| (a) Consistent with Insurance Code §1301.0055(a)(3),
concerning Network Adequacy Standards, where necessary to avoid a
violation of the network adequacy requirements of §3.3704 of
this title (relating to Freedom of Choice; Availability of Preferred
Providers) in a county that the insurer wishes to include in its service
area, an insurer may apply for a waiver from one or more of the network
adequacy requirements in §3.3704(f) of this title. After considering
all pertinent evidence in a public hearing under Insurance Code §1301.00565,
concerning Public Hearing on Network Adequacy Standards Waivers, the
commissioner may grant the waiver if the requestor shows good cause,
subject to the limits on waivers provided in Insurance Code §1301.0055(a)(5).
The commissioner may deny a waiver request if good cause is not shown
and may impose reasonable conditions on the grant of the waiver.
(b) An insurer seeking a waiver under subsection (a)
of this section must submit waiver and access plan information required
under §3.3712(c) of this title (related to Network Configuration
Filings) and information justifying the waiver request as specified
in this subsection using the attempt to contract form available at
www.tdi.texas.gov. An insurer must submit the network compliance and
waiver request form and the attempt to contract form to the department
using SERFF or another electronic method that is acceptable to the
department. For each waiver requested with respect to a type of physician
or provider in a given county, the insurer must provide either the
information specified by paragraph (1) of this subsection or the information
specified by paragraph (2) of this subsection, as appropriate.
(1) If providers or physicians are available within
the relevant service area for the covered service or services for
which the insurer requests a waiver, the insurer's request for waiver
must include, within the attempt to contract form:
(A) a list of the providers or physicians within the
relevant service area that the insurer attempted to contract with,
identified by name and specialty or facility type, and including the
physician or provider's address and county; national provider identifier,
contact name, email, and phone number; and for facility-based physicians
or providers, the group name and associated facility;
(B) a description of how and when the insurer last
contacted each provider or physician that demonstrates that the insurer
made a good faith effort to contract, as defined in Insurance Code §1301.00565(a),
including:
(i) in the case of a waiver that is being requested
more than two consecutive times for the same network adequacy standard
in the same county, evidence that the insurer made multiple good faith
attempts during each of the prior consecutive waiver periods;
(ii) in the case of a waiver that is being requested
more than four times within a 21-year period for the same network
adequacy standard in the same county, evidence that the insurer has
been unable to remedy the issue through good faith efforts;
(C) a description of any reason each provider or physician
gave for declining to contract with the insurer, such as the provider's
or physician's participation in any exclusivity arrangement or other
external factors that affect the ability of the parties to contract;
(D) a description of all steps the insurer will take
to attempt to improve its network to make future requests to renew
the waiver unnecessary;
(E) a description of the source or sources the insurer
uses to identify physicians and providers that are available in the
service area, and how often the insurer monitors these sources for
new physicians and providers entering the service area; and
(F) a description of the insurer's policies and procedures
for reaching out to available physicians and providers, including
how many attempts the insurer makes and if different policies and
procedures apply for different specialty types.
(2) If there are no providers or physicians available
within the relevant service area with whom a contract would allow
the insurer to meet the specific standard for the covered service
or services for which the insurer requests a waiver, the insurer's
request for waiver must state this fact.
(c) At the same time an insurer files a request for
waiver or a request to renew a waiver, it must file an access plan,
to be taken into consideration by the commissioner in deciding whether
to grant or deny a waiver request, subject to Insurance Code §1301.00566,
concerning Effect of Network Adequacy Standards Waiver on Balance
Billing Prohibitions. The insurer must:
(1) develop access plan procedures consistent with
subsection (j) of this section; and
(2) file the access plan as required in §3.3712(c)(2)(C)(iv)
of this title.
(d) If the insurer believes that the information provided
under subsection (b) of this section in the attempt to contract form
includes proprietary information that is confidential and not subject
to disclosure as public information under Government Code Chapter
552, concerning Public Information, the insurer must mark the document
as confidential in SERFF. If the insurer marks the document as confidential,
it must include in the filing an explanation of which information
contained in the document is proprietary, and which information is
not. However, consistent with Insurance Code 1301.00565(g), certain
information is subject to release regardless of marking, and the department
may publish or otherwise release such information. The insurer is
not permitted to mark the entire filing as confidential. When scheduling
a hearing related to a waiver request, the department will send a
notice of the hearing to any provider or physician named in the waiver
request.
(e) Any provider or physician may elect to provide
a response to an insurer's request for waiver by sending an email
to networkwaivers@tdi.texas.gov within 15 days after receiving notice
from the department. The response, if filed, must indicate whether
the provider or physician consents to being identified at a hearing
related to the waiver request and may include evidence that is pertinent
to the waiver request for the commissioner's consideration.
(f) If the department grants a waiver under subsection
(a) of this section, the department will post on the department's
website information relevant to the grant of a waiver, consistent
with Insurance Code §1301.0055(a)(3).
(g) An insurer may apply for renewal of a waiver described
in subsection (a) of this section annually.
(1) Application for renewal of a waiver must be filed
in the manner described in subsection (d) of this section and submitted
at the time the insurer files its annual report under §3.3709
of this title (relating to Annual Network Adequacy Report).
(2) At the same time the insurer files an application
for renewal of a waiver, the insurer must develop and file any applicable
access plan the insurer uses in accordance with the waiver, in the
manner specified by subsection (c) of this section.
(h) When granting a waiver, the department will specify
the one-year period for which the waiver will apply. A waiver will
expire at the end of the period specified by the department unless
the insurer requests a renewal under subsection (g) of this section
and the department approves the insurer's request for renewal.
(i) If the status of a network utilized in any preferred
provider benefit plan changes so that the health benefit plan no longer
complies with the network adequacy requirements specified in §3.3704
of this title for a specific county, the insurer must establish an
access plan within 30 days of the date on which the network becomes
noncompliant and, within 90 days of the date on which the network
becomes noncompliant, apply for a waiver in accordance with subsection
(a) of this section requesting that the department approve the continued
use of the access plan.
(j) An insurer must establish and implement documented
procedures, as specified in this subsection, for use in all service
areas for which an access plan is submitted, as required by subsections
(c), (i), or (m) of this section. These procedures must be made available
to the department upon request. When a preferred provider is not available
within the network adequacy standards under §3.3704(f) of this
title (relating to Freedom of Choice; Availability of Preferred Providers)
to provide a medically necessary covered service, the insurer must
use a documented procedure to:
(1) identify requests for preauthorization of services
for insureds that are likely to require the rendition of services
by physicians or providers that do not have a contract with the insurer;
(2) upon request by an insured or an individual acting
on behalf of an insured, and within the time appropriate to the circumstances
relating to the delivery of the services and the condition of the
patient but in no event to exceed five business days, approve a network
gap exception and facilitate access to care by recommending at least
two physicians or providers that:
Cont'd... |
