28 Tex. Admin. Code § 3.3707 - Waiver Due to Failure to Contract in Local Markets
(a) Consistent with Insurance Code §
1301.0055(a)(3),
concerning Network Adequacy Standards, where necessary to avoid a violation of
the network adequacy requirements of §
3.3704 of this title (relating to
Freedom of Choice; Availability of Preferred Providers) in a county that the
insurer wishes to include in its service area, an insurer may apply for a
waiver from one or more of the network adequacy requirements in §
3.3704(f) of
this title. After considering all pertinent evidence in a public hearing under
Insurance Code §
1301.00565, concerning
Public Hearing on Network Adequacy Standards Waivers, the commissioner may
grant the waiver if the requestor shows good cause, subject to the limits on
waivers provided in Insurance Code §
1301.0055(a)(5).
The commissioner may deny a waiver request if good cause is not shown and may
impose reasonable conditions on the grant of the waiver.
(b) An insurer seeking a waiver under
subsection (a) of this section must submit waiver and access plan information
required under §
3.3712(c) of
this title (related to Network Configuration Filings) and information
justifying the waiver request as specified in this subsection using the attempt
to contract form available at www.tdi.texas.gov. An insurer must submit the
network compliance and waiver request form and the attempt to contract form to
the department using SERFF or another electronic method that is acceptable to
the department. For each waiver requested with respect to a type of physician
or provider in a given county, the insurer must provide either the information
specified by paragraph (1) of this subsection or the information specified by
paragraph (2) of this subsection, as appropriate.
(1) If providers or physicians are available
within the relevant service area for the covered service or services for which
the insurer requests a waiver, the insurer's request for waiver must include,
within the attempt to contract form:
(A) a
list of the providers or physicians within the relevant service area that the
insurer attempted to contract with, identified by name and specialty or
facility type, and including the physician or provider's address and county;
national provider identifier, contact name, email, and phone number; and for
facility-based physicians or providers, the group name and associated
facility;
(B) a description of how
and when the insurer last contacted each provider or physician that
demonstrates that the insurer made a good faith effort to contract, as defined
in Insurance Code §
1301.00565(a),
including:
(i) in the case of a waiver that is
being requested more than two consecutive times for the same network adequacy
standard in the same county, evidence that the insurer made multiple good faith
attempts during each of the prior consecutive waiver periods;
(ii) in the case of a waiver that is being
requested more than four times within a 21-year period for the same network
adequacy standard in the same county, evidence that the insurer has been unable
to remedy the issue through good faith efforts;
(C) a description of any reason each provider
or physician gave for declining to contract with the insurer, such as the
provider's or physician's participation in any exclusivity arrangement or other
external factors that affect the ability of the parties to contract;
(D) a description of all steps the insurer
will take to attempt to improve its network to make future requests to renew
the waiver unnecessary;
(E) a
description of the source or sources the insurer uses to identify physicians
and providers that are available in the service area, and how often the insurer
monitors these sources for new physicians and providers entering the service
area; and
(F) a description of the
insurer's policies and procedures for reaching out to available physicians and
providers, including how many attempts the insurer makes and if different
policies and procedures apply for different specialty types.
(2) If there are no providers or
physicians available within the relevant service area with whom a contract
would allow the insurer to meet the specific standard for the covered service
or services for which the insurer requests a waiver, the insurer's request for
waiver must state this fact.
(c) At the same time an insurer files a
request for waiver or a request to renew a waiver, it must file an access plan,
to be taken into consideration by the commissioner in deciding whether to grant
or deny a waiver request, subject to Insurance Code §
1301.00566, concerning
Effect of Network Adequacy Standards Waiver on Balance Billing Prohibitions.
The insurer must:
(1) develop access plan
procedures consistent with subsection (j) of this section; and
(2) file the access plan as required in §
3.3712(c)(2)(C)(iv)
of this title.
(d) If the insurer believes that the
information provided under subsection (b) of this section in the attempt to
contract form includes proprietary information that is confidential and not
subject to disclosure as public information under Government Code Chapter 552,
concerning Public Information, the insurer must mark the document as
confidential in SERFF. If the insurer marks the document as confidential, it
must include in the filing an explanation of which information contained in the
document is proprietary, and which information is not. However, consistent with
Insurance Code
1301.00565(g),
certain information is subject to release regardless of marking, and the
department may publish or otherwise release such information. The insurer is
not permitted to mark the entire filing as confidential. When scheduling a
hearing related to a waiver request, the department will send a notice of the
hearing to any provider or physician named in the waiver request.
