| (a) An HMO must file a network adequacy report with
the department on or before August 15 of each year and before marketing
any plan in a new service area after August 15, 2017. The network
adequacy report must specify:
(1) the trade name of each HMO plan in which enrollees
currently participate;
(2) the applicable service area of each plan; and
(3) whether the HMO service delivery network supporting
each plan meets the requirements in §11.1607 of this title (relating
to Accessibility and Availability Requirements).
(b) If applicable, the network adequacy report must
include an access plan that complies with §11.1607 of this title.
(c) As part of the annual network adequacy report,
the HMO must provide additional data specified in this subsection
for the previous calendar year. The data must be reported on the basis
of each of the geographic regions specified in §3.3711 of this
title (relating to Geographic Regions). If none of the HMO's plans
include a service area that is located within a particular geographic
region, the insurer must specify in the report that there is no applicable
data for that region. The HMO report must include the number of:
(1) claims paid for out-of-network benefits that were
not based on an emergency or the unavailability of network physicians
or providers under Insurance Code §1271.155 (concerning Emergency
Care) or §1271.055 (concerning Out-of-Network Services);
(2) claims for out-of-network benefits that were based
on an emergency or the unavailability of network physicians or providers
under Insurance Code §1271.155 or §1271.055;
(3) complaints by non-network physicians and providers;
(4) complaints by network physicians and providers
relating to inability to refer enrollees to network physicians or
providers because network physicians or providers are not available;
(5) complaints by enrollees relating to the dollar
amount of the HMO's payment for basic health care benefits;
(6) complaints by enrollees concerning balance billing;
(7) complaints by enrollees relating to the unavailability
of network physicians or providers;
(8) complaints by enrollees relating to the accuracy
of network physician and provider listings; and
(9) complaints by physicians and providers relating
to the accuracy of network physician and provider listings.
(d) The annual network adequacy report required under
this section must be submitted electronically in a format and by a
method acceptable to the department. Unless and until a standardized
form and method for submitting the above information is made available
by the department, acceptable formats include Microsoft Word and Excel
documents. Unless and until another electronic method of submission
is required, the report must be submitted to the department's email
address, mcqa@tdi.texas.gov, and must indicate in the subject field
that the email relates to the filing of the annual network adequacy
report.
(e) If the Commissioner determines that the HMO's network
and any access plan supporting the network are inadequate to ensure
that benefits are available to all enrollees or are inadequate to
ensure that all covered health care services are provided in a manner
ensuring availability of and accessibility to adequate personnel,
specialty care, and facilities, the Commissioner may order one or
more of the following sanctions under the Commissioner's authority
in Insurance Code Chapter 82 (concerning Sanctions) and Insurance
Code Chapter 83 (concerning Emergency Ceases and Desist Orders) to
issue cease and desist orders:
(1) reduction of a service area;
(2) cessation of marketing in parts of the state; and
(3) cessation of marketing entirely and withdrawal
from the HMO market.
(f) This section does not affect the Commissioner's
authority to take or order any other appropriate action under the
Commissioner's authority in the Insurance Code.
(g) This section does not apply to a health benefit
plan written by an HMO for a contract with the Health and Human Services
Commission (HHSC) to provide services under the Texas Children's Health
Insurance Program (CHIP), Medicaid, or with the State Rural Health
Care System.
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