Health Benefit Plan Network Access and Adequacy Model Act

What this document is

Health Benefit Plan Network Access and Adequacy Model Act is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• NAIC Model #74: Section 5 (Network Adequacy)

  “Covered persons shall have access to emergency services twenty-four (24) hours per day, seven (7) days per week.”

• NAIC Model #74: Section 9 (Provider Directories)

  “In making the directory available electronically, the carrier shall ensure that the general public is able to view all of the current providers for a plan through a clearly identifiable link or tab and without creating or accessing an account or entering a policy or contract number.”

• NAIC Model 74: Section 9A(2)(a) (Provider Directories)

  “The health carrier shall update each network plan provider directory at least monthly.”

• NAIC Health Benefit Plan Network Access and Adequacy Model Act § 5C(1)(a), Network Adequacy - obtaining a covered benefit from a non-participating provider

  “A health carrier shall have a process to assure that a covered person obtains a covered benefit at an in-network level of benefits, including an in-network level of cost-sharing, from a non-participating provider, or shall make other arrangements acceptable to the commissioner when: (a) The health...”

• NAIC Health Benefit Plan Network Access and Adequacy Model Act § 5A(1), Network Adequacy - network sufficiency standard

  “A health carrier providing a network plan shall maintain a network that is sufficient in numbers and appropriate types of providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered services to covered persons, including children and...”

• Health Benefit Plan Network Access and Adequacy Model Act § 6E (Requirements for Health Carriers and Participating Providers)

  “In no event shall a participating provider collect or attempt to collect from a covered person any money owed to the provider by the health carrier.”

• Health Benefit Plan Network Access and Adequacy Model Act § 7B(2) (Requirements for Participating Facilities with Non-Participating Facility-Based Providers)

  “At the time of admission in the participating facility where the non-emergency services are to be performed on the covered person, the facility shall provide the covered person with the written disclosure, as outlined in Paragraph (1), and obtain the covered person’s or the covered person’s...”

• Health Benefit Plan Network Access and Adequacy Model Act § 6C (Requirements for Health Carriers and Participating Providers)

  “Every contract between a health carrier and a participating provider shall set forth that in the event of a health carrier or intermediary insolvency or other cessation of operations, the provider’s obligation to deliver covered services to covered persons without balance billing will continue until the earlier of:”

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