|(a) Each health benefit plan delivered or issued for
delivery by an HMO must include an HMO delivery network that is adequate
and complies with Insurance Code §843.082 (concerning Requirements
for Approval of Application).
(b) There must be a sufficient number of primary care
physicians and specialists with hospital admitting privileges to participating
facilities who are available and accessible 24 hours per day, seven
days per week, within the HMO's service area to meet the health care
needs of the HMO's enrollees.
(c) An HMO must make general, special, and psychiatric
hospital care available and accessible 24 hours per day, seven days
per week, within the HMO's service area.
(d) If an HMO limits enrollees' access to a limited
provider network, it must ensure that the limited provider network
complies with all requirements of this section.
(e) An HMO must make emergency care available and accessible
24 hours per day, seven days per week, without restrictions on where
the services are rendered.
(f) All covered services that are offered by an HMO
must be sufficient in number and location to be readily available
and accessible within the service area to all enrollees.
(g) An HMO must arrange for covered health care services,
including referrals to specialists, to be accessible to enrollees
on a timely basis on request and consistent with these guidelines:
(1) urgent care must be available within 24 hours for
medical, dental, and behavioral health conditions;
(2) routine care must be available within:
(A) three weeks for medical conditions;
(B) eight weeks for dental conditions; and
(C) two weeks for behavioral health conditions.
(3) Preventive health services must be available within:
(A) two months for a child;
(B) three months for an adult; and
(C) four months for dental services.
(h) An HMO is required to provide an adequate network
for its entire service area. All covered services must be accessible
and available so that travel distances from any point in its service
area to a point of service are no greater than:
(1) 30 miles for primary care and general hospital
(2) 75 miles for specialty care, special hospitals,
and single health care service plan physicians or providers.
(i) Access to certain institutional providers. An HMO
network providing access to more than one institutional provider in
a region must make a good-faith effort to have a mix of for-profit,
nonprofit, and tax-supported institutional participating providers,
unless the mix is not feasible due to geographic, economic, or other
operational factors. An HMO must give special consideration to contracting
with teaching hospitals and hospitals that provide indigent care or
care for uninsured individuals as a significant percentage of their
overall patient load.
(j) An HMO that is unable to meet the requirements
of subsections (b) - (h) of this section must file an access plan
for approval with the department in compliance with §11.301 of
this title (relating to Filing Requirements). The access plan must
(1) the geographic area within the service area in
which a sufficient number of contracted physicians and providers are
not available, including a specification of the class of physician
(2) a map for each specialty, with key and scale, that
identifies the geographic areas within the service area in which the
health care services, physicians, and providers are not available;
(3) the reason or reasons that the network does not
meet the adequacy requirements specified in this section;
(4) procedures that the HMO will use to assist enrollees
in obtaining medically necessary services when no network physician
or provider is available, including procedures to coordinate care
to hold enrollees harmless and eliminate or limit the likelihood of
(5) a list of the physicians and providers within the
relevant service area that the HMO attempted to contract with, identified
by name and specialty or facility type, with:
(A) a description of how and when the HMO last contacted
each physician, provider, or facility; and
(B) a description of the reason each physician, provider,
or facility gave for declining to contract with the HMO;
(6) procedures detailing how out-of-network benefit
claims will be handled when no physicians or providers are available,
including procedures for compliance with §11.1611 of this title
(relating to Out-of-Network Claims; Non-Network Physicians and Providers);
(7) steps the HMO will take to attempt to bring its
network into compliance with this section; and
(8) a process for negotiating with a non-network physician
or provider before services being rendered, when feasible.
(k) An HMO must submit an access plan that complies
with subsection (j) of this section along with the annual report on
network adequacy under §11.1610 of this title (relating to Annual
Network Adequacy Report).
(l) Notwithstanding subsection (h) of this section,
an HMO that has a contract with the Health and Human Services Commission
is not required to meet the access requirements prescribed in this
section for covered services provided to participants in the Children's
Health Insurance Program Perinatal Program.
(m) An HMO may make arrangements with physicians or
providers outside the service area for enrollees to receive a higher
level of skill or specialty than the level available within the HMO
service area, such as, but not limited to, transplants and treatment
of cancer, burns, and cardiac diseases. An HMO may not require an
enrollee to travel out of the service area to receive the services.
(n) An HMO is not required to expand services outside
its service area to accommodate enrollees who live outside the service
area but work within the service area.
(o) In compliance with Insurance Code Chapter 1455
(concerning Telemedicine and Telehealth), each evidence of coverage
or certificate delivered or issued for delivery by an HMO may provide
enrollees the option to access covered health care services through
a telehealth service or telemedicine service.