Current through Reg. 50, No. 13; March 28, 2025
(a)
All services specified by this section must be provided by a provider who holds
a current appropriate Texas license, unless the provider is exempt from license
requirements.
(b) The network must
ensure that the network's provider panel includes:
(1) an adequate number of contracted treating
doctors and specialists, who must be available and accessible to employees 24
hours a day, seven days a week, within the network's service area;
(2) sufficient numbers and types of health
care providers to ensure choice, access, and quality of care to injured
employees;
(3) an adequate number
of treating doctors and specialists who have admitting privileges at one or
more network hospitals located within the network's service area to make any
necessary hospital admissions;
(4)
hospital services that are available and accessible 24 hours a day, seven days
a week, within the network's service area. The network must provide for the
necessary hospital services by contracting with general, special, and
psychiatric hospitals, as applicable;
(5) physical and occupational therapy
services and chiropractic services that are available and accessible within the
network's service area;
(6)
emergency care that is available and accessible 24 hours a day, seven days a
week, without restrictions as to where the services are rendered; and
(7) an adequate number of doctors who are
qualified to provide maximum medical improvement and impairment rating services
as required under Labor Code §
408.023, concerning List
of Approved Doctors; Duties of Treating Doctors.
(c) Except for emergencies, a network must
arrange for services, including referrals to specialists, to be accessible to
injured employees within the time appropriate to the circumstances and
condition of the injured employee, but not later than 21 calendar days after
the date of the original request.
(d) Each network must provide that network
services are sufficiently accessible and available as necessary to ensure that
the distance from any point in the network's service area to a point of service
by a treating doctor or general hospital is not greater than:
(1) 30 miles in nonrural areas; and
(2) 60 miles in rural areas.
(e) Each network must provide that
network services are sufficiently accessible and available as necessary to
ensure that the distance from any point in the network's service area to a
point of service by a specialist or specialty hospital is not greater than:
(1) 75 miles in nonrural areas; and
(2) 75 miles in rural areas.
(f) For portions of the service
area in which the network or department identifies noncompliance with this
section, the network must file an access plan with the department for approval
at least 30 days before implementation of the plan if any health care service
or a network provider is not available to an employee because:
(1) providers are not located within the
required distances;
(2) the network
is unable to obtain provider contracts after good faith attempts; or
(3) providers meeting the network's minimum
quality-of-care and credentialing requirements are not located within the
required distances.
(g)
The access plan required under subsection (f) of this section must include:
(1) a description of the geographic area in
which services or providers are not available, identified by county, city, ZIP
code, mileage, or other identifying data;
(2) a map, with key and scale, which
identifies the areas in which such health care services or providers are not
available;
(3) documentation that
demonstrates how the network determined that providers are not located within
the required distances;
(4) the
network's general plan for making health care services and providers available
to injured employees in each geographic area identified in the access plan,
including:
(A) the names, addresses, and
specialties of the network providers and a listing of the services to be
provided through the network that meet the health care needs of the employees;
and
(B) a network development and
provider contracting plan through which health care services or providers will
be made available and accessible to employees in these geographic areas in the
future;
(5) if a general
hospital is not available in an approved nonrural county, or a general acute
hospital is available in an approved nonrural area but refuses to contract with
the network, lists of:
(A) contracted
providers who have admitting privileges in a general hospital in each approved
nonrural area who may admit injured employees; and
(B) alternative but contracted nonacute care
facilities that can provide required acute hospital services to injured
employees;
(6) a list of
the physicians, providers, and facilities within the relevant service area that
the network attempted to contract with, identified by name and specialty or
facility type, with:
(A) a description of how
and when the network 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
network; and
(7) any
other information necessary to allow the department to assess and approve the
network's access plan.
(h) The network may make arrangements with
providers outside the service area to enable employees to receive skilled or
specialty care not available within the network service area.
(i) The network is not required to expand
services outside the network's service area to accommodate employees who live
outside the service area.
