KPIC Participating Provider Network includes a national provider PPO network accessed specifically according to carrier needs and where KPIC has enrollees. KPIC has network providers in the State of Colorado and currently has enrollees located in the following counties:

Adams Alamosa Arapahoe Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Conejos Crowley Custer Delta Denver Dolores Douglas Eagle El Paso Elbert Fremont Garfield Gilpin Hinsdale Jackson


Jefferson Lake Larimer Las Animas Logan Mesa Mineral Montrose Morgan Otero Park Phillips Pitkin Prowers Pueblo Rio Blanco Sedgwick Teller Weld Yuma Website identification: Enrollees can access their care by PHCS Network providers by going to http://info.kaiserpermanente.org/html/kpic-colorado particularly the Colorado Provider Directory Page under the Provider Directory. The Colorado Provider Directory Page has a link to the www.Multiplan.com/Kaiser where enrollees can access the Provider Directory of the PHCS Network Providers. In the same page, under Direct Contract Provider Listing, enrollees can access the Provider Directory of the direct contracted providers. Contact information: Enrollees may call Customer Service at 1-855-364-3184 or 711 (TTY) for assistance. The remainder of this document sets forth the processes utilized by PHCS to support its insurance carrier clients in the provision of an access plan in Colorado.

• Each of the required components of the access plan is listed in bold. • Certain of the requirements cover aspects of the health benefit plan or other insurance

company related area, and are designated by a note indicating that the response needs to be provided by the insurance carrier.

• As used in this document, the term “provider” includes both individual health care providers and hospitals.

• Network Adequacy and Corrective Action Processes

II. NETWORK ADEQUACY AND CORRECTIVE ACTION PROCESS

A. Summary of the carrier’s network adequacy standards measured and results of measurements

Pursuant to 3 CCR 702-4-2-53, the PHCS Network was measured using KPIC enrollee membership information to determine KPIC compliance with Colorado network adequacy standards. The PHCS Network is not intended to meet Dental and Pharmacy requirements. Generally, speaking carriers contracting with the PHCS Network will have their own Dental and/or Pharmacy networks or contract with a separate network for these services. The

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results of the network adequacy findings as it pertains to the PHCS Network will eliminate the Dental and Pharmacy requirements from review. More than ninety percent of KPIC enrollees have adequate access to services in Colorado. When breaking down network adequacy by county classifications the PHCS Network has found the following: 1. Large Metropolitan Areas, as defined by the Centers for Medicare & Medicaid Services

(“CMS”) which is based on the US Census Bureau and the Office of Management and Budget criteria, the PHCS Network has contracted with more than seven thousand providers resulting in an average of one provider for every 0.073 KPIC enrollee. Ninety percent or more of all KPIC enrollees have access to providers in the specific specialties and geographic distributions defined in 3 CCR 702-4-2-53 (excluding Dentists and Pharmacies).

2. Metropolitan Areas, as defined by the Centers for Medicare & Medicaid Services (“CMS”) which is based on the US Census Bureau and the Office of Management and Budget criteria, the PHCS Network has contracted with more than thirty-one thousand providers resulting in an average of one provider for every 0.059 KPIC enrollee. Ninety percent or more of all KPIC enrollees have access to providers in the specific specialties and geographic distributions defined in 3 CCR 702-4-2-53 (excluding Dentists and Pharmacies).

3. Micropolitan Areas, as defined by the Centers for Medicare & Medicaid Services (“CMS”) which is based on the US Census Bureau and the Office of Management and Budget criteria, the PHCS Network has contracted with more than three thousand providers resulting in an average of one provider for every 0.015 KPIC enrollee. Although, the majority of specialty types in Micropolitan Areas have at least ninety percent of enrollees with access to services according to 3 CCR 702-4-2-53, the below specialties have the average provider geographic distribution in Micropolitan areas (excluding dentists and pharmacies): a. Gynecology, OB/GYN. Only 4.3 percent of KPIC enrollees (i.e. 2 enrollees) are

without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 5.9 miles and the maximum

distance to the first provider is 39.9 miles. ii. The average distance to the second provider is 7.4 miles and the maximum

distance to the second provider is 40 miles. iii. The following counties do not meet the geographic access requirements

established in 3 CCR 702-4-2-53 for at least 90% of enrollees:


a. Garfield b. Pediatrics – Routine/Primary Care. Only 10.9 percent (i.e. 5 enrollees) of KPIC

enrollees are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 8.2 miles and the maximum

distance to the first provider is 40 miles. ii. The average distance to the second provider is 9.1 miles and the maximum


established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Garfield c.

c. Allergy and Immunology. Only 10.9 percent of KPIC enrollees (i.e. 5 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 17.9 miles and the maximum

distance to the first provider is 70miles. ii. The average distance to the second provider is 70.1miles and the maximum

distance to the second provider is 141.2 miles. iii. The following counties do not meet the geographic access requirements

established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Garfield

d. Gastroenterology. Only 13 percent of KPIC enrollees (i.e. 6 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 14 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Garfield

e. Gynecology only. Only 26.1 percent of KPIC enrollees (i.e. 12 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 25.6 miles and the maximum

distance to the first provider is 94.9 miles.


ii. The average distance to the second provider is 39.5 miles and the maximum distance to the second provider is 94.9 miles.

iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Garfield

f. Infectious Disease. Only 23.9 percent of KPIC enrollees (i.e. 11 enrollees) are without

access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 37 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Mesa

g. Nephrology. Only 23.9 percent of KPIC enrollees (i.e. 11 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 24.9 miles and the maximum

distance to the first provider is 80.3 miles. ii. The average distance to the second provider is 27 miles and the maximum

distance to the second provider is 96.3 miles. iii. The following counties do not meet the geographic access requirements established

in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Garfield

h. Neurological Surgery. Only 34.8 percent of KPIC enrollees (i.e. 16 enrollees) are

without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 46.4 miles and the maximum





a. La Plata i. Rheumatology. Only 56.5 percent of KPIC enrollees (i.e. 26 enrollees) are without

access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 76.9 miles and the maximum


distance to the second provider is 152.3 miles. iii. The following counties do not meet the geographic access requirements established

in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle

b. Garfield c. Mesa

j. Urology. Only 17.4 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 23.9 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Mesa

k. Vascular Surgery. Only 54.3 percent of KPIC enrollees (i.e. 25 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 77.3 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Garfield b. Mesa c. Eagle


l. Outpatient Dialysis. Only 26.1 percent of KPIC enrollees (i.e. 12 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 28.4 miles and the maximum

distance to the first provider is 96 miles. ii. The average distance to the second provider is 42 miles and the maximum


established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Garfield

m. Diagnostic Radiology. Only 30.4 percent of KPIC enrollees (i.e. 14 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 32.2 miles and the maximum




n. Mammography. Only 30.4 percent of KPIC enrollees (i.e. 14 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 32.2 miles and the maximum




o. Surgical Services (Outpatient or ASC). Only 2.2 percent of KPIC enrollees (i.e. 1 enrollee) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 11.8 miles and the maximum




iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Garfield

p. Occupational Therapy. Only 58.7 percent of KPIC enrollees (i.e. 27 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 73.8 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Garfield c. Mesa

q. Inpatient Psychiatric Facility. Only 17.4 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 26.3 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Eagle b. Garfield

4. Rural Areas as defined by the Centers for Medicare & Medicaid Services (“CMS”) which is based on the US Census Bureau and the Office of Management and Budget criteria, the PHCS Network has contracted with more than twenty-five hundred providers resulting in an average of one provider for every 0.033 KPIC enrollee. Although, the majority of specialty types in Rural Areas have at least ninety percent of enrollees with access to services according to 3 CCR 702-4-2-53, the below specialties have the average provider geographic distribution in Rural areas (excluding dentists and pharmacies):


a. Cardiovascular Disease. Only 11.6 percent of KPIC enrollees (i.e. 10 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 21.3 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Montrose

b. Gynecology, OB/GYN. Only 3.5 percent of KPIC enrollees (i.e. 3 enrollees) is without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 12.3 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Otero

c. Dermatology. Only 17.4 percent of KPIC enrollees (i.e. 15 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 28.7 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Alamosa b. Logan c. Morgan d. Otero

d. Gastroenterology. Only 18.6 percent of KPIC enrollees (i.e. 16 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees:


i. The average distance to the first provider is 30.1 miles and the maximum distance to the first provider is 94.5 miles.


iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Montrose b. Alamosa c. Chaffee

e. Podiatry. Only 15.1 percent of KPIC enrollees (i.e. 13 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 25.2 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Montrose b. Otero

f. Rheumatology. Only 10.5 percent of KPIC enrollees (i.e. 9 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 50.3 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Alamosa b. Delta c. Montrose

g. Vascular Surgery. Only 5.8 percent of KPIC enrollees (i.e. 5 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 37.7 miles and the maximum




iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Delta b. Montrose

h. Surgical Services (Outpatient or ASC). Only 17.4 percent of KPIC enrollees (i.e. 15 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 34.2 miles and the maximum




i. Diagnostic Radiology. Only 24.4 percent of KPIC enrollees (i.e. 21 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 38.7 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Otero

j. Mammography. Only 24.4 percent of KPIC enrollees (i.e. 21 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 38.7 miles and the maximum





a. Chaffee b. Logan c. Morgan d. Otero

k. Occupational Therapy. Only 48.8 percent of KPIC enrollees (i.e. 42 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 49.3 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Alamosa b. Delta c. Logan d. Montrose e. Morgan f. Otero

l. Psychiatry. Only 16.3 percent of KPIC enrollees (i.e. 14 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 32.4 miles and the maximum




m. Neurology. Only 3.5 percent of KPIC enrollees (i.e. 3 enrollee) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees:




iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Otero

n. Oncology – Medical, Surgical. Only 9.3 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 21.2 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Alamosa b. Otero

o. Pulmonology. Only 9.3 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 20.9 miles and the maximum




p. Urology. Only 3.5 percent of KPIC enrollees (i.e. 3 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 18 miles and the maximum




iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Otero

q. Outpatient Dialysis. Only 7 percent of KPIC enrollees (i.e. 6 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 27.5 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Chaffee b. Otero

r. Physical Therapy. Only 9.3 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 18 miles and the maximum

distance to the first provider is 80.9 miles. ii. The average distance to the second provider is 28.3miles and the maximum



s. Speech Therapy. Only 8 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 18 miles and the maximum


distance to the second provider is 82 miles.


iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Alamosa b. Otero

5. Counties with Extreme Access Considerations (“CEAC”) Areas, as defined by the Centers for Medicare & Medicaid Services (“CMS”) which is based on the US Census Bureau and the Office of Management and Budget criteria, the PHCS Network has contracted with more than one thousand providers resulting in an average of one provider for every 0.022 KPIC enrollee. Ninety percent or more of all KPIC enrollees have access to providers in the specific specialties and geographic distributions defined in 3 CCR 702-4-2-53 (excluding Dentists and Pharmacies). Although, the majority of specialty types in Rural Areas have at least ninety percent of enrollees with access to services according to 3 CCR 702-4-2-53, the below specialties have the average provider geographic distribution in Rural areas (excluding dentists and pharmacies): a. Allergy and Immunology. Only 21.9 percent of KPIC enrollees (i.e. 14 enrollees) are

without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 69.8 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Phillips b. Sedgwick c. Yuma

b. Dermatology. Only 26.6 percent of KPIC enrollees (i.e. 17 enrollee) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 68.9 miles and the maximum

distance to the first provider is 147.7 miles. ii. The average distance to the second provider is 173miles and the maximum


established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca


b. Phillips c. Prowers d. Sedgwick

c. Infectious Diseases. Only 12.5 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 77.4 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Phillips c. Sedgwick

d. Gynecology, OB/GYN. Only 14.1 percent of KPIC enrollees (i.e. 9 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 39.6 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Mineral b. Sedgwick c. Las Animas

e. Neurological Surgery. Only 10.9 percent of KPIC enrollees (i.e. 7 enrollee) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 59.6 miles and the maximum


distance to the second provider is 146.3 miles.


iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Phillips b. Sedgwick

f. Occupational Therapy. Only 34.4 percent of KPIC enrollees (i.e. 22 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 81.5 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Cheyenne c. Phillips d. Prowers e. Rio Blanco f. Sedgwick g. Yuma

g. Psychiatry. Only 31.2 percent of KPIC enrollees (i.e. 20 enrollee) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 72.5 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Cheyenne c. Phillips d. Prowers e. Sedgwick

h. Outpatient Dialysis. Only 12.5 percent of KPIC enrollees (i.e. 8 enrollee) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This


generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 61.8 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Bent c. Cheyenne d. Prowers

i. Rheumatology. Only 12.5 percent of KPIC enrollees (i.e. 8 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 79.4 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Phillips c. Sedgwick

j. Plastic Surgery. Only 10.9 percent of KPIC enrollees (i.e. 7 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 69.5 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Sedgwick


k. Podiatry. Only 10.9 percent of KPIC enrollees (i.e. 7 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 51.1 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Cheyenne c. Prowers

l. Pulmonology. Only 10.9 percent of KPIC enrollees (i.e. 7 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 58.6 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Cheyenne c. Prowers

m. Mammography. Only 25 percent of KPIC enrollees (i.e. 16 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 63.1 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca b. Phillips


c. Sedgwick n. Diagnostic Radiology. Only 25 percent of KPIC enrollees (i.e. 16 enrollees) are

without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 63.1 miles and the maximum



established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca

b. Phillips c. Sedgwick

o. Surgical Services (Outpatient or ASC). Only 32.8 percent of KPIC enrollees (i.e. 21 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees:


ii. The average distance to the second provider is 81.1 miles and the maximum distance to the second provider is 160 miles.

iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: b. Baca c. Cheyenne d. Phillips e. Prowers f. Sedgwick g. Yuma

p. Vascular Surgery. Only 3.1% of the KPIC enrollees (i.e. 2 enrollees) are without access within the prescribed requirements established in 3 CCR 702-4-2-53. This generally meets PHCS Network standards. Below are the defined access requirements for enrollees: i. The average distance to the first provider is 63.3 miles and the maximum


distance to the second provider is 150.2 miles.


iii. The following counties do not meet the geographic access requirements established in 3 CCR 702-4-2-53 for at least 90% of enrollees: a. Baca

b. Rio Blanco

6. Pharmacy Providers

The PHCS Network does not include pharmacies. Kaiser Permanente Insurance Company (KPIC) contracts with MedImpact for pharmacy benefit management and services. KPIC maintains a network of 618 pharmacies at 612 locations in the Large Metro and Metro counties within a 30-mile radius and 204 pharmacies at 201 locations in the Micro, Rural, & CEAC Counties within a 60-mile radius.

7. Access to Services and Waiting Time Standards The PHCS Network received zero waiting time complaints from KPIC enrollees in 2017 and to date in 2018 has received zero complaints. Practitioners are required contractually to comply with all applicable laws, including those pertaining to appointment wait times. Absent complaints on this matter, it is assumed all providers meet the Access to Services and Waiting Time Standards required by the state of Colorado.

8. Availability Standards The availability standards were met in all counties where the network had available providers in those counties. The provider to enrollee ratios exceeded the state of Colorado requirements. The following counties did not have sufficient number of providers to meet the needs of the enrollees, but was only due to the lack of providers in those counties. Expanding access beyond the county lines will result in better results as permitted by the geographic access standards in rural areas. The below list may not accurately reflect access to services:

Primary Care Providers: Clear Creek, Dolores, Gilpin, Specialists: Bent, Crowley, Dolores, Gilpin, Hinsdale, Mineral, Obstetricians, Gynecologists, OBGYN: Baca, Clear Creek, Custer, Dolores, Elbert, Gilpin, Jackson, Rio Blanco, Otero, Conejos, Crowley, Hinsdale, Mineral, Park, Phillips, Sedgwick, and Yuma


