| (a) Online directory. An HMO must develop and maintain
a directory of contracting physicians and health care providers, display
the directory on a public Internet website maintained by the HMO,
and ensure that a direct electronic link to the directory is conspicuously
displayed on the electronic summary of benefits and coverage of each
plan issued by the HMO. The directory must:
(1) include the name, address, telephone number, and
specialty, if any, of each physician and provider;
(2) clearly indicate each health benefit plan issued
by the HMO that may provide coverage for services provided by each
physician or provider included in the directory;
(3) be electronically searchable by physician or health
care provider name and location;
(4) be publicly accessible without the necessity of
providing a password, a username, or personally identifiable information;
and
(5) be reviewed on an ongoing basis and corrected or
updated, if necessary, not less than once each month.
(b) Identification of limited networks and index. An
HMO must clearly identify limited provider networks within its service
area by providing a separate listing of its limited provider networks
and an alphabetical listing of all the physicians and providers, including
specialists, available in the limited provider network. An HMO must
include an index of the alphabetical listing of all physicians and
providers, including behavioral health providers and substance abuse
treatment providers, if applicable, within the HMO's service area,
and must indicate the limited provider network(s) to which the physician
or provider belongs and the page number where the physician or provider's
name can be found.
(c) Notice of rights under an HMO plan required. An
HMO must include the notice specified in Figure: 28 TAC §11.1612(c),
in all evidences of coverage certificates, disclosures of plan terms,
and member handbooks in at least a 12-point font:
Attached Graphic
(d) Disclosure concerning access to network physician
and provider listing. An HMO must provide notice to all enrollees
at least annually describing how the enrollee may access a current
listing of all network physicians and 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 enrollees may obtain assistance during regular business
hours to find available network physicians and providers.
(e) Disclosure concerning network information. An HMO
must provide notice to all enrollees at least annually of:
(1) information that is updated at least annually regarding
the following network information for each service area, or for the
entire state if the plan is offered on a statewide service-area basis:
(A) the number of enrollees in the service area or
region;
(B) for each physician and provider area of practice,
including at a minimum internal medicine, family or general practice,
pediatric practitioner practice, obstetrics and gynecology, anesthesiology,
psychiatry, and general surgery, the number of contracted physicians
and providers, an indication of whether an active access plan under §11.1607
of this title (relating to Accessibility and Availability Requirements)
applies to the services furnished by that class of physician or provider
in the service area or region, and how the access plan may be obtained
or viewed, if applicable; and
(C) for hospitals, the number of contracted hospitals
in the service area or region, an indication of whether an active
access plan in compliance with §11.1607 of this title applies
to hospital services in that service area or region, and how the access
plan may be obtained or viewed, if applicable;
(2) information that is updated at least annually regarding
whether any access plans approved under §11.1607 of this title
apply to the plan and that complies with the following:
(A) if an access plan applies to facility services
or to internal medicine, family or general practice, pediatric practitioner
practice, obstetrics and gynecology, anesthesiology, psychiatry, or
general surgery services, this must be specifically noted;
(B) the information may be categorized by service area
or county if the HMO's plan is not offered on a statewide service
area basis, or for the entire state if the plan is offered on a statewide
service area basis; and
(C) the information must identify how to obtain or
view the access plan.
(f) Website disclosures. An HMO must provide information
on its website regarding the HMO or health benefit plans offered by
the HMO for use by current or prospective enrollees must provide a:
(1) web-based physician and provider listing for use
by current and prospective enrollees; and
(2) web-based listing of the state regions, counties,
or three-digit ZIP code areas within the HMO's service area(s), indicating,
as appropriate, for each region, county, or ZIP code area, as applicable,
that the HMO has:
(A) determined that its network meets the network adequacy
requirements of this subchapter; or
(B) determined that its network does not meet the network
adequacy requirements of this subchapter.
(g) Reliance on physician and provider listing in certain
cases. A claim for services rendered by a noncontracted physician
or provider must be paid in the same manner as if no contracted physician
or provider had been available under §11.1611 of this title (relating
to Out-of-Network Claims; Non-Network Physicians and Providers), as
applicable, if an enrollee demonstrates that:
(1) in obtaining services, the enrollee reasonably
relied on a statement that a physician or provider was a contracted
physician or provider as specified in:
(A) a physician and provider listing; or
(B) provider information on the HMO's website;
(2) the physician and provider listing or website information
was obtained from the HMO, the HMO's website, or the website of a
third party designated by the HMO to provide that information for
use by its enrollees;
(3) the physician and provider listing or website information
was obtained not more than 30 days before the date of services; and
(4) the physician and provider listing or website information
obtained indicates that the provider is a contracted provider within
the HMO's network.
(h) Additional listing-specific disclosure requirements.
In all contracted physician and provider listings, including any web-based
postings of information made available by the HMO to provide information
to enrollees about contracted physicians and providers, the HMO must
comply with the following requirements:
(1) the physician and provider information must include
a method for enrollees to identify the hospitals that have contractually
agreed with the HMO to facilitate the usage of contracted providers
by exercising good-faith efforts to accommodate requests from enrollees
to use contracted physicians and providers;
(2) the physician and provider information must indicate
whether each contracted physician and provider is accepting enrollees
as new patients or participates in closed provider networks serving
only certain enrollees;
(3) the physician and provider information must provide
an email address and a toll-free telephone number through which enrollees
may notify the HMO of inaccurate information in the listing, with
specific reference to:
(A) information about the physician's or provider's
contract status; and
(B) whether the physician or provider is accepting
new patients;
(4) the physician and provider information must provide
a method by which enrollees may identify contracted facility-based
physicians able to provide services at contracted facilities;
(5) the physician and provider information must include
a statement of limitations of accessibility and referrals to specialists,
including any limitations imposed by a limited provider network;
(6) as provided in Insurance Code §1456.003 (concerning
Required Disclosure: Health Benefit Plan), the physician and provider
information must give the identity of any health care facilities within
the provider network in which facility-based physicians or other health
care practitioners do not participate in the health benefit plan's
provider network;
(7) the provider information must specifically identify
those facilities at which the insurer has no contracts with a class
of facility-based physician or provider, specifying the applicable
provider class;
(8) the physician and provider information must be
dated;
(9) the physician and provider information must be
provided in at least 10-point font;
(10) for each health care provider that is a facility
included in a listing, the HMO must:
Cont'd... |
