| (a) An insurer must submit network configuration information
as specified in this section in connection with a request for a waiver
under §3.3707 of this title (relating to Waiver Due to Failure
to Contract in Local Markets), an annual network adequacy report required
under §3.3709 of this title (relating to Annual Network Adequacy
Report), or an application for a network modification under §3.3722
of this title (relating to Application for Preferred and Exclusive
Provider Benefit Plan Approval; Qualifying Examination; Network Modifications).
(b) A network configuration filing must be submitted
to the department using SERFF or another electronic method that is
acceptable to the department.
(c) A network configuration filing must contain the
following items.
(1) Provider listing data. The insurer must use the
provider listings form available at www.tdi.texas.gov to provide a
comprehensive searchable and sortable listing of physicians and health
care providers in the plan's network that includes:
(A) information about the insurer, including the insurer's
name, National Association of Insurance Commissioners number, network
name, and network ID;
(B) information about each preferred provider, including:
(i) the preferred provider's name, address of practice
location, county, and telephone number;
(ii) the preferred provider's national provider identifier
(NPI) number and Texas license number;
(iii) the preferred provider's specialty type, license,
or facility type, as applicable, using the categories specified in
the form; and
(iv) whether the preferred provider offers telemedicine
or telehealth; and
(C) information about a preferred provider that is
not a facility, including information on the preferred provider's
facility privileges.
(2) Network compliance analysis. The insurer must use
the network compliance and waiver request form available at www.tdi.texas.gov
to provide a listing of each county in the insurer's service area
and data regarding network compliance for each county, including:
(A) the number of each type of preferred provider in
the plan's network, using the provider specialty types specified in
the form;
(B) information indicating whether the network adequacy
standards specified in §3.3704 of this title (relating to Freedom
of Choice; Availability of Preferred Providers) are met with respect
to each type of physician or provider, including specifying the nature
of the deficiency (such as insufficient providers, insufficient choice,
or deficient appointment wait times);
(C) if the network adequacy standards are not met for
a given type of physician or provider, a waiver request and an access
plan consistent with §3.3707 of this title (relating to Waiver
Due to Failure to Contract in Local Markets), including an explanation
of:
(i) the reason the waiver is needed, including whether
the waiver is needed because there are no physicians or providers
available with whom a contract would allow the insurer to meet the
network adequacy standards, or because of a failure to contract with
available providers;
(ii) if the waiver is needed because of a failure to
contract with available providers, each year for which the waiver
has previously been approved, beginning with 2024;
(iii) the total number of currently practicing physicians
or providers that are located within each county and the source of
this information; and
(iv) the access plan procedures the insurer will use
to assist insureds in obtaining medically necessary services when
no preferred provider is available within the network adequacy standards,
including procedures to coordinate care to limit the likelihood of
balance billing, consistent with the procedures established in §3.3707(j)
of this title; and
(D) except for a network offered in connection with
an exclusive provider benefit plan, an insurer must include a description
of how the insurer provides access to different types of facilities,
as required by Insurance Code §1301.0055(b)(6), concerning Network
Adequacy Standards.
(3) Online provider listing. The insurer must include
a link to the online provider listing made available to insureds and
a pdf copy of the provider listing that is made available to insureds
that request a nonelectronic version.
(4) Access plan for unforeseen network gaps. The insurer
must include a copy of the access plan required in §3.3707(m)
of this title, which applies to any unforeseen circumstance in which
an insured is unable to access covered health care services within
the network adequacy standards provided in §3.3704 of this title.
(d) The information submitted as required under this
section is considered public information under Government Code Chapter
552, concerning Public Information, and the insurer may not submit
the provider listings form or network compliance and waiver request
form in a manner that precludes the public release of the information.
The department will use the data submitted under this section to publish
network data consistent with Insurance Code §§1301.0055(a)(3),
concerning Network Adequacy Standards, 1301.00565(g), concerning Public
Hearing on Network Adequacy Standards Waivers, and 1301.009, concerning
Annual Report.
(e) Upon request by TDI, an insurer must provide access
to any information necessary for the commissioner to evaluate and
make a determination of compliance with quality of care and network
adequacy standards, including the information set forth in Insurance
Code §1301.0056(e), concerning Examinations and Fees.
|
