§ 59A-23-25 — Provider network adequacy

A. An insurer shall maintain an adequate provider network to provide mental health or substance use disorder services. B. The superintendent shall ensure access to mental health or substance use disorder services providers, including parity with medical and surgical services provider access, through regulation and review of claims processing, provider reimbursement procedures, network adequacy and provider reimbursement rate adequacy. C. An insurer shall ensure that the process by which reimbursement rates for mental health and substance use disorder services are determined is comparable to and no more stringent than the process for reimbursement of medical or surgical benefits. In developing provider reimbursement rates, an insurer shall demonstrate that it has performed a comparability analysis of provider: (1) reimbursement rates in surrounding states; (2) reimbursement rates between mental health and substance use disorder providers and medical or surgical providers; and (3) credentialing processes for mental health and substance use disorder providers and medical or surgical providers. D. An insurer shall undertake all efforts, including increasing provider reimbursement rates through the processes and strategies described in Subsection C of this section, to ensure state-mandated network adequacy for the provision of mental health or substance use disorder services. E. When in-network access to mental health or substance use disorder services is not reasonably available, an insurer shall provide access to out-of-network services with the same cost-sharing obligations to the insured as those required for in-network services.

Legislative History

Laws 2023, ch. 114, § 17.