Pediatricians: Baca, Cheyenne, Clear Creek, Custer, Dolores, Elbert, Gilpin, Pitkin, Conejos, Crowley, Hinsdale, Jackson, Mineral, Park, Phillips, and Rio Blanco Behavioral Health, Mental Health and Substance Abuse Disorder Providers: Baca, Cheyenne, Clear Creek, Bent, Conejos, Crowley, Custer, Dolores, Gilpin, Las Animas, Mineral, Otero, Phillips, Sedgwick Hospitals (Includes Emergency Rooms): Clear Creek, Custer, Dolores, Elbert, Fremont, Gilpin, Jackson, Bent, Crowley, Hinsdale, Mineral, and Park Emergency (Free Standing Only – Excludes Hospital Emergency Rooms): Alamosa, Baca, Broomfield, Chaffee, Cheyenne, Conejos, Custer, Delta, Dolores, Eagle, Elbert, Fremont, Garfield, Gilpin, Jackson, Las Animas, Logan, Montrose, Morgan, Phillips, Prowers, Rio Blanco, Sedgwick, Teller, Yuma Clear Creek, Bent, Crowley, Hinsdale, Mineral, and Park Urgent Care Facilities: Baca, Chaffee, Cheyenne, Custer, Dolores, Fremont, Gilpin, Jackson, Prowers, Teller, Weld, Alamosa, Clear Creek, Delta, Elbert, Logan, Montrose, Morgan, Otero, Bent, Conejos, Crowley, Hinsdale, Las Animas, Mineral, Park, Phillips, Rio Blanco, Sedgwick, Yuma, Garfield, Mesa, and Pueblo Behavioral Health, Mental Health and Substance Abuse Disorder Facilities: Baca, Chaffee, Cheyenne, Custer, Dolores, Fremont, Gilpin, Jackson, Prowers, Teller, Alamosa, Clear Creek, Delta, Elbert, Logan, Montrose, Morgan, Bent, Conejos, Crowley, Hinsdale, Las Animas, Mineral, Park, Phillips, Rio Blanco, Sedgwick, Yuma, Eagle, Garfield, and Broomfield

B. Carrier’s quantifiable and measurable process for monitoring and assuring the sufficiency of the network

The PHCS Network Access and Availability are monitored no less than annually, according to the PHCS Network’s Policy PS-001, Access and Availability, or upon documentation of significant volume differentials from PHCS Primary Network providers and MPI clients accessing the PHCS Primary Network and data comparing PHCS Primary Network Access and Availability with its competitors. If, at any time, a geographic area in which 80% of the area does not meet the defined access standards, the Regional Director develops and implements a corrective action plan to comply with the PHCS access standards. Network Development will contractually require PHCS Primary Network practitioners, as appropriate, to ensure that medical and health care services are available to covered individuals 24 hours a day, 7 days a week. Unless otherwise required by state law or regulation, Network Development will require network practitioners to agree that the


expected waiting time for covered individuals to schedule an appointment shall comply with the standards outlined in the MultiPlan Professional Handbook located at www.multiplan.com. The PHCS Network does not recognize telehealth as a separate specialty type, but instead a type of service offered by providers. Providers offering telehealth services typically identify such services on their credentialing application. The PHCS Network data systems are restrictive and unable to report on telehealth providers to support network access and adequacy requirements in Colorado.

C. Carrier’s description of all applicable standards used for selecting and tiering providers

The PHCS Network includes providers that meet network credentialing criteria as established by MultiPlan, Inc., which are consistent with the National Committee for Quality Assurance (“NCQA”), including but not limited to, verifying appropriate licensure, education and training, board certification, work history, DEA licensure, accreditation/certification status, review of sanctions and a review of an acceptable history of professional liability claims. Providers not meeting established credentialing criteria are subject to rejection or termination from network participation. Providers that have been previously terminated from the network for quality of care reasons may not be eligible for network participation up reapplication to the network. The PHCS Network has been certified by NCQA in Credentialing since 2001 and continues to maintain such certification to this day. The PHCS Network does not tier its providers.

D. Carrier’s quality assurance standards

The PHCS Networks quality management program operates according to the policies and procedures authorized by the QMC and its Executive Committee as defined in the MultiPlan, Inc. Quality Program Plan. The Quality Management Program provides a consistent, integrated framework for ensuring that the activities of MPI support compliance with all applicable accreditation and certification standards, internal service standards, state and federal laws and regulations and contractual obligations, including but not limited to, access and availability and quality of care in the network. In addition, the program is designed to promote activities within the PHCS Network that are intended to maintain compliance with all applicable standards through a system of monitoring, assessing, and improving performance and various functions. It also provides the infrastructure necessary to document and resolve complaints related to all applicable standards, to maintain a centralized complaint database, and to evaluate and


report on trends and patterns identified through the analysis of complaint data. The Quality Management Program has specific Quality Improvement indicators that are used to measure network performance and identify opportunities for and barriers to improvement. In addition to the Quality Program Plan, the PHCS Network utilizes two (2) tools to identify, evaluate and remedy problems relating to access, continuity and quality of care. One tool utilized is re-credentialing. Participating providers are re-credentialed every three (3) years to ensure that the participating provider continues to meet the established standards of PHCS for network participation. The second tool used by PHCS is its complaint and grievance resolution process. PHCS accepts complaints and grievances from covered persons, providers, and insurance carrier clients. When PHCS receives a complaint about a provider regarding access, continuity or quality of care, the complaint is forwarded to the PHCS Service Operations Department. The Service Operations Department conducts a review of the complaint, seeking information from both the complainant and the provider. If the information obtained by PHCS during the recredentialing process or the complaint resolution process warrants action, two (2) avenues are available; (1) if circumstances warrant, the matter is reviewed with the provider, and the provider is afforded an opportunity to resolve the issue(s), or (2) if the provider fails to remedy the issue, the PHCS Network initiates termination of the provider contract. A termination may be reported to the National Provider Databank if it meets established reportable criteria. The PHCS Network reserves the right to immediately terminate any provider that poses an imminent danger to patient health. The provider is suppressed from all directories and is afforded a right to appeal.

