| (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), clearly indicate each health benefit
plan issued by the HMO 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 HMO that
may provide coverage for the services provided by the facility; and
(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.
(i) Annual enrollee notice concerning use of an access
plan. An HMO operating a plan that relies on an access plan as specified
in §11.1600 of this title (relating to Information to Prospective
and Current Contract Holders and Enrollees) and §11.1607 of this
title must provide notice of this fact to each enrollee participating
in the plan at issuance and at least 30 days before renewal. The notice
must include:
(1) a link to any webpage listing of regions, counties,
or ZIP codes made available under subsection (e)(2) of this section;
and
(2) information on how to obtain or view any access
plan or plans the HMO uses.
(j) Disclosure of substantial decrease in the availability
of certain contracted physicians. An HMO is required to provide notice
as specified in this subsection of a substantial decrease in the availability
of contracted facility-based physicians at a contracted facility.
(1) A decrease is substantial if:
(A) the contract between the HMO and any facility-based
physician group that comprises 75% or more of the contracted physicians
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 contracted physicians
for that specialty at the facility terminates, and the HMO receives
notice as required under §11.901 of this title (relating to Required
and Prohibited Provisions).
(2) Despite paragraph (1) of this subsection, no notice
of a substantial decrease is required if:
(A) alternative contracted physicians or 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 enrollees at the facility so the percentage level of contracted
physicians of that specialty at the facility is returned to a level
equal to or greater than the percentage level that was available before
the substantial decrease; or
(B) the HMO certifies to the department, by email to
mcqa@tdi.texas.gov, that the HMO's determination that the termination
of the physician contract has not caused the contracted physician
service delivery network for any plan supported by the network to
be noncompliant with the adequacy standards specified in §11.1607
of this title, as those standards apply to the applicable physician
specialty.
(3) An HMO 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 contracted physicians
on the portion of the HMO's website where its physician and provider
listing is available to enrollees.
(4) Notice of any contract termination specified in
paragraph (1)(A) or (B) of this subsection and of the decrease in
availability of physicians must be maintained on the HMO's website
until the earlier of:
(A) the date on which adequate contracted physicians
of the same specialty become available to enrollees at the facility
at the percentage level specified in paragraph (2)(A) of this subsection;
(B) six months from the date that the HMO initially
posts the notice; or
(C) the date on which the HMO provides to the department,
by email to mcqa@tdi.texas.gov, the certification specified in paragraph
(2)(B) of this subsection.
(5) An HMO must post notice as specified in paragraph
(3) of this subsection and update its web-based contracted physician
and 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 HMO 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.
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