| (a) Network adequacy report required. An insurer must
file a network adequacy report with the department on or before April
1 of each year and prior to marketing any plan in a new service area.
(b) General content of report. The report required
in subsection (a) of this section must specify:
(1) the trade name of each preferred provider benefit
plan in which insureds currently participate;
(2) the applicable service area of each plan; and
(3) whether the preferred provider service delivery
network supporting each plan is adequate under the standards in §3.3704
of this title (relating to Freedom of Choice; Availability of Preferred
Providers).
(c) Additional content applicable only to annual reports.
As part of the annual report on network adequacy, each insurer must
provide additional demographic data as specified in paragraphs (1)
- (6) of this subsection for the previous calendar year. The data
must be reported on the basis of each of the geographic regions specified
in §3.3711 of this title (relating to Geographic Regions). If
none of the insurer's preferred provider benefit plans includes a
service area that is located within a particular geographic region,
the insurer must specify in the report that there is no applicable
data for that region. The report must include the number of:
(1) claims for out-of-network benefits, excluding claims
paid at the preferred benefit coinsurance level;
(2) claims for out-of-network benefits that were paid
at the preferred benefit coinsurance level;
(3) complaints by nonpreferred providers;
(4) complaints by insureds relating to the dollar amount
of the insurer's payment for basic benefits or concerning balance
billing;
(5) complaints by insureds relating to the availability
of preferred providers; and
(6) complaints by insureds relating to the accuracy
of preferred provider listings.
(d) Filing the report. The annual report required under
this section must be submitted electronically in a format acceptable
to the department. Acceptable formats include Microsoft Word and Excel
documents. The report must be submitted to the following email address:
LifeHealth@tdi.texas.gov.
(e) Exceptions. This section does not apply to a preferred
or exclusive provider benefit plan written by an insurer for a contract
with the Health and Human Services Commission to provide services
under the Texas Children's Health Insurance Program (CHIP), Medicaid,
or with the State Rural Health Care System.
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