E. Carrier’s description of corrective actions process that will be used to remedy networks found to be inadequate.

The PHCS Network’s Network Development Department will address Access and/or Availability deficiencies in the PHCS Network through an action plan as approved by the Vice President, National Contracting and/or Senior Vice President, Network Development, as appropriate. The Vice President National Contracting/Senior Vice President(s) and Regional Director(s) responsible for the market(s)/network(s) analyzes root causes and the nature of the Access and/or Availability deficiency, prioritizes opportunities to remedy deficiencies, and recommends a plan of action to the Vice President, Contracts and Development. Upon approval of the action plan by the Vice


President, Contracts and Development, Network Development staff implements the action plan. Corrective action plans and progress is reported to the Quality Management Committee at least annually for review and accountability.

F. If a network is found to be inadequate, the carrier will explain/describe specific actions to be taken, including remedies, timeframes, schedule for implementation, and proposed notifications & communications with the Division, providers and policyholders.

1. General Colorado Access and Availability Corrective Action Plan

By July 31, 2018, the PHCS network will query the NPPES Registry to locate providers that do not participate in the PHCS network in counties where additional providers are needed to comply with Colorado Access and Availability requirements. The providers identified in the query will be evaluated to determine if providers are eligible for network participation. Providers that may have been terminated from the network for quality of care reasons will not be considered eligible. The final list of additional eligible providers wil be identified by September 15, 2018. Providers will be contacted and invited to join the PHCS Network. The outreach to the identified providers will be completed by October 15, 2018. The Network Development staff will follow up on the targets every 30 days until the providers agree to participate, or the providers decline to participate in the PHCS network. The outreach efforts will be tracked for reporting purposes. Contract negotiation and finalization of the credentialing process averaged 180 days. It is understood that many Rural and CEAC counties may not have many available providers. In the event that no providers are available for a specific specialty in a specific county, the PHCS network will not be able to meet the Colorado Network Access and Availability requirements.

2. Essential Community Provider Colorado Corrective Action Plan

The PHCS Network has contracted with over 30% of available ECP providers that are included on the Non-Exhaustive listing published by CMS. No action is required.

3. Colorado Directory Corrective Action Plan

The PHCS Network's Provider directories do not currently contain the following fields: 1. Practitioner and Facility URLs, if available 2. Practitioner Medical Group Affiliation


3. Facility ECP designation (Print Directories) 4. Facility Services 5. Provider E-mail addresses

The PHCS Network is currently working on a complete overhaul of all directories to include all state specific criteria, including that of Colorado. The current directory is limited by the coding and unable to accommodate all fields required by states. The rebuild is expected to be completed by 12/31/2018, at the latest. As new requirements are added by states, the new directory will be able to accommodate the changes more so than our current directory and its underlying code. Provider E-mail addresses may extend beyond the stated deadline, herein, as additional operational considerations were recently identified by the PHCS Network directory project team responsible for overseeing this and other state directory implementations. Facility Services is part of a network-wide data management project. When adding Facility Services to the directories, it was discovered the underlying data was inaccurate. The PHCS Network has begun a project to redefine the service choices available in our data systems. Once complete, phase 2 will begin correcting the data in our systems. This process will take a year or longer, and we hope to have it completed and verified at the time of each Facility's next credentialing cycle which is every 3 years.

G. The carrier’s process to assure that a covered person is able to obtain a covered benefit, at the in-network level of benefit, from a non-participating provider should the carrier’s network prove to not be sufficient.

An enrollee may contact KPIC Customer Service at 1-855-364-3184 for assistance in finding an available Participating Provider. If an enrollee who resides in a county with an inadequate network has already received care from a Non-Participating Provider, it is recommended that he/she notifies KPIC through its utilization management functional area (UM) at 1-888-525-1553 about the care received and the reason for seeing that Non-Participating Provider. UM will reach out to KPIC's internal operations department to validate the network inadequacy. Once it has been determined that the enrollee obtained care from a Non-Participating Provider due to inadequate network, a notation is placed on the enrollee’s claim to have it paid at the Participating Provider benefit level. The explanation of benefits (EOB) which the enrollee receives will indicate that the claim was paid at the Participating Provider benefit level. Claims will not be adjusted when it is determined that the network is adequate and enrollee intended to see the Non-Participating Provider. This is in line with a provision in KPIC’s Network Adequacy Policies and Procedures which provides that where an insured seeks the rendition of


covered services from a Non-Participating Provider as a result of the deemed inadequacy of the Participating Provider network, the affected insured is reimbursed at the Participating Provider level of benefits and is held harmless by KPIC from any balance billing. In line with this policy, this is being implemented by KPIC.

H. The carrier’s process to ensure that covered services or treatment rendered at a network facility, including ancillary services or treatment rendered by an out-of-network provider performing the services or treatment at a network facility, shall be covered at no greater cost to the covered person than if the services or treatment were obtained from an in-network provider.

