| (A) have expertise in the necessary specialty;
(B) are reasonably available considering the medical
condition and location of the insured; and
(C) the insured may choose to use without being liable
for any amount charged by the physician or provider that exceeds the
insured's cost-sharing responsibilities under the preferred provider
benefit level;
(3) furnish to insureds, prior to the services being
rendered, an explanation of their rights, consistent with §3.3708(b)(1)(B)
of this title (relating to Payment of Certain Out-of-Network Claims);
(4) except when a physician or provider is prohibited
from balance billing, as specified in §3.3708(a)(1) - (4) of
this title, notify insureds that they may be liable for any amounts
charged by the physician or provider that are more than the insurer's
reimbursement rate, unless the insured uses a physician or provider
recommended by the insurer.
(5) identify claims filed by nonpreferred providers
in instances in which no preferred provider was available to the insured;
and
(6) make initial and, if required, subsequent payment
of the claims in the manner required by this subchapter.
(k) For the purposes of paragraph (j)(2) of this section,
a network gap exception means an insurer's approval for an insured
to receive care from a nonpreferred provider under the preferred provider
benefit level because access to care through a preferred provider
is not available within network adequacy standards. When facilitating
care as required under paragraph (j)(2) of this section, a recommended
physician or provider is reasonably available if they are:
(1) a nonpreferred provider within the network adequacy
standards in §3.3704(f) of this title; or
(2) a preferred or nonpreferred provider outside of
the network adequacy standards in §3.3704(f) of this title, only
if the distance to reach the recommended physician or provider is
not more than 15% farther than the distance to reach the nearest available
physician or provider.
(l) An access plan may include a process for negotiating
with a nonpreferred provider prior to services being rendered, when
feasible.
(m) As a contingency, and to protect insureds from
any unforeseen circumstance in which an insured is unable to reasonably
access covered health care services within the network adequacy standards
provided in §3.3704 of this title, an insurer must submit an
access plan that applies broadly to all counties within the service
area and all types of physicians and providers, and includes the information
specified in §3.3712(c)(2)(C)(iv) of this title.
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| Source Note: The provisions of this §3.3707 adopted 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 |
