| (a) Network adequacy report required. On or before
April 1 of each year and prior to marketing any plan in a new service
area, an insurer must submit a network adequacy report for each network
to be used with a preferred or exclusive provider benefit plan. The
network adequacy report must be submitted to the department using
SERFF or another electronic method that is acceptable to the department.
(b) General content of report. The report required
in subsection (a) of this section must specify:
(1) the insurer's name, National Association of Insurance
Commissioners number, network name, and network ID;
(2) the network configuration information specified
in §3.3712 of this title (relating to Network Configuration Filings);
(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); and
(4) if applicable, the waiver request and access plan
information as specified in §3.3707 of this title (relating to
Waiver Due to Failure to Contract in Local Markets).
(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)
- (7) 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:
(1) the number of insureds served by the network in
the most recent calendar year and the number of insureds projected
to be served by the network in the upcoming calendar year;
(2) total complaints;
(3) complaints by nonpreferred providers;
(4) complaints by insureds relating to the dollar amount
of the insurer's payment for out-of-network benefits or concerning
balance billing;
(5) complaints relating to the availability of preferred
providers;
(6) complaints relating to the accuracy of preferred
provider listings; and
(7) actuarial data on the current and projected utilization
of each type of physician or provider within each region, including:
(A) the current and projected number of preferred providers
of each specialty type;
(B) claims data for the most recent calendar year,
including:
(i) the number of preferred provider claims;
(ii) the number of claims for out-of-network benefits,
excluding claims paid at the preferred benefit coinsurance level;
(iii) the number of claims for out-of-network benefits
that were paid at the preferred benefit coinsurance level;
(iv) the number of unique enrollees with one or more
claims; and
(v) the number of unique physicians or providers with
one or more claims.
(d) Filing the report. The annual report required under
this section must be submitted electronically in SERFF or another
electronic method that is acceptable to the department using the annual
network adequacy report form available at www.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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| Source Note: The provisions of this §3.3709 adopted to be effective December 6, 2011 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827; amended to be effective March 30, 2021, 46 TexReg 2026; amended to be effective April 25, 2024, 49 TexReg 2497 |
