2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0055. Network Adequacy Standards

Sec. 1301.0055.  NETWORK ADEQUACY STANDARDS.  (a)  The commissioner shall by rule adopt network adequacy standards that:
(1)  require an insurer offering a preferred provider benefit plan to:
(A)  monitor compliance with network adequacy standards, including provisions of this chapter relating to network adequacy, on an ongoing basis, reporting any material deviation from network adequacy standards to the department within 30 days of the date the material deviation occurred; and
(B)  promptly take any corrective action required to ensure that the network is compliant not later than the 90th day after the date the material deviation occurred unless:
(i)  there are no uncontracted licensed physicians or health care providers in the affected county; or
(ii)  the insurer requests a waiver under this subsection;
(2)  ensure availability of, and accessibility to, a full range of contracted physicians and health care providers to provide current and projected utilization of health care services for adult and minor insureds;
(3)  may allow a waiver for a departure from network adequacy standards for a period not to exceed one year if the commissioner determines after receiving public testimony at a public hearing under Section 1301.00565 that good cause is shown and posts on the department's Internet website the name of the preferred provider benefit plan, the insurer offering the plan, each affected county, the specific network adequacy standards waived, and the insurer's access plan;
(4)  require disclosure by the insurer of the information described by Subdivision (3) in all promotion and advertisement of the preferred provider benefit plan for which a waiver is allowed under that subdivision;
(5)  except as provided by Subdivision (6), limit a waiver from being issued to a preferred provider benefit plan:
(A)  more than twice consecutively for the same network adequacy standard in the same county unless the insurer demonstrates, in addition to the good cause described by Subdivision (3), multiple good faith attempts to bring the plan into compliance with the network adequacy standard during each of the prior consecutive waiver periods; or
(B)  more than a total of four times within a 21-year period for each county in a service area for issues that may be remedied through good faith efforts; and
(6)  authorize the commissioner to issue a waiver that would otherwise be unavailable under Subdivision (5) if the waiver request demonstrates, and the department confirms annually, that there are no uncontracted physicians or health care providers in the area to meet the specific standard for a county in a service area.
(b)  The standards described by Subsection (a)(2) must include factors regarding time, distance, and appointment availability. The factors must:
(1)  require that all insureds are able to receive an appointment with a preferred provider within the maximum travel times and distances established under Sections 1301.00553 and 1301.00554;
(2)  require that all insureds are able to receive an appointment with a preferred provider within the maximum appointment wait times established under Section 1301.00555;
(3)  require a preferred provider benefit plan to ensure sufficient choice, access, and quality of physicians and health care providers, in number, size, and geographic distribution, to be capable of providing the health care services covered by the plan from preferred providers to all insureds within the insurer's designated service area, taking into account the insureds' characteristics, medical conditions, and health care needs, including:
(A)  the current utilization of covered health care services within the counties of the service area; and
(B)  an actuarial projection of utilization of covered health care services, physicians, and health care providers needed within the counties of the service area to meet the needs of the number of projected insureds;
(4)  require a sufficient number of preferred providers of emergency medicine, anesthesiology, pathology, radiology, neonatology, oncology, including medical, surgical, and radiation oncology, surgery, and hospitalist, intensivist, and diagnostic services, including radiology and laboratory services, at each preferred hospital, ambulatory surgical center, or freestanding emergency medical care facility that credentials the particular specialty to ensure all insureds are able to receive covered benefits, including access to clinical trials covered by the health benefit plan, at that preferred location;
(5)  require that all insureds have the ability to access a preferred institutional provider listed in Section 1301.00553 within the maximum travel times and distances established under Section 1301.00553 for the corresponding county classification;
(6)  require that insureds have the option of facilities, if available, of pediatric, for-profit, nonprofit, and tax-supported institutions, with special consideration to contracting with:
(A)  teaching hospitals that provide indigent care or care for uninsured individuals as a significant percentage of their overall patient load; and
(B)  teaching facilities that specialize in providing care for rare and complex medical conditions and conducting clinical trials;
(7)  require that there is an adequate number of preferred provider physicians who have admitting privileges at one or more preferred provider hospitals located within the insurer's designated service area to make any necessary hospital admissions;
(8)  provide for necessary hospital services by requiring  contracting with general, pediatric, specialty, and psychiatric hospitals on a preferred benefit basis within the insurer's designated service area, as applicable;
(9)  ensure that emergency care, as defined by Section 1301.155, is available and accessible 24 hours a day, seven days a week, by preferred providers;
(10)  ensure that covered urgent care is available and accessible from preferred providers within the insurer's designated service area within 24 hours for medical and behavioral health conditions;
(11)  require an adequate number of preferred providers to be available and accessible to insureds 24 hours a day, seven days a week, within the insurer's designated service area; and
(12)  require sufficient numbers and classes of preferred providers to ensure choice, access, and quality of care across the insurer's designated service area.
(c)  Subsection (b)(6) does not apply to an exclusive provider benefit plan if the plan has:
(1)  contracted with preferred provider hospitals in sufficient number capable of meeting the covered inpatient and outpatient health care benefits for current and actuarially projected utilization in accordance with Subsection (b)(3); or
(2)  received a waiver under Subsection (a).
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 2, eff. June 19, 2009.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 5, eff. September 1, 2023.