Current through Reg. 49, No. 38; September 20, 2024
(a) Provider
accessibility.
(1) A managed care
organization (MCO) must provide a broad-based and accessible provider network
within the service area to ensure member accessibility to a choice of two or
more of each of the managed care program's provider types within the time or
distance standards set forth below or as otherwise required by HHSC.
Attached
Graphic
(2) For
STAR+PLUS, STAR Health, and STAR Kids, a health care MCO must ensure the
reasonable availability and accessibility of a choice of two or more of each of
the long-term services and supports (LTSS) and home and community-based
services providers to the extent required by HHSC. These providers must be
reasonably accessible to members, as determined by HHSC.
(3) For providers not specifically listed in
paragraphs (1) or (2) of this subsection, an MCO must provide reasonable
availability and accessibility of providers within the service area to ensure
member accessibility to providers in time or distance, or as otherwise required
by HHSC.
(4) An MCO must allow a
member to choose his network provider to the extent possible and appropriate,
as required by RSA
438.3(l).
(b) Texas Health Steps. In
addition to the requirements in subsection (a) of this section:
(1) a health care MCO must have a network of
providers in sufficient numbers to provide medical checkups, diagnostic
services, and treatment services in accordance with state and federal
regulations, including 42 U.S.C. 1396d(r) and 25 TAC Chapter 33 (relating to
Early and Periodic Screening, Diagnosis, and Treatment), to all enrolled
members age 20 and younger in the service area; and
(2) a dental MCO must have main dentist
providers in their network in sufficient numbers to provide dental checkups,
diagnostic services, and treatment services in accordance with state and
federal regulations, including 42 U.S.C. 1396d(r) and 25 TAC Chapter 33, to all
enrolled members age 20 and younger in the service area.
(c) Wait times.
(1) A health care MCO must have PCPs in
sufficient numbers to ensure that no member must wait an unreasonable amount of
time for an appointment, and that no member must wait an unreasonable amount of
time to be seen at their appointed time.
(2) A dental MCO must have main dentist
providers in sufficient numbers to ensure that no member must wait an
unreasonable amount of time for an appointment, and that no member must wait an
unreasonable amount of time to be seen at their appointed time.
(d) Exceptions and exemptions. If
any service or provider is not available to a member within the time or
distance requirement specified in subsection (a) of this section, the MCO may
submit an exemption request to HHSC. Exemptions are considered on a
case-by-case basis. HHSC may also allow the MCOs to comply with subsection (a)
of this section at a percentage less than 100%.
(e) Service or provider outside the service
area. The provisions in subsection (a) of this section do not preclude an MCO
from making arrangements with a provider outside the service area for members
to receive services from a provider with a higher level of skill or specialty
than the level that is available within the MCO service area. For health care
MCOs, this can include treatment of cancer, burns, and cardiac
diseases.
(f) Provider education
and training.
(1) A health care MCO must
provide education and training to providers on the specific health and
behavioral health problems and needs of members.
(2) A dental MCO must provide education and
training to providers on the specific dental health problems and needs of
members.
(3) All MCOs must provide
education and training regarding the contract and rule requirements for
accessibility and availability. Each MCO must coordinate education and training
activities for providers with HHSC.
(g) Cultural competency.
(1) An MCO must provide a broad-based and
accessible provider network within the service area to ensure member
accessibility to providers that meet cultural competency and language
requirements. An MCO must ensure that cultural barriers do not deter members'
timely access to health care services or dental services.
(2) An MCO must develop a written cultural
competency plan describing how the MCO will effectively provide health care
services or dental services to members from varying cultures, races, ethnic
backgrounds, and religions as well as those with disabilities, to ensure those
characteristics do not pose barriers to gaining access to needed services.
(A) The cultural competency plan must adhere
to the National Standards for Culturally and Linguistically Appropriate
Services in Health and Health Care (National CLAS Standards); and
(B) The MCO must:
(i) employ multi-cultural and multi-lingual
staff;
(ii) arrange and pay for
interpreter services, including written, spoken, and sign language
interpretation, for members to ensure availability of effective communication
regarding treatment, medical history, or health condition;
(iii) display to HHSC through the written
plan a method for incorporating the plan into the MCO's policy-making process,
administration, and daily practices;
(iv) maintain policies and procedures, and
make information available to members and providers, outlining the manner in
which members and the members' providers can access competent interpreter
services, including written, spoken, and sign language interpretation, when the
member is in a provider's office or accessing emergency services; and
(v) submit the written plan and plan updates
and edits to HHSC for review and approval at intervals specified by
HHSC.
(h) Verbal and physical barriers. An MCO must
ensure that communication and physical access barriers do not deter members'
timely access to health care services or dental services. The MCO must provide
information in appropriate communication formats, including formats accessible
to people with disabilities.
(i)
Significant traditional providers. An MCO must not exclude Significant
Traditional Providers from its network for a period of time and under
conditions determined by HHSC and specified in the contract.
