| (3) In determining the percentages specified in paragraph
(2) of this subsection, an insurer may consider claims filed in a
12-month period designated by the insurer ending not more than 12
months before the date the information specified in paragraph (2)
of this subsection is provided to the insured.
(4) The provider information must indicate whether
each preferred provider is accepting new patients.
(5) The provider information must provide a method
by which insureds may notify the insurer of inaccurate information
in the listing, with specific reference to:
(A) information about the provider's contract status;
and
(B) whether the provider is accepting new patients.
(6) The provider information must provide a method
by which insureds may identify preferred provider facility-based physicians
able to provide services at preferred provider facilities.
(7) The provider information must be provided in at
least 10-point font.
(8) The provider information must specifically identify
those facilities at which the insurer has no contracts with a class
of facility-based provider, specifying the applicable provider class.
(9) The provider information must be dated.
(10) For each health care provider that is a facility
included in the listing, the insurer must:
(A) create separate headings under the facility name
for radiologists, anesthesiologists, pathologists, emergency department
physicians, neonatologists, and assistant surgeons;
(B) under each heading described by subparagraph (A)
of this paragraph, list each preferred facility-based physician practicing
in the specialty corresponding with that heading;
(C) for the facility and each facility-based physician
described by subparagraph (B) of this paragraph, clearly indicate
each health benefit plan issued by the insurer that may provide coverage
for the services provided by that facility, physician, or facility-based
physician group;
(D) for each facility-based physician described by
subparagraph (B) of this paragraph, include the name, street address,
telephone number, and any physician group in which the facility-based
physician practices; and
(E) include the facility in a listing of all facilities
and indicate:
(i) the name of the facility;
(ii) the municipality in which the facility is located
or county in which the facility is located if the facility is in the
unincorporated area of the county; and
(iii) each health benefit plan issued by the insurer
that may provide coverage for the services provided by the facility.
(11) The listing must list each facility-based physician
individually and, if a physician belongs to a physician group, also
as part of the physician group.
(m) Annual policyholder notice concerning use of a
local market access plan. An insurer operating a preferred provider
benefit plan that relies on a local market access plan as specified
in §3.3707 of this title (relating to Waiver Due to Failure to
Contract in Local Markets) must provide notice of this fact to each
individual and group policyholder participating in the plan at policy
issuance and at least 30 days prior to renewal of an existing policy.
The notice must include:
(1) a link to any webpage listing of regions, counties,
or ZIP codes made available pursuant to subsection (e)(2) of this
section;
(2) information on how to obtain or view any local
market access plan or plans the insurer uses; and
(3) a link to the department's website where the department
posts information relevant to the grant of waivers.
(n) Disclosure of substantial decrease in the availability
of certain preferred providers. An insurer is required to provide
notice as specified in this subsection of a substantial decrease in
the availability of preferred facility-based physicians at a preferred
provider facility.
(1) A decrease is substantial if:
(A) the contract between the insurer and any facility-based
physician group that comprises 75% or more of the preferred providers
for that specialty at the facility terminates; or
(B) the contract between the facility and any facility-based
physician group that comprises 75% or more of the preferred providers
for that specialty at the facility terminates, and the insurer receives
notice as required under §3.3703(a)(26) of this title (relating
to Contracting Requirements).
(2) Notwithstanding paragraph (1) of this subsection,
no notice of a substantial decrease is required if the requirements
specified in either subparagraph (A) or (B) of this paragraph are
met:
(A) alternative preferred providers of the same specialty
as the physician group that terminates a contract as specified in
paragraph (1) of this subsection are made available to insureds at
the facility so the percentage level of preferred providers of that
specialty at the facility is returned to a level equal to or greater
than the percentage level that was available prior to the substantial
decrease; or
(B) the insurer provides to the department, by email
to mcqa@tdi.texas.gov, a certification of the insurer's determination
that the termination of the provider contract has not caused the preferred
provider service delivery network for any plan supported by the network
to be noncompliant with the adequacy standards specified in §3.3704
of this title (relating to Freedom of Choice; Availability of Preferred
Providers), as those standards apply to the applicable provider specialty.
(3) An insurer must prominently post notice of any
contract termination specified in paragraph (1)(A) or (B) of this
subsection and the resulting decrease in availability of preferred
providers on the portion of the insurer's website where its provider
listing is available to insureds.
(4) Notice of any contract termination specified in
paragraph (1)(A) or (B) of this subsection and of the decrease in
availability of providers must be maintained on the insurer's website
until the earlier of:
(A) the date on which adequate preferred providers
of the same specialty become available to insureds at the facility
at the percentage level specified in paragraph (2)(A) of this subsection;
(B) six months from the date that the insurer initially
posts the notice; or
(C) the date on which the insurer provides to the department,
by email to mcqa@tdi.texas.gov, a certification as specified in paragraph
(2)(B) of this subsection indicating the insurer's determination that
the termination of provider contract does not cause noncompliance
with adequacy standards.
(5) An insurer must post notice as specified in paragraph
(3) of this subsection and update its Internet-based preferred provider
listing as soon as practicable and in no case later than two business
days after:
(A) the effective date of the contract termination
as specified in paragraph (1)(A) of this subsection; or
(B) the later of:
(i) the date on which an insurer receives notice of
a contract termination as specified in paragraph (1)(B) of this subsection;
or
(ii) the effective date of the contract termination
as specified in paragraph (1)(B) of this subsection.
(o) Disclosures concerning reimbursement of out-of-network
services. An insurer must make disclosures in all insurance policies,
certificates, and outlines of coverage concerning the reimbursement
of out-of-network services as specified in this subsection.
(1) An insurer must disclose how reimbursements of
nonpreferred providers will be determined.
(2) Except in an exclusive provider benefit plan, if
an insurer reimburses nonpreferred providers based directly or indirectly
on data regarding usual, customary, or reasonable charges by providers,
the insurer must disclose the source of the data, how the data is
used in determining reimbursements, and the existence of any reduction
that will be applied in determining the reimbursement to nonpreferred
providers.
(3) Except in an exclusive provider benefit plan, if
an insurer bases reimbursement of nonpreferred providers on any amount
other than full billed charges, the insurer must:
(A) disclose that the insurer's reimbursement of claims
for nonpreferred providers may be less than the billed charge for
the service;
(B) disclose that the insured may be liable to the
nonpreferred provider for any amounts not paid by the insurer;
(C) provide a description of the methodology by which
the reimbursement amount for nonpreferred providers is calculated;
and
Cont'd... |
