Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3707 - Waiver Due to Failure to Contract in Local Markets

Current through Reg. 49, No. 28; July 12, 2024
(a) Consistent with
					 Insurance Code §
											1301.0055(a)(3),
					 concerning Network Adequacy Standards, where necessary to avoid a violation of
					 the network adequacy requirements of §
											3.3704 of this title (relating to
					 Freedom of Choice; Availability of Preferred Providers) in a county that the
					 insurer wishes to include in its service area, an insurer may apply for a
					 waiver from one or more of the network adequacy requirements in §
											3.3704(f) of this
					 title. After considering all pertinent evidence in a public hearing under
					 Insurance Code §
											1301.00565, concerning
					 Public Hearing on Network Adequacy Standards Waivers, the commissioner may
					 grant the waiver if the requestor shows good cause, subject to the limits on
					 waivers provided in Insurance Code §
											1301.0055(a)(5).
					 The commissioner may deny a waiver request if good cause is not shown and may
					 impose reasonable conditions on the grant of the waiver.
(b) An insurer seeking a waiver under
					 subsection (a) of this section must submit waiver and access plan information
					 required under §3.3712(c) of this title (related to Network Configuration
					 Filings) and information justifying the waiver request as specified in this
					 subsection using the attempt to contract form available at
www.tdi.texas.gov
. An insurer must
					 submit the network compliance and waiver request form and the attempt to
					 contract form to the department using SERFF or another electronic method that
					 is acceptable to the department. For each waiver requested with respect to a
					 type of physician or provider in a given county, the insurer must provide
					 either the information specified by paragraph (1) of this subsection or the
					 information specified by paragraph (2) of this subsection, as appropriate.
(1) If providers or physicians are available
					 within the relevant service area for the covered service or services for which
					 the insurer requests a waiver, the insurer's request for waiver must include,
					 within the attempt to contract form:
(A) a
					 list of the providers or physicians within the relevant service area that the
					 insurer attempted to contract with, identified by name and specialty or
					 facility type, and including the physician or provider's address and county;
					 national provider identifier, contact name, email, and phone number; and for
					 facility-based physicians or providers, the group name and associated
					 facility;
(B) a description of how
					 and when the insurer last contacted each provider or physician that
					 demonstrates that the insurer made a good faith effort to contract, as defined
					 in Insurance Code §
													1301.00565(a),
					 including:
(i) in the case of a waiver that is
					 being requested more than two consecutive times for the same network adequacy
					 standard in the same county, evidence that the insurer made multiple good faith
					 attempts during each of the prior consecutive waiver periods;
(ii) in the case of a waiver that is being
					 requested more than four times within a 21-year period for the same network
					 adequacy standard in the same county, evidence that the insurer has been unable
					 to remedy the issue through good faith efforts;
(C) a description of any reason each provider
					 or physician gave for declining to contract with the insurer, such as the
					 provider's or physician's participation in any exclusivity arrangement or other
					 external factors that affect the ability of the parties to contract;
(D) a description of all steps the insurer
					 will take to attempt to improve its network to make future requests to renew
					 the waiver unnecessary;
(E) a
					 description of the source or sources the insurer uses to identify physicians
					 and providers that are available in the service area, and how often the insurer
					 monitors these sources for new physicians and providers entering the service
					 area; and
(F) a description of the
					 insurer's policies and procedures for reaching out to available physicians and
					 providers, including how many attempts the insurer makes and if different
					 policies and procedures apply for different specialty types.