| (A) alternative preferred providers of the same specialty
as the physician or provider 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 determines 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;
or
(B) six months from the date that the insurer initially
posts the notice.
(5) An insurer must post notice as specified in paragraph
(3) of this subsection and update its website 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) An insurer must disclose how the plan will cover
out-of-network services received when medically necessary covered
services are not reasonably available through a preferred provider,
consistent with §3.3708 of this title and how an enrollee can
obtain assistance with accessing care in these circumstances, consistent
with §3.3707(k) of this title.
(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, unless
balance billing protections apply, as specified in §3.3708(a)(1)
- (4) of this title;
(C) provide a description of the methodology by which
the reimbursement amount for nonpreferred providers is calculated;
and
(D) provide to insureds a method to obtain a real-time
estimate of the amount of reimbursement that will be paid to a nonpreferred
provider for a particular service.
|
| Source Note: The provisions of this §3.3705 adopted 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 November 3, 2016, 41 TexReg 8605; amended to be effective May 16, 2017, 42 TexReg 2537; amended to be effective March 30, 2021, 46 TeReg 2026; amended to be effective April 25, 2024, 49 TexReg 2497 |
