28 Tex. Admin. Code § 11.1612 - Mandatory Disclosure Requirements
(a)
Physician and provider directory. An HMO must develop and maintain a directory
of contracting physicians and health care providers, display the directory on a
public website maintained by the HMO, and ensure that a direct electronic link
to the directory is conspicuously displayed on the electronic summary of
benefits and coverage of each plan issued by the HMO. Any directory provided by
the HMO, including an online directory, must:
(1) include the name, address, telephone
number, and specialty, if any, of each physician and provider and indicate
whether each contracted physician and provider is accepting enrollees as new
patients or participates in closed provider networks serving only certain
enrollees;
(2) include a statement
of limitations of accessibility and referrals to specialists, including any
limitations imposed by a limited provider network;
(3) be dated and provided in at least
10-point type;
(4) clearly indicate
each health benefit plan issued by the HMO that may provide coverage for
services provided by each physician or provider included in the
directory;
(5) when provided
electronically, be searchable by physician or health care provider name and
location;
(6) be publicly
accessible without the necessity of providing a password, a username, or
personally identifiable information;
(7) be reviewed on an ongoing basis and
corrected or updated, if necessary, not less than once each month;
and
(8) include an email address
and a toll-free telephone number through which enrollees may notify the HMO of
inaccurate information in the directory.
(b) Identification of limited networks and
index. An HMO must clearly identify limited provider networks within its
service area by providing a separate listing of its limited provider networks
and an alphabetical listing of all the physicians and providers, including
specialists, available in the limited provider network. An HMO must include an
index of the alphabetical listing of all physicians and providers, including
behavioral health providers and substance abuse treatment providers, if
applicable, within the HMO's service area, and must indicate the limited
provider network or networks the physician or provider belongs to and the page
number where the physician's or provider's name can be found.
(c) Notice of rights under an HMO plan
required. An HMO must include the notice specified in Figure: 28 TAC §
11.1612(c), in
all evidences of coverage certificates, disclosures of plan terms, and member
handbooks in at least 12-point type:
(d)
Disclosure concerning access to network physician and provider listing. An HMO
must provide notice to all enrollees at least annually describing how the
enrollee may access a current listing of all network physicians and providers
on a cost-free basis. The notice must include, at a minimum, information about
how to obtain a nonelectronic copy of the listing and a telephone number
enrollees may call to get help during regular business hours to find available
network physicians and providers.
(e) Disclosure concerning network
information. An HMO must provide notice to all enrollees at least annually of
information that is updated at least annually regarding the following network
information for each service area or county, or for the entire state if the
plan is offered on a statewide service-area basis:
(1) the number of enrollees in the service
area or region;
(2) for each
physician and provider area of practice, including at a minimum internal
medicine, family or general practice, pediatric practitioner practice,
obstetrics and gynecology, anesthesiology, psychiatry, and general surgery, the
number of contracted physicians and providers, an indication of whether an
active access plan under §
11.1607 of this title (relating to
Accessibility and Availability Requirements) applies to the services furnished
by that class of physician or provider in the service area or region, and how
the access plan may be obtained or viewed, if applicable; and
(3) for hospitals, the number of contracted
hospitals in the service area or region, an indication of whether an active
access plan in compliance with §
11.1607 of this title applies to
hospital services in that service area or region, and how the access plan may
be obtained or viewed, if applicable.
(f) Website disclosures. An HMO must provide
information on its website for use by current or prospective enrollees that
includes a:
(1) physician and provider listing
for use by current and prospective enrollees; and
(2) listing of the state regions, counties,
or three-digit ZIP code areas within the HMO's service area, indicating, as
appropriate, for each region, county, or ZIP code area, as applicable, that the
HMO has:
(A) determined that its network meets
the network adequacy requirements of this subchapter; or
(B) determined that its network does not meet
the network adequacy requirements of this
subchapter.
