28 Tex. Admin. Code § 11.1607 - Accessibility and Availability Requirements
(a) Each health benefit plan delivered or
issued for delivery by an HMO must include an HMO delivery network that is
adequate and complies with Insurance Code §
843.082 (concerning
Requirements for Approval of Application).
(b) There must be a sufficient number of
primary care physicians and specialists with hospital admitting privileges to
participating facilities who are available and accessible 24 hours per day,
seven days per week, within the HMO's service area to meet the health care
needs of the HMO's enrollees.
(c)
An HMO must make general, special, and psychiatric hospital care available and
accessible 24 hours per day, seven days per week, within the HMO's service
area.
(d) If an HMO limits
enrollees' access to a limited provider network, it must ensure that the
limited provider network complies with all requirements of this
section.
(e) An HMO must make
emergency care available and accessible 24 hours per day, seven days per week,
without restrictions on where the services are rendered.
(f) All covered services that are offered by
an HMO must be sufficient in number and location to be readily available and
accessible within the service area to all enrollees.
(g) An HMO must arrange for covered health
care services, including referrals to specialists, to be accessible to
enrollees on a timely basis on request and consistent with these guidelines:
(1) urgent care must be available within 24
hours for medical, dental, and behavioral health conditions;
(2) routine care must be available within:
(A) three weeks for medical
conditions;
(B) eight weeks for
dental conditions; and
(C) two
weeks for behavioral health conditions.
(3) Preventive health services must be
available within:
(A) two months for a
child;
(B) three months for an
adult; and
(C) four months for
dental services.
(h) An HMO is required to provide an adequate
network for its entire service area. All covered services must be accessible
and available so that travel distances from any point in its service area to a
point of service are no greater than:
(1) 30
miles for primary care and general hospital care; and
(2) 75 miles for specialty care, special
hospitals, and single health care service plan physicians or
providers.
(i) Access to
certain institutional providers. An HMO network providing access to more than
one institutional provider in a region must make a good-faith effort to have a
mix of for-profit, nonprofit, and tax-supported institutional participating
providers, unless the mix is not feasible due to geographic, economic, or other
operational factors. An HMO must give special consideration to contracting with
teaching hospitals and hospitals that provide indigent care or care for
uninsured individuals as a significant percentage of their overall patient
load.
(j) An HMO that is unable to
meet the requirements of subsections (b) - (h) of this section must file an
access plan for approval with the department in compliance with §
11.301 of this title (relating to
Filing Requirements). The access plan must specify:
(1) the geographic area within the service
area in which a sufficient number of contracted physicians and providers are
not available, including a specification of the class of physician or
provider;
(2) a map for each
specialty, with key and scale, that identifies the geographic areas within the
service area in which the health care services, physicians, and providers are
not available;
(3) the reason or
reasons that the network does not meet the adequacy requirements specified in
this section;
(4) procedures that
the HMO will use to assist enrollees in obtaining medically necessary services
when no network physician or provider is available, including procedures to
coordinate care to hold enrollees harmless and eliminate or limit the
likelihood of balance billing;
(5)
a list of the physicians and providers within the relevant service area that
the HMO attempted to contract with, identified by name and specialty or
facility type, with:
(A) a description of how
and when the HMO 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
HMO;
(6) procedures
detailing how out-of-network benefit claims will be handled when no physicians
or providers are available, including procedures for compliance with §
11.1611 of this title (relating to
Out-of-Network Claims; Non-Network Physicians and Providers);
(7) steps the HMO will take to attempt to
bring its network into compliance with this section; and
(8) a process for negotiating with a
non-network physician or provider before services being rendered, when
feasible.
(k) An HMO must
submit an access plan that complies with subsection (j) of this section along
with the annual report on network adequacy under §
11.1610 of this title (relating to
Annual Network Adequacy Report).
(l) Notwithstanding subsection (h) of this
section, an HMO that has a contract with the Health and Human Services
Commission is not required to meet the access requirements prescribed in this
section for covered services provided to participants in the Children's Health
Insurance Program Perinatal Program.
(m) An HMO may make arrangements with
physicians or providers outside the service area for enrollees to receive a
higher level of skill or specialty than the level available within the HMO
service area, such as, but not limited to, transplants and treatment of cancer,
burns, and cardiac diseases. An HMO may not require an enrollee to travel out
of the service area to receive the services.
(n) An HMO is not required to expand services
outside its service area to accommodate enrollees who live outside the service
area but work within the service area.
(o) In compliance with Insurance Code Chapter
1455 (concerning Telemedicine and Telehealth), each evidence of coverage or
certificate delivered or issued for delivery by an HMO may provide enrollees
the option to access covered health care services through a telehealth service
or telemedicine service.
(p)
Subsections (j) and (k) of this section do not apply to a health benefit plan
written 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.
Notes
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