28 Tex. Admin. Code § 11.1610 - Annual Network Adequacy Report
(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 o 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.
Notes
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