Current through Reg. 50, No. 13; March 28, 2025
(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:
Attached
Graphic
(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.
