| (1) Preferred provider benefit plan notice.
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(2) Exclusive provider benefit plan notice.
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(g) Untrue or misleading information prohibited. No
insurer, or agent or representative of an insurer, may cause or permit
the use or distribution of information which is untrue or misleading.
(h) Disclosure concerning access to preferred provider
listing. The insurer must provide notice to all insureds at least
annually describing how the insured may access a current listing of
all preferred providers on a cost-free basis. The notice must include,
at a minimum, information concerning how to obtain a nonelectronic
copy of the listing and a telephone number through which insureds
may obtain assistance during regular business hours to find available
preferred providers.
(i) Required updates of available provider listings.
The insurer must ensure that it updates all electronic or nonelectronic
listings of preferred providers made available to insureds at least
every three months.
(j) Annual provision of provider listing required in
certain cases. If no Internet-based preferred provider listing or
other method of identifying current preferred providers is maintained
for use by insureds, the insurer must distribute a current preferred
provider listing to all insureds no less than annually by mail, or
by an alternative method of delivery if an alternative method is agreed
to by the insured, group policyholder on behalf of the group, or certificate
holder.
(k) Reliance on provider listing in certain cases.
A claim for services rendered by a nonpreferred provider must be paid
in the same manner as if no preferred provider had been available
under §3.3708(b) - (d) of this title (relating to Payment of
Certain Basic Benefit Claims and Related Disclosures) and §3.3725(d)
- (f) of this title (relating to Payment of Certain Out-of-Network
Claims), as applicable, if an insured demonstrates that:
(1) in obtaining services, the insured reasonably relied
upon a statement that a physician or provider was a preferred provider
as specified in:
(A) a provider listing; or
(B) provider information on the insurer's website;
(2) the provider listing or website information was
obtained from the insurer, the insurer's website, or the website of
a third party designated by the insurer to provide such information
for use by its insureds;
(3) the provider listing or website information was
obtained not more than 30 days prior to the date of services; and
(4) the provider listing or website information obtained
indicates that the provider is a preferred provider within the insurer's
network.
(l) Additional listing-specific disclosure requirements.
In all preferred provider listings, including any Internet-based postings
of information made available by the insurer to provide information
to insureds about preferred providers, the insurer must comply with
the requirements in paragraphs (1) - (9) of this subsection.
(1) The provider information must include a method
for insureds to identify those hospitals that have contractually agreed
with the insurer to facilitate the usage of preferred providers as
specified in subparagraphs (A) and (B) of this paragraph.
(A) The hospital will exercise good faith efforts to
accommodate requests from insureds to utilize preferred providers.
(B) In those instances in which a particular facility-based
physician or physician group is assigned at least 48 hours prior to
services being rendered, the hospital will provide the insured with
information that is:
(i) furnished at least 24 hours prior to services being
rendered; and
(ii) sufficient to enable the insured to identify the
physician or physician group with enough specificity to permit the
insured to determine, along with preferred provider listings made
available by the insurer, whether the assigned facility-based physician
or physician group is a preferred provider.
(2) The provider information must include a method
for insureds to identify, for each preferred provider hospital, the
percentage of the total dollar amount of claims filed with the insurer
by or on behalf of facility-based physicians that are not under contract
with the insurer. The information must be available by class of facility-based
physician, including radiologists, anesthesiologists, pathologists,
emergency department physicians, and neonatologists.
(3) In determining the percentages specified in paragraph
(2) of this subsection, an insurer may consider claims filed in a
12-month period designated by the insurer ending not more than 12
months before the date the information specified in paragraph (2)
of this subsection is provided to the insured.
(4) The provider information must indicate whether
each preferred provider is accepting new patients.
(5) The provider information must provide a method
by which insureds may notify the insurer of inaccurate information
in the listing, with specific reference to:
(A) information about the provider's contract status;
and
(B) whether the provider is accepting new patients.
(6) The provider information must provide a method
by which insureds may identify preferred provider facility-based physicians
able to provide services at preferred provider facilities.
(7) The provider information must be provided in at
least 10 point font.
(8) The provider information must specifically identify
those facilities at which the insurer has no contracts with a class
of facility-based provider, specifying the applicable provider class.
(9) The provider information must be dated.
(m) Annual policyholder notice concerning use of a
local market access plan. An insurer operating a preferred provider
benefit plan that relies on a local market access plan as specified
in §3.3707 of this title (relating to Waiver Due to Failure to
Contract in Local Markets) must provide notice of this fact to each
individual and group policyholder participating in the plan at policy
issuance and at least 30 days prior to renewal of an existing policy.
The notice must include:
(1) a link to any webpage listing of regions, counties,
or ZIP codes made available pursuant to subsection (e)(2) of this
section;
(2) information on how to obtain or view any local
market access plan or plans the insurer uses; and
(3) a link to the department's website where the department
posts information relevant to the grant of waivers.
(n) Disclosure of substantial decrease in the availability
of certain preferred providers. An insurer is required to provide
notice as specified in this subsection of a substantial decrease in
the availability of preferred facility-based physicians at a preferred
provider facility.
(1) A decrease is substantial if:
(A) the contract between the insurer and any facility-based
physician group that comprises 75 percent or more of the preferred
providers for that specialty at the facility terminates; or
(B) the contract between the facility and any facility-based
physician group that comprises 75 percent or more of the preferred
providers for that specialty at the facility terminates, and the insurer
receives notice as required under §3.3703(a)(26) of this title
(relating to Contracting Requirements).
(2) Notwithstanding paragraph (1) of this subsection,
no notice of a substantial decrease is required if the requirements
specified in either subparagraph (A) or (B) of this paragraph are
met:
(A) alternative preferred providers of the same specialty
as the physician group that terminates a contract as specified in
paragraph (1) of this subsection are made available to insureds at
the facility so the percentage level of preferred providers of that
specialty at the facility is returned to a level equal to or greater
than the percentage level that was available prior to the substantial
decrease; or
(B) the insurer provides to the department, by e-mail
to mcqa@tdi.texas.gov, a certification of the insurer's determination
that the termination of the provider contract has not caused the preferred
provider service delivery network for any plan supported by the network
to be noncompliant with the adequacy standards specified in §3.3704
of this title (relating to Freedom of Choice; Availability of Preferred
Providers), as those standards apply to the applicable provider specialty.
(3) An insurer must prominently post notice of any
contract termination specified in paragraph (1)(A) or (B) of this
subsection and the resulting decrease in availability of preferred
providers on the portion of the insurer's website where its provider
listing is available to insureds.
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