| (a) All services specified by this section must be
provided by a provider who holds a current appropriate Texas license,
unless the provider is exempt from license requirements.
(b) The network must ensure that the network's provider
panel includes:
(1) an adequate number of contracted 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 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 must 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, concerning List of Approved
Doctors; Duties of Treating Doctors.
(c) Except for emergencies, a network must 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 must 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 must 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) documentation that demonstrates how the network
determined that providers are not located within the required distances;
(4) the network's general plan for making health care
services and providers available to injured employees in each geographic
area identified in the access plan, 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; and
(B) a network development and provider contracting
plan through which health care services or providers will be made
available and accessible to employees in these geographic areas in
the future;
(5) if a general hospital is not available in an approved
nonrural county, or a general acute hospital is available in an approved
nonrural area but refuses to contract with the network, lists of:
(A) contracted providers who have admitting privileges
in a general hospital in each approved nonrural area who may admit
injured employees; and
(B) alternative but contracted nonacute care facilities
that can provide required acute hospital services to injured employees;
(6) a list of the physicians, providers, and facilities
within the relevant service area that the network attempted to contract
with, identified by name and specialty or facility type, with:
(A) a description of how and when the network last
contacted each physician, provider, or facility; and
(B) a description of the reason each physician, provider,
or facility gave for declining to contract with the network; and
(7) any other information necessary to allow the department
to assess and approve 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.
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