Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter KK - EXCLUSIVE PROVIDER BENEFIT PLAN › Section 3.9204 - Contracting with Health Care Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) An issuer shall notify, by publication or
				  in writing, all health care providers in the service area of its intent to
				  offer an EPP and of the opportunity to participate. The issuer shall provide
				  such notice prior to issuance of the initial EPP and yearly
				  thereafter.
(b) An issuer shall on
				  request make available and disclose to any health care provider the issuer's
				  written application procedures, qualifications and information concerning
				  requirements for participation as an exclusive provider. An issuer shall
				  provide written notice of the reasons it denied the application to each health
				  care provider who applies to contract and who is denied.
(c) An issuer may not, on the sole basis of
				  category or specific type of license or authorization, deny to any health care
				  provider licensed or otherwise authorized to practice in this state,
				  participation to provide health care services that are covered by the issuer,
				  and within the scope of licensure or authorization of that health care
				  provider.
(d) This subsection does
				  not prohibit the issuer from rejecting an application from a health care
				  provider based on the determination that the plan has sufficient qualified
				  health care providers.
(e) Each
				  exclusive provider contract (or subcontract) must provide that, before
				  terminating a contract with an exclusive provider, the contracting entity must
				  provide a written explanation to the exclusive provider of the reasons for
				  termination. On request and before the effective date of the termination, but
				  within a period not to exceed 60 days, a provider will be entitled to a review
				  of the issuer's proposed termination by an advisory review panel, except in a
				  case in which there is imminent harm to patient health or an action by a state
				  medical or dental board, other medical or dental licensing board, or other
				  licensing board or other government entity, that effectively impairs the health
				  care provider's ability to practice medicine, dentistry, or another profession,
				  or in a case of fraud or malfeasance. The advisory review panel shall be
				  composed of exclusive providers, including at least one representative in the
				  health care provider's specialty or a similar specialty, if available,
				  appointed to serve on the standing quality assurance committee or utilization
				  review committee of the issuer. The issuer must consider the decision of the
				  advisory review panel, but it is not binding on the issuer. The issuer will
				  provide to the affected health care provider, on request, a copy of the
				  recommendation of the advisory review panel and the issuer's
				  determination.
(f) Each exclusive
				  provider contract (or subcontract) must provide that an issuer or provider
				  shall give reasonable advance notice to an insured of the impending termination
				  from the plan of an exclusive provider who is currently treating the insured.
				  Each contract must also provide that the termination of the exclusive
				  provider's contract, except for reason of medical competence or professional
				  behavior, does not release the issuer from the obligation to reimburse the
				  exclusive provider who is treating a patient of special circumstance, such as a
				  person who has a disability, acute condition, or life-threatening illness or is
				  past the twenty-fourth week of pregnancy, at no less than the contract rate for
				  that insured's care in exchange for continuity of ongoing treatment of an
				  insured then receiving medically necessary treatment in accordance with the
				  dictates of medical prudence. For purposes of this subsection, "special
				  circumstance" means a condition such that the treating health care provider
				  reasonably believes that discontinuing care by the treating health care
				  provider could cause harm to the patient. The treating health care provider
				  must identify the special circumstance and must request that the insured be
				  permitted to continue treatment under the health care provider's care and agree
				  not to seek payment from the patient of any amounts for which the insured would
				  not be responsible if the exclusive provider were still in the EPP network.
				  Each exclusive provider contract shall provide procedures for resolving
				  disputes regarding the necessity for continued treatment by the exclusive
				  provider. This section does not extend the obligation of the issuer to
				  reimburse the terminated health care provider for ongoing treatment of an
				  insured beyond the 90th day after the effective date of the termination, or
				  beyond nine months in the case of an insured who at the time of the termination
				  has been diagnosed with a terminal illness. However, the obligation of the
				  issuer to reimburse the terminated health care provider for services to an
				  insured who at the time of the termination is past the 24th week of pregnancy,
				  extends through delivery of the child, immediate postpartum care, and any
				  follow-up checkup within the first six weeks of delivery.
(g) On request by the exclusive provider, an
				  issuer must provide an expedited review process to any exclusive provider who
				  is terminated or deselected. If the exclusive provider is deselected for
				  reasons other than at the provider's request, the issuer may not notify
				  insureds of the exclusive provider's deselection until the effective date of
				  the termination or the time a review panel makes a formal recommendation. If an
				  exclusive provider is deselected for reasons related to imminent harm, the
				  issuer may notify insureds immediately.
(h) An exclusive provider contract (or
				  subcontract) may not contain any clause purporting to indemnify the issuer for
				  any tort liability resulting from acts or omissions of the issuer.
(i) An exclusive provider contract (or
				  subcontract) shall specify that the exclusive provider will hold an insured
				  harmless for payment of the cost of covered health care services in the event
				  the issuer fails to pay the provider for health care services.
(j) An issuer that conducts or uses economic
				  profiling of exclusive providers must make available upon request from a
				  network provider the economic profile of that provider, including the standards
				  by which the provider is measured. An economic profile must recognize the
				  characteristics of an exclusive provider's practice that may account for
				  variations from expected costs.
(k)
				  An exclusive provider contract must require the health care provider to post,
				  in the office of the health care provider, a notice to insureds of the process
				  for resolving complaints with the issuer. The notice must include the Texas
				  Department of Insurance's toll-free telephone number for filing non-Medicaid
				  complaints.
(l) An exclusive
				  provider contract may not prohibit, attempt to prohibit, or discourage an
				  exclusive provider from discussing with or communicating in good faith to a
				  current, prospective, or former patient, or a party designated by a patient,
				  with respect to:
(1) information or opinions
				  regarding the patient's health care, including the patient's medical condition
				  or treatment options;
(2)
				  information or opinions regarding the provisions, terms, requirements, or
				  services of the EPP as they relate to the medical needs of the patient;
				  or
(3) the fact that the exclusive
				  provider's contract has terminated or that the exclusive provider will
				  otherwise no longer be providing health care services under the EPP.