| (a) Provider accessibility.
(1) A managed care organization (MCO) must provide
a broad-based and accessible provider network within the service area
to ensure member accessibility to a choice of two or more of each
of the managed care program's provider types within the time or distance
standards set forth below or as otherwise required by HHSC.
Attached Graphic
(2) For STAR+PLUS, STAR Health, and STAR Kids, a health
care MCO must ensure the reasonable availability and accessibility
of a choice of two or more of each of the long-term services and supports
(LTSS) and home and community-based services providers to the extent
required by HHSC. These providers must be reasonably accessible to
members, as determined by HHSC.
(3) For providers not specifically listed in paragraphs
(1) or (2) of this subsection, an MCO must provide reasonable availability
and accessibility of providers within the service area to ensure member
accessibility to providers in time or distance, or as otherwise required
by HHSC.
(4) An MCO must allow a member to choose his network
provider to the extent possible and appropriate, as required by 42
C.F.R. §438.3(l).
(b) Texas Health Steps. In addition to the requirements
in subsection (a) of this section:
(1) a health care MCO must have a network of providers
in sufficient numbers to provide medical checkups, diagnostic services,
and treatment services in accordance with state and federal regulations,
including 42 U.S.C. 1396d(r) and 25 TAC Chapter 33 (relating to Early
and Periodic Screening, Diagnosis, and Treatment), to all enrolled
members age 20 and younger in the service area; and
(2) a dental MCO must have main dentist providers in
their network in sufficient numbers to provide dental checkups, diagnostic
services, and treatment services in accordance with state and federal
regulations, including 42 U.S.C. 1396d(r) and 25 TAC Chapter 33, to
all enrolled members age 20 and younger in the service area.
(c) Wait times.
(1) A health care MCO must have PCPs in sufficient
numbers to ensure that no member must wait an unreasonable amount
of time for an appointment, and that no member must wait an unreasonable
amount of time to be seen at their appointed time.
(2) A dental MCO must have main dentist providers in
sufficient numbers to ensure that no member must wait an unreasonable
amount of time for an appointment, and that no member must wait an
unreasonable amount of time to be seen at their appointed time.
(d) Exceptions and exemptions. If any service or provider
is not available to a member within the time or distance requirement
specified in subsection (a) of this section, the MCO may submit an
exemption request to HHSC. Exemptions are considered on a case-by-case
basis. HHSC may also allow the MCOs to comply with subsection (a)
of this section at a percentage less than 100%.
(e) Service or provider outside the service area. The
provisions in subsection (a) of this section do not preclude an MCO
from making arrangements with a provider outside the service area
for members to receive services from a provider with a higher level
of skill or specialty than the level that is available within the
MCO service area. For health care MCOs, this can include treatment
of cancer, burns, and cardiac diseases.
(f) Provider education and training.
(1) A health care MCO must provide education and training
to providers on the specific health and behavioral health problems
and needs of members.
(2) A dental MCO must provide education and training
to providers on the specific dental health problems and needs of members.
(3) All MCOs must provide education and training regarding
the contract and rule requirements for accessibility and availability.
Each MCO must coordinate education and training activities for providers
with HHSC.
(g) Cultural competency.
(1) An MCO must provide a broad-based and accessible
provider network within the service area to ensure member accessibility
to providers that meet cultural competency and language requirements.
An MCO must ensure that cultural barriers do not deter members' timely
access to health care services or dental services.
(2) An MCO must develop a written cultural competency
plan describing how the MCO will effectively provide health care services
or dental services to members from varying cultures, races, ethnic
backgrounds, and religions as well as those with disabilities, to
ensure those characteristics do not pose barriers to gaining access
to needed services.
(A) The cultural competency plan must adhere to the
National Standards for Culturally and Linguistically Appropriate Services
in Health and Health Care (National CLAS Standards); and
(B) The MCO must:
(i) employ multi-cultural and multi-lingual staff;
(ii) arrange and pay for interpreter services, including
written, spoken, and sign language interpretation, for members to
ensure availability of effective communication regarding treatment,
medical history, or health condition;
(iii) display to HHSC through the written plan a method
for incorporating the plan into the MCO's policy-making process, administration,
and daily practices;
(iv) maintain policies and procedures, and make information
available to members and providers, outlining the manner in which
members and the members' providers can access competent interpreter
services, including written, spoken, and sign language interpretation,
when the member is in a provider's office or accessing emergency services;
and
(v) submit the written plan and plan updates and edits
to HHSC for review and approval at intervals specified by HHSC.
(h) Verbal and physical barriers. An MCO must ensure
that communication and physical access barriers do not deter members'
timely access to health care services or dental services. The MCO
must provide information in appropriate communication formats, including
formats accessible to people with disabilities.
(i) Significant traditional providers. An MCO must
not exclude Significant Traditional Providers from its network for
a period of time and under conditions determined by HHSC and specified
in the contract.
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