KPIC has a process in place for claims from Non-Participating ancillary providers rendering services in a contracted or Participating facility. Ancillary providers include, but are not limited to, radiologists, pathologists, anesthesiologists and assistant surgeons. Claims from ancillary providers are reviewed, adjudicated and paid at the Participating Provider benefit level. Facility types include: inpatient/outpatient hospital services, ambulatory surgical centers, emergency room, skilled nursing facility, long term acute care/rehabilitation facility, inpatient/outpatient behavioral health facility, and comprehensive inpatient rehabilitation facility, and outpatient rehabilitation facility. In the review and adjudication, claims from Non-Participating ancillary providers are evaluated to determine if they are related to the Participating facility episode. Upon determination that the services provided by the Non-Participating ancillary providers are related to the facility episode, the claims are priced and benefits are applied under the Participating Provider Tier.

I. The carrier’s process for monitoring access to in-network (Participating Provider) physician specialist services for emergency room care, anesthesiology, radiology, hospitalist care and pathology/laboratory services at its participating facilities.

The PHCS Networks provider handbooks require providers to comply with applicable state and/or federal laws as such laws pertain to appointment wait times or access to care. Carriers utilizing the PHCS Network may forward access complaints to PHCS to investigate as a corporate quality management investigation.


III. NETWORK ACCESS PLAN PROCEDURES FOR REFERRALS

A. Location(s)/availability of provider directory(ies), how often it is updated, and availability in other languages.

KPIC makes available its provider listing through: 1) the group employer; 2) its Customer Service line (1-855-364-3184) and (3) electronically via its web site: http://info.kaiserpermanente.org/html/kpic-colorado. The Certificate of Insurance (COI), under the HOW TO ACCESS YOUR SERVICES AND OBTAIN APPROVAL OF BENEFITS section contains the following provision: “To verify the current participation status of a provider, please call the toll-free number listed in the Participating Provider directory. A current copy of KPIC’s Participating Provider is available from Your employer, or call the phone number listed on Your ID card or You may visit KPIC’s contracted provider network web site at: www.Multiplan.com/Kaiser or KPIC’s web site at http://info.kaiserpermanente.org/html/kpic-colorado. If a Covered Person receives care from a Non-Participating Provider, benefits under the Group Policy will be payable at the Non-Participating Provider level.” KPIC in its website: http://info.kaiserpermanente.org/html/kpic-colorado particularly in its Colorado Provider Directory Page has provided the website: www.Multiplan.com/Kaiser which will direct insureds to the Provider Directory for a list of PHCS Network Providers for KPIC. The list of Direct Contracted Providers will also be found in the same Colorado Provider Directory Page in the KPIC website. Please be informed the list of direct contract providers is updated quarterly at this time. A process is currently not in place to update on a monthly basis. KPIC Operations will submit a request for a translated directory to a Translation Service who will complete the requested translation work and return the final documents to KPIC Operations within 3-5 business days once the Statement of Work has been approved. Translated directories will be mailed by KPIC Operations with 48 hours after receipt of the translation.


http://www.multiplan.com/Kaiser

http://info.kaiserpermanente.org/html/kpic-colorado



B. Full description of the referral process, including at a minimum:

1. A provision that referral options cannot be restricted to less than all providers in the network that are qualified to provide covered specialty services; except that a health benefit plan may offer variable deductibles, coinsurance and/or copayments to encourage the selection of certain providers.

The KPIC health benefit plans are open-ended plans where insureds are free to self-refer to any specialist in the Participating Provider Tier and the Non-Participating Provider Tier. Benefit plans that utilize the PHCS network do not utilize a referral process. Physicians may make such referrals as they deem appropriate in their best medical judgment.

2. A process for timely referrals for access to specialty care

KPIC plans that utilize the PHCS network do not utilize a referral process. Physicians may make such referrals as they deem appropriate in their best medical judgment.

3. A process for expediting the referral process when indicated by medical condition.

KPIC plans that utilize the PHCS network do not utilize a referral process. Physicians may make such referrals as they deem appropriate in their best medical judgment.

4. A provision that referrals approved by the carrier cannot be retrospectively denied except for fraud or abuse.

KPIC plans that utilize the PHCS network do not utilize a referral process. Physicians may make such referrals as they deem appropriate in their best medical judgment. The KPIC PPO and 3-Tiered POS Plans are open-ended plans where insureds can openly self-refer to any specialist in and out of the PHCS Network.

5. A provision that referrals approved by the carrier cannot be changed after the preauthorization is provided unless there is evidence of fraud or abuse.

KPIC plans that utilize the PHCS Network do not utilize a referral process. Physicians may make such referrals as they deem appropriate in their best medical judgment. The KPIC products are open-ended plans where insureds can openly self-refer to any specialist in and out of the PHCS network.


Please note that, once a Pre-certification is approved, such approval of pre-certification will not be reversed and benefits will be covered, subject to the provisions of the Group Policy.

6. A health benefit plan that offers variable deductibles, coinsurance, and/or copayments shall provide adequate and clear disclosure, as required by law, of variable deductibles and copayments to enrollees, and the amount of any deductible or copayment shall be reflected on the benefit card provided to the enrollees;

Covered services under the KPIC’s PPO and 3-Tiered POS plans are received from Participating Providers at the Participating Provider Tier and Non-Participating Providers at the Non-Participating Provider Tier. The provider the enrollee selects can affect the dollar amount an enrollee must pay. Enrollees have lower out-of-pocket costs for services received from a Participating Provider. KPIC offers lower cost shares (deductibles, applicable coinsurance or copayment) for covered services obtained under the Participating Provider Tier. It is to be noted however that KPIC is not responsible for an enrollee’s decision to receive treatment, services or supplies from Participating or Non-Participating Providers. There is a provision in the COI particularly the How to Access Your Services and Obtain Approval of Benefits which explains this. The Schedule of Benefits (Who Pay What) and Member Payment Responsibility section of the COI shows lower cost share values under the Participating Provider Tier as compared to the Non-Participating Provider Tier. The identification cards provided to enrollees reflect the plan deductible and applicable cost share.