(e) Any provider or physician may elect to
provide a response to an insurer's request for waiver by sending an email to
networkwaivers@tdi.texas.gov within 15 days after receiving notice from the
department. The response, if filed, must indicate whether the provider or
physician consents to being identified at a hearing related to the waiver
request and may include evidence that is pertinent to the waiver request for
the commissioner's consideration.
(f) If the department grants a waiver under
subsection (a) of this section, the department will post on the department's
website information relevant to the grant of a waiver, consistent with
Insurance Code §
1301.0055(a)(3).
(g) An insurer may apply for renewal of a
waiver described in subsection (a) of this section annually.
(1) Application for renewal of a waiver must
be filed in the manner described in subsection (d) of this section and
submitted at the time the insurer files its annual report under §
3.3709 of this title (relating to
Annual Network Adequacy Report).
(2) At the same time the insurer files an
application for renewal of a waiver, the insurer must develop and file any
applicable access plan the insurer uses in accordance with the waiver, in the
manner specified by subsection (c) of this section.
(h) When granting a waiver, the department
will specify the one-year period for which the waiver will apply. A waiver will
expire at the end of the period specified by the department unless the insurer
requests a renewal under subsection (g) of this section and the department
approves the insurer's request for renewal.
(i) If the status of a network utilized in
any preferred provider benefit plan changes so that the health benefit plan no
longer complies with the network adequacy requirements specified in §
3.3704 of this title for a
specific county, the insurer must establish an access plan within 30 days of
the date on which the network becomes noncompliant and, within 90 days of the
date on which the network becomes noncompliant, apply for a waiver in
accordance with subsection (a) of this section requesting that the department
approve the continued use of the access plan.
(j) An insurer must establish and implement
documented procedures, as specified in this subsection, for use in all service
areas for which an access plan is submitted, as required by subsections (c),
(i), or (m) of this section. These procedures must be made available to the
department upon request. When a preferred provider is not available within the
network adequacy standards under §
3.3704(f) of
this title (relating to Freedom of Choice; Availability of Preferred Providers)
to provide a medically necessary covered service, the insurer must use a
documented procedure to:
(1) identify requests
for preauthorization of services for insureds that are likely to require the
rendition of services by physicians or providers that do not have a contract
with the insurer;
(2) upon request
by an insured or an individual acting on behalf of an insured, and within the
time appropriate to the circumstances relating to the delivery of the services
and the condition of the patient but in no event to exceed five business days,
approve a network gap exception and facilitate access to care by recommending
at least two physicians or providers that:
(A)
have expertise in the necessary specialty;
(B) are reasonably available considering the
medical condition and location of the insured; and
(C) the insured may choose to use without
being liable for any amount charged by the physician or provider that exceeds
the insured's cost-sharing responsibilities under the preferred provider
benefit level;
(3)
furnish to insureds, prior to the services being rendered, an explanation of
their rights, consistent with §
3.3708(b)(1)(B)
of this title (relating to Payment of Certain Out-of-Network Claims);
(4) except when a physician or provider is
prohibited from balance billing, as specified in §
3.3708(a)(1) -
(4) of this title, notify insureds that they
may be liable for any amounts charged by the physician or provider that are
more than the insurer's reimbursement rate, unless the insured uses a physician
or provider recommended by the insurer.
(5) identify claims filed by nonpreferred
providers in instances in which no preferred provider was available to the
insured; and
(6) make initial and,
if required, subsequent payment of the claims in the manner required by this
subchapter.
(k) For the
purposes of paragraph (j)(2) of this section, a network gap exception means an
insurer's approval for an insured to receive care from a nonpreferred provider
under the preferred provider benefit level because access to care through a
preferred provider is not available within network adequacy standards. When
facilitating care as required under paragraph (j)(2) of this section, a
recommended physician or provider is reasonably available if they are:
(1) a nonpreferred provider within the
network adequacy standards in §
3.3704(f) of
this title; or
(2) a preferred or
nonpreferred provider outside of the network adequacy standards in §
3.3704(f) of
this title, only if the distance to reach the recommended physician or provider
is not more than 15% farther than the distance to reach the nearest available
physician or provider.
(l) An access plan may include a process for
negotiating with a nonpreferred provider prior to services being rendered, when
feasible.
(m) As a contingency, and
to protect insureds from any unforeseen circumstance in which an insured is
unable to reasonably access covered health care services within the network
adequacy standards provided in §
3.3704 of this title, an insurer
must submit an access plan that applies broadly to all counties within the
service area and all types of physicians and providers, and includes the
information specified in §
3.3712(c)(2)(C)(iv)
of this title.
Notes
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