| (B) the contract between the facility and any facility-based
physician group that comprises 75% 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 email
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.
(4) Notice of any contract termination specified in
paragraph (1)(A) or (B) of this subsection and of the decrease in
availability of providers must be maintained on the insurer's website
until the earlier of:
(A) the date on which adequate preferred providers
of the same specialty become available to insureds at the facility
at the percentage level specified in paragraph (2)(A) of this subsection;
(B) six months from the date that the insurer initially
posts the notice; or
(C) the date on which the insurer provides to the department,
by email to mcqa@tdi.texas.gov, a certification as specified in paragraph
(2)(B) of this subsection indicating the insurer's determination that
the termination of provider contract does not cause noncompliance
with adequacy standards.
(5) An insurer must post notice as specified in paragraph
(3) of this subsection and update its Internet-based preferred provider
listing as soon as practicable and in no case later than two business
days after:
(A) the effective date of the contract termination
as specified in paragraph (1)(A) of this subsection; or
(B) the later of:
(i) the date on which an insurer receives notice of
a contract termination as specified in paragraph (1)(B) of this subsection;
or
(ii) the effective date of the contract termination
as specified in paragraph (1)(B) of this subsection.
(o) Disclosures concerning reimbursement of out-of-network
services. An insurer must make disclosures in all insurance policies,
certificates, and outlines of coverage concerning the reimbursement
of out-of-network services as specified in this subsection.
(1) An insurer must disclose how reimbursements of
nonpreferred providers will be determined.
(2) Except in an exclusive provider benefit plan, if
an insurer reimburses nonpreferred providers based directly or indirectly
on data regarding usual, customary, or reasonable charges by providers,
the insurer must disclose the source of the data, how the data is
used in determining reimbursements, and the existence of any reduction
that will be applied in determining the reimbursement to nonpreferred
providers.
(3) Except in an exclusive provider benefit plan, if
an insurer bases reimbursement of nonpreferred providers on any amount
other than full billed charges, the insurer must:
(A) disclose that the insurer's reimbursement of claims
for nonpreferred providers may be less than the billed charge for
the service;
(B) disclose that the insured may be liable to the
nonpreferred provider for any amounts not paid by the insurer;
(C) provide a description of the methodology by which
the reimbursement amount for nonpreferred providers is calculated;
and
(D) provide to insureds a method to obtain a real-time
estimate of the amount of reimbursement that will be paid to a nonpreferred
provider for a particular service.
(p) Plan designations. A preferred provider benefit
plan that utilizes a preferred provider service delivery network that
complies with the network adequacy requirements for hospitals under §3.3704
of this title without reliance on an access plan may be designated
by the insurer as having an "Approved Hospital Care Network" (AHCN).
If a preferred provider benefit plan utilizes a preferred provider
service delivery network that does not comply with the network adequacy
requirements for hospitals specified in §3.3704 of this title,
the insurer is required to disclose that the plan has a "Limited Hospital
Care Network":
(1) on the insurer's outline of coverage; and
(2) on the cover page of any provider listing describing
the network.
(q) Loss of status as an AHCN. If a preferred provider
benefit plan designated as an AHCN under subsection (p) of this section
no longer complies with the network adequacy requirements for hospitals
under §3.3704 of this title and does not correct such noncompliant
status within 30 days of becoming noncompliant, the insurer must:
(1) notify the department in writing concerning such
change in status as specified on the department's website;
(2) cease marketing the plan as an AHCN; and
(3) inform all insureds of such change of status at
the time of renewal.
|
| Source Note: The provisions of this §3.3705 adopted to be effective July 15, 1999, 24 TexReg 5204; amended to be effective December 6, 2011, 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827; amended to be effective November 3, 2016, 41 TexReg 8605; amended to be effective May 16, 2017, 42 TexReg 2537; amended to be effective March 30, 2021, 46 TeReg 2026 |