C. The carrier’s process allowing members to access services outside the network when necessary.

The KPIC products are open-ended plans where insureds can openly self-refer to any provider in and out of the Participating Provider network.


IV. NETWORK ACCESS PLAN DISCLOSURES AND NOTICES

A. Method for informing covered persons of the plan’s services and features through disclosures and notices to policyholders.

KPIC annually provides enrollees with a Certificate of Insurance (COI) summarizing the benefits and services available to each enrollee. Coverage varies depending on the particular plan in which he/she is enrolled. Enrollees may obtain a printed copy of the COI by calling Customer Service at 1-855-364-3184 or 711 (TTY).

B. Required disclosures, pursuant to CRS §10-16-704(9).

1. Carrier’s grievance procedures, which shall be in conformance with Division regulations concerning prompt investigation of health claims involving utilization review and grievance procedures

As regards grievances involving utilization review decisions, such as denial of pre-service and concurrent claims due to Pre-Certification determination, KPIC, has laid down its procedures under the APPEALS AND COMPLAINTS section of the Certificate of Insurance (COI). The COI, under the HOW TO ACCESS YOUR SERVICES AND OBTAIN APPROVAL OF BENEFITS section contains the following provision:

“Please refer to the APPEALS AND COMPLAINTS section of this Certificate for claims, which have been denied due to a Pre-certification determination. Also, refer to the same section where a benefit is denied, in whole or in part, due to a failure to obtain Pre-certification for services rendered by a Non-Participating Provider.”

Additionally, the urgent and non-urgent pre-service and concurrent care claims and appeals procedures are explained in detail under the APPEALS AND COMPLAINTS section of the COI, which include among others: the applicable time frame for filing an appeal; the need for any additional information which KPIC will be requesting from the enrollees within a prescribed period; the time frame within which to decide the appeal; the availability of a voluntary second level appeal at the option of the enrollee; and the availability of the expedited external review if warranted under certain circumstances.


The provisions in the APPEALS AND COMPLAINTS section of the COI are in accord with the Colorado Insurance Code and DOI regulations on prompt investigation of health claims involving utilization review and grievance procedures.

2. The extent to which specialty medical services, including but not limited to

physical therapy, occupational therapy, and rehabilitation services are available;

KPIC makes available its provider listing through: 1) the group employer; and 2) its Customer Service line: 1-855-364-3184. The Certificate of Insurance, under the HOW TO ACCESS YOUR SERVICES AND OBTAIN APPROVAL OF BENEFITS section contains the following provision:

“To verify the current participation status of a provider, please call the toll-free number listed in the Participating Provider directory. A current copy of KPIC’s Participating Provider directory is available from Your employer or You may call the phone number listed on Your ID card or You may visit KPIC’s contracted provider network at www.Multiplan.com/Kaiser or KPIC’s web site at http://info.kaiserpermanente.org/html/kpic-colorado.”

KPIC in its website: http://info.kaiserpermanente.org/html/kpic-colorado provides the website: www.Multiplan.com/Kaiser which directs its enrollees to the Provider Directory for a list of PHCS participating providers.

3. The carrier’s procedures for providing and approving emergency and non-

emergency medical care

Emergency Services are covered twenty-four (24) hours a day, even (7) days a week, anywhere in the world. Enrollees are advised via its Certificate of Insurance (COI) and even its Customer Service toll free number that if one has an Emergency Medical Condition, to call 911 or go to the nearest emergency room. Note that KPIC uses the prudent layperson test for emergency. If an enrollee receives Emergency Care/Services and cannot, at the time of emergency, reasonably reach a Participating Provider, that emergency care rendered during the course of the emergency will be paid for in accordance with the terms of the Group Policy, at benefit levels at least equal to those applicable to treatment by a Participating Providers for emergency care.


4. The carrier’s process for choosing and changing network providers

The KPIC products are open-ended plans allowing access to providers in and outside the Participating Provider network. There are no restrictions on choice of providers or changing network providers.

5. The carrier’s documented process to address the needs, including access and

accessibility of services, of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with physical or mental disabilities

KPIC’s Language Assistance Tagline (Help with Your Language) together with the Notice of Non-Discrimination are attached to significant documents that are sent to the enrollees pursuant to Section 1557 of the Affordable Care Act (Act). The Language Assistance Tagline offers language assistance services in the form of oral interpretation at no cost to enrollees by calling 1-800-632-9700 or 711 (TTY).

6. The carrier’s documented process to identify the potential needs of special

populations

During the initial credentialing process, Credentialing Operations obtains information regarding the ability of providers to address the needs of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with physical and mental disabilities. Online directories include information pertaining to the languages spoken at a practitioner’s office. Covered persons can obtain information regarding a provider’s practice, including languages spoken, by telephoning PHCS at a toll-free telephone number provided to the covered person by the insurance carrier. All insurance carriers and covered persons may utilize the network provider nomination process via the network website at www.multiplan.com to nominate providers for network participation to address the special needs of covered persons.


