| (C) Insurance Code §1301.00553, concerning Maximum
Travel Time and Distance Standards by Preferred Provider Type, which
applies maximum travel time in minutes and maximum distance in miles
for a county based on the county's classification as specified in
the network compliance and waiver request form available at www.tdi.texas.gov;
(D) Insurance Code §1301.00554, concerning Other
Maximum Distance Standard Requirements; Commissioner Authority;
(E) Insurance Code §1301.00555, concerning Maximum
Appointment Wait Time Standards, effective for a policy delivered,
issued for delivery, or renewed on or after September 1, 2025; and
(F) Insurance Code §1301.006.
(2) An adequate network must, for each insured residing
in the service area, ensure that all insureds can access a choice
of at least two preferred providers for each physician specialty and
each class of health care provider within the time and distance standards
specified in Insurance Code §1301.00553 and §1301.00554.
(3) To provide a sufficient number of the specified
types of preferred providers with the specialty and diagnostic types
listed in Insurance Code §1301.0055(b)(4), a network must include
at least two preferred physicians for each applicable specialty and
diagnostic type at each preferred hospital, ambulatory surgical center,
or freestanding emergency medical care facility that credentials the
particular specialty.
(4) For specialty care and specialty hospitals for
which time and distance standards are not otherwise specified in Insurance
Code §1301.00553, an adequate network must ensure that all insureds
residing in the service area can access a choice of at least two preferred
providers within a distance not greater than 75 miles.
(g) Network monitoring and corrective action. Insurers
must monitor compliance with subsection (f) of this section on an
ongoing basis, taking any needed corrective action as required to
ensure that the network is adequate. Consistent with Insurance Code §1301.0055,
an insurer must report any material deviation from the network adequacy
standards to the department within 30 days of the date the material
deviation occurred, by submitting a network configuration filing as
specified in §3.3712 of this title (relating to Network Configuration
Filings). Unless there are no uncontracted licensed physicians or
providers within the service area to meet the standard in the affected
county, or the insurer requests a waiver, the insurer must promptly
take corrective action to ensure that the network is compliant not
later than the 90th day after the date the material deviation occurred.
(h) Service areas. For purposes of this subchapter,
a preferred provider benefit plan may have one or more contiguous
or noncontiguous service areas, but may not divide a county. Any service
areas that are smaller than statewide must be defined in terms of
one or more Texas counties.
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| Source Note: The provisions of this §3.3704 adopted to be effective July 1, 1986, 11 TexReg 2810; amended to be effective December 28, 1990, 15 TexReg 7183; amended to be effective December 6, 1995, 20 TexReg 9697; amended to be effective June 1, 1996, 21 TexReg 2465; amended to be effective July 15, 1999, 24 TexReg 5204; amended to be effective December 6, 2011, 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827; amended to be effective April 25, 2024, 49 TexReg 2497 |
