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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 10WORKERS' COMPENSATION HEALTH CARE NETWORKS
SUBCHAPTER ENETWORK OPERATIONS
RULE §10.80Accessibility and Availability Requirements

(a) All services specified by this section must be provided by a provider who holds a current appropriate license, unless the provider is exempt from license requirements.

(b) The network shall ensure that the network's provider panel includes:

  (1) an adequate number of treating doctors and specialists, who must be available and accessible to employees 24 hours a day, seven days a week, within the network's service area;

  (2) sufficient numbers and types of health care providers to ensure choice, access, and quality of care to injured employees;

  (3) an adequate number of the treating doctors and specialists who have admitting privileges at one or more network hospitals located within the network's service area to make any necessary hospital admissions;

  (4) hospital services that are available and accessible 24 hours a day, seven days a week, within the network's service area. The network shall provide for the necessary hospital services by contracting with general, special, and psychiatric hospitals, as applicable;

  (5) physical and occupational therapy services and chiropractic services that are available and accessible within the network's service area;

  (6) emergency care that is available and accessible 24 hours a day, seven days a week, without restrictions as to where the services are rendered; and

  (7) an adequate number of doctors who are qualified to provide maximum medical improvement and impairment rating services as required under Labor Code §408.023.

(c) Except for emergencies, a network shall arrange for services, including referrals to specialists, to be accessible to injured employees within the time appropriate to the circumstances and condition of the injured employee, but not later than 21 calendar days after the date of the original request.

(d) Each network shall provide that network services are sufficiently accessible and available as necessary to ensure that the distance from any point in the network's service area to a point of service by a treating doctor or general hospital is not greater than:

  (1) 30 miles in nonrural areas; and

  (2) 60 miles in rural areas.

(e) Each network shall provide that network services are sufficiently accessible and available as necessary to ensure that the distance from any point in the network's service area to a point of service by a specialist or specialty hospital is not greater than:

  (1) 75 miles in nonrural areas; and

  (2) 75 miles in rural areas.

(f) For portions of the service area in which the network or department identifies noncompliance with this section, the network must file an access plan with the department for approval at least 30 days before implementation of the plan if any health care service or a network provider is not available to an employee because:

  (1) providers are not located within the required distances;

  (2) the network is unable to obtain provider contracts after good faith attempts; or

  (3) providers meeting the network's minimum quality of care and credentialing requirements are not located within the required distances.

(g) The access plan required under subsection (f) of this section must include:

  (1) a description of the geographic area in which services or providers are not available, identified by county, city, ZIP code, mileage, or other identifying data;

  (2) a map, with key and scale, which identifies the areas in which such health care services or providers are not available;

  (3) for each geographic area identified as not having adequate health care services or providers available, the reason or reasons that health care services or providers cannot be made available;

  (4) the network's general plan for making health care services and providers available to injured employees in each geographic area identified, including:

    (A) the names, addresses and specialties of the network providers and a listing of the services to be provided through the network that meet the health care needs of the employees;

    (B) a listing of any health care services to be made available in the geographic area;

    (C) a general description of the procedures to be followed by the network to assure that certain health care services are made available and accessible to employees in the geographic areas identified as being areas in which the health care services or providers are not available and accessible; and

    (D) a network development plan through which health care services or providers will be made available and accessible to employees in these geographic areas in the future;

  (5) any other information which is necessary to allow the department to assess the network's access plan.

(h) The network may make arrangements with providers outside the service area to enable employees to receive skilled or specialty care not available within the network service area.

(i) The network is not required to expand services outside the network's service area to accommodate employees who live outside the service area.


Source Note: The provisions of this §10.80 adopted to be effective December 5, 2005, 30 TexReg 8099

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