7. The carrier’s methods for assessing the health care needs of covered persons, tracking and assessing clinical outcomes from network services, assessing needs on an on-going basis, assessing the needs of diverse populations, and evaluating consumer satisfaction with services provided

PHCS operates a complaint and grievance resolution process that accepts complaints and grievances from covered persons, providers and insurance carrier clients. PHCS tracks and analyzes the complaints received and compiles quarterly reports presented to the Quality Management Committee for review. Trends observed are analyzed to determine root causes and resolve concerns. The Service Operations Department brings issues regarding the health care needs and consumer satisfaction to the attention of the appropriate internal operational area. Each operational area is charged with continuously improving the processes utilized by PHCS to deliver its services. Each PHCS department also is charged with addressing issues identified by Service Operations.

V. PLANS FOR COORDINATION AND CONTINUITY OF CARE

A. The carrier’s documented process for ensuring the coordination and continuity of care for covered persons referred to specialty providers

The benefit plans that utilize the PHCS Network do not make referrals to specialists. Rather, that responsibility is left to the covered person’s physician. In addition, the benefit plans do not utilize any type of referral process. Physicians may make referrals as they deem appropriate in their best medical judgment. Physicians are contractually obligated to render care in a manner that assures availability, adequacy and continuity of care to covered persons. Additionally, physicians are contractually obligated to render services in accordance with generally accepted medical practice and professionally recognized standards. Thus, physicians are required to ensure the coordination and continuity of care for covered persons referred to specialty providers.

B. The carrier’s documented process for ensuring the coordination and continuity of care for covered persons using ancillary services, including social services and other community resources


Ancillaries are contractually obligated to render care in a manner that assures availability, adequacy and continuity of care to covered persons. Additionally, ancillaries are contractually obligated to render services in accordance with generally accepted medical practice and professionally recognized standards. Thus, ancillaries are required to ensure the coordination and continuity of care for covered persons.

C. The carrier’s documented process for ensuring appropriate discharge planning.

PHCS Network providers are contractually obligated to render services in accordance with generally accepted medical practice and professionally recognized standards.

D. The carrier’s process for enabling covered persons to change primary care providers

Benefit plans that utilize the PHCS network do not require covered persons to enroll with a specific primary care provider. The covered person is free to change primary care providers at any time and without prior notice to the insurance carrier.

E. The carrier’s proposed plan and process for providing continuity of care in the event of contract termination between the carrier and any of its participating providers or in the event of the carrier’s insolvency or other inability to continue operations. The proposed plan and process must include an explanation of how covered persons shall be notified in the case of a provider contract termination, the carrier’s insolvency, or of any other cessation of operations, as well as how policyholders impacted by such events will be transferred to other providers in a timely manner.

KPIC’s process for Continuity of Care is as follows: 1. If a provider terminates or is removed from KPIC’s network, provider and KPIC will

identify all covered persons who are currently seeking care with those providers and also any other covered persons who had services with that Provider in the last 12 months.

2. For covered persons identified, KPIC will provide notification on the provider Termination.

3. KPIC will also provide information and options on continuity of care with other providers within our network that is convenient to the covered person. Covered persons will receive a Member Care Transition Form so that they can provide additional details on the type of care they are receiving which will help KPIC identify provider options that meets the covered person’s needs.


4. The Member Care Transition Form will be also posted on KPIC’s website that covered persons access. Covered persons can also call 1-888-525-1553 to request Transition of Care Form.

5. Once the covered person is able to provide the details on the care they would like to continue, the KPIC Team will review the request and work with the covered person and provide options to continue their care.

6. The KPIC team will take care of any authorization/referral that is needed for the covered person to continue services with another provider

7. The KPIC Team will follow covered person’s benefit plans and provisions as well as State/Federal laws and regulations as they continue to help the covered person with their care transition.

8. Covered persons will continue to have access to the grievance and appeals process. The provider contracts utilized by PHCS require providers to continue to render care and comply with the terms of the contract following termination for those covered persons who are undergoing a course of treatment or are hospitalized on the date of contract termination. The provider shall, at minimum, comply with C.R.S. §10-16-705. The provider’s obligations continue (i) until the course of treatment is completed; (ii) for a period of ninety (90) days or through the current period of active treatment for those covered persons undergoing active treatment for a chronic or acute medical condition, whichever time period is shorter; (iii) throughout the second and third trimester of pregnancy and/or through postpartum care, if requested by the covered person; or (iv) until provider makes reasonable and medically appropriate arrangements to transfer the covered persons to the care of another provider, making such transfer to an in-network provider whenever appropriate (except as specified in subsections (ii) and (iii). KPIC shall make a good faith effort to provide both written notice of a provider’s removal, leaving, or non-renewal from the network, and the provider information pursuant to legal and regulatory requirements, within fifteen (15) working days of receipt or issuance of a notice from the Participating Provider. This notice shall be provided to all covered persons who are identified as patients by the provider, are on a carrier’s patient list for that provider, or who have been seen by the provider being removed or leaving the network within the previous twelve (12) months.


F. A carrier must file and make available upon request the fact that the carrier has a “hold harmless” provision in its provider contracts, prohibiting contracted providers from balance-billing covered persons in the event of the carrier’s insolvency or other inability to continue operations in compliance with CRS § 10-16-705(3) Network access plan requirements and demonstrations.

The PHCS Network contracts with providers in Colorado include a State Law Coordinating Provision Exhibit that contains a hold harmless provision consistent with the requirements of C.R.S. §10-16-705(3), that prohibits a network provider from collecting from a covered person any money owed to such network provider by a carrier.

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