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 3.3704 - Freedom of Choice; Availability of Preferred Providers

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Fairness requirements. A preferred provider benefit plan is not considered
					 unjust under Insurance Code Chapter 1701, concerning Policy Forms, or to
					 unfairly discriminate under Insurance Code Chapter 542, Subchapter A,
					 concerning Unfair Claim Settlement Practices, or Chapter 544, Subchapter B,
					 concerning Other General Prohibitions Against Discrimination by Insurers, or to
					 violate Insurance Code Chapter 1451, Subchapter A, concerning General
					 Provisions; Subchapter B, concerning Designation of Practitioners Under
					 Accident and Health Insurance Policy; or Subchapter C, concerning Selection of
					 Practitioners, provided that:
(1) in
					 accordance with Insurance Code §§
												1251.005, concerning
					 Payment of Benefits; 1251.006, concerning Policy May Not Specify Service
					 Provider; 1301.003, concerning Preferred Provider Benefit Plans and Exclusive
					 Provider Benefit Plans Permitted, 1301.006, concerning Availability of and
					 Accessibility to Health Care Services; 1301.051, concerning Designation as
					 Preferred Provider; 1301.053, concerning Appeal Relating to Designation as
					 Preferred Provider; 1301.054, concerning Notice to Practitioners of Preferred
					 Provider Benefit Plan; 1301.055, concerning Complaint Resolution; 1301.057 -
					 1301.062, concerning Termination of Participation; Expedited Review Process,
					 Economic Profiling, Quality Assessment, Compensation on Discounted Fee Basis,
					 Preferred Provider Networks, and Preferred Provider Contracts Between Insurers
					 and Podiatrists; 1301.064, concerning Contract Provisions Relating to Payment
					 of Claims; 1301.065, concerning Shifting of Insurer's Tort Liability
					 Prohibited; 1301.151, concerning Insured's Right to Treatment; 1301.156,
					 concerning Payment of Claims to Insured; and 1301.201, concerning Contracts
					 with and Reimbursement for Nurse First Assistants, the preferred provider
					 benefit plan does not require that a service be rendered by a particular
					 hospital, physician, or practitioner;
(2) insureds are provided with direct and
					 reasonable access to all classes of physicians and practitioners licensed to
					 treat illnesses or injuries and to provide services covered by the preferred
					 provider benefit plan;
(3) insureds
					 have the right to treatment and diagnostic techniques as prescribed by a
					 physician or other health care provider included in the preferred provider
					 benefit plan;
(4) insureds have the
					 right to continuity of care as set forth in Insurance Code §§
												1301.152 -
					 1301.154, concerning
					 Continuing Care in General, Continuity of Care, and Obligation for Continuity
					 of Care of Insurer, respectively;
(5) insureds have the right to emergency care
					 services as set forth in Insurance Code §
												1301.0053, concerning
					 Exclusive Provider Benefit Plans: Emergency Care; and §1301.155,
					 concerning Emergency Care; and §
												3.3708 of this title (relating to
					 Payment of Certain Out-of-Network Claims and Related Disclosures);
(6) the out-of-network (basic) level of
					 coverage, excluding a reasonable difference in deductibles, is not more than
					 50% less than the higher level of coverage, except as provided under an
					 exclusive provider benefit plan. A reasonable difference in deductibles is
					 determined considering the benefits of each individual policy;
(7) the rights of an insured to exercise full
					 freedom of choice in the selection of a physician or provider, or in the
					 selection of a preferred provider under an exclusive provider benefit plan, are
					 not restricted by the insurer, including by requiring an insured to select a
					 primary care physician or provider or obtain a referral before seeking
					 care;
(8) if the insurer is issuing
					 other health insurance policies in the service area that do not provide for the
					 use of preferred providers, the out-of-network level of coverage of a plan that
					 is not an exclusive provider benefit plan is reasonably consistent with other
					 health insurance policies offered by the insurer that do not provide for a
					 different level of coverage for use of a preferred provider;
(9) any actions taken by an insurer engaged
					 in utilization review under a preferred provider benefit plan are taken under
					 Insurance Code Chapter 4201, concerning Utilization Review Agents, and Chapter
					 19, Subchapter R, of this title (relating to Utilization Reviews for Health
					 Care Provided Under a Health Benefit Plan or Health Insurance Policy) and the
					 insurer does not penalize an insured solely on the basis of a failure to obtain
					 a preauthorization;
(10) a
					 preferred provider benefit plan that is not an exclusive provider benefit plan
					 may provide for a different level of coverage for use of a nonpreferred
					 provider if the referral is made by a preferred provider only if full
					 disclosure of the difference is included in the plan and the written
					 description as required by §
												3.3705(b) of this
					 title (relating to Nature of Communications with Insureds; Readability,
					 Mandatory Disclosure Requirements, and Plan Designations);
(11) both preferred provider benefits and
					 out-of-network level benefits are reasonably available to all insureds within a
					 designated service area; and
(12)
					 if medically necessary covered services are not reasonably available through
					 preferred physicians or providers, insureds have the right to receive care from
					 a nonpreferred provider in accordance with Insurance Code §
												1301.005, concerning
					 Availability of Preferred Providers, and §1301.0052, concerning Exclusive
					 Provider Benefit Plans: Referrals for Medically Necessary Services, and §
												3.3708 of this title, as
					 applicable.