(g)
Reliance on physician and provider listing in certain cases. A claim for
services rendered by a noncontracted physician or provider must be paid in the
same manner as if no contracted physician or provider had been available under
§
11.1611 of this title (relating to
Out-of-Network Claims; Non-Network Physicians and Providers), as applicable,
and the HMO must make restitution to the enrollee for any amounts the enrollee
demonstrates that they paid the physician or provider above what they would
have paid a network physician or provider, if an enrollee demonstrates that:
(1) in obtaining services, the enrollee
reasonably relied on a statement that a physician or provider was a contracted
physician or provider as specified in:
(A) a
physician and provider listing; or
(B) provider information on the HMO's
website;
(2) the
physician and provider listing or website information was obtained from the
HMO, the HMO's website, or the website of a third party designated by the HMO
to provide that information for use by its enrollees; and
(3) the physician and provider listing or
website information was obtained not more than 30 days before the date of
services.
(h) Additional
listing-specific disclosure requirements. In all contracted physician and
provider listings, including any web-based postings of information made
available by the HMO to provide information to enrollees about contracted
physicians and providers, the HMO must comply with the requirements in
Insurance Code Chapter 1451, Subchapter K, and paragraphs (1) and (2) of this
subsection. The requirements of this subsection do not apply to provider
listings for a single health care service that provides coverage only for
dental or vision care.
(1) The physician and
provider information must provide a method by which enrollees may identify
contracted facility-based physicians and providers able to provide services at
contracted facilities, consistent with Insurance Code §
1451.504, concerning
Physician and Health Care Provider Directories.
(2) The physician and provider information
must specifically identify any network facility at which the HMO has no
contracts with a class of facility-based physician, specifying the applicable
type of facility-based physician, consistent with Insurance Code Chapter 1456,
concerning Disclosure of Provider Status.
(i) Annual enrollee notice concerning use of
an access plan. An HMO operating a plan that relies on an access plan as
specified in §
11.1600 of this title (relating to
Information to Prospective and Current Contract Holders and Enrollees) and §
11.1607 of this title must provide
notice of this fact to each enrollee participating in the plan at issuance and
at least 30 days before renewal. The notice must include a link to any webpage
listing of information on network waivers and access plans made available under
subsection (e) of this section.
(j)
Disclosure of substantial decrease in the availability of certain contracted
physicians or providers. An HMO is required to provide notice as specified in
this subsection of a substantial decrease in the availability of contracted
facility-based physicians or providers at a contracted facility.
(1) A decrease is substantial if:
(A) the contract between the HMO and any
facility-based physician or provider group that comprises 75% or more of the
contracted physicians or providers for that specialty at the facility
terminates; or
(B) the contract
between the facility and any facility-based physician or provider group that
comprises 75% or more of the contracted physicians or providers for that
specialty at the facility terminates, and the HMO receives notice as required
under §
11.901 of this title (relating to
Required and Prohibited Provisions).
(2) For purposes of this subsection,
decreases in numbers of physicians and other providers must be assessed
separately, but no notice of a substantial decrease is required if:
(A) alternative contracted physicians or
providers of the same specialty as the physician or provider group that
terminates a contract as specified in paragraph (1) of this subsection are made
available to enrollees at the facility so the percentage level of contracted
physicians or providers of that specialty at the facility is returned to a
level equal to or greater than the percentage level that was available before
the substantial decrease; or
(B)
the HMO determines that the termination of the contract has not caused the
network to be noncompliant with the adequacy standards specified in §
11.1607 of this title, as those
standards apply to the applicable physician or provider
specialty.
(3) An HMO
must prominently post notice of any contract termination specified in paragraph
(1)(A) or (B) of this subsection and the resulting decrease in availability of
contracted physicians or providers on the portion of the HMO's website where
its physician and provider listing is available to enrollees.
(4) Notice of any contract termination
specified in paragraph (1)(A) or (B) of this subsection and of the decrease in
availability of physicians or providers must be maintained on the HMO's website
until the earlier of:
(A) the date on which
adequate contracted physicians or providers of the same specialty become
available to enrollees at the facility at the percentage level specified in
paragraph (2)(A) of this subsection; or
(B) six months from the date that the HMO
initially posts the notice.
(5) An HMO must post notice as specified in
paragraph (3) of this subsection and update its web-based contracted physician
and provider listing as soon as practicable and in no case later than two
business days after:
(A) the effective date of
the contract termination as specified in paragraph (1)(A) of this subsection;
or
(B) the later of:
(i) the date on which an HMO receives notice
of a contract termination as specified in paragraph (1)(B) of this subsection;
or
(ii) the effective date of the
contract termination as specified in paragraph (1)(B) of this
subsection.
Notes
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