Current through Reg. 50, No. 13; March 28, 2025
(a) An
insurer must submit network configuration information as specified in this
section in connection with a request for a waiver under §
3.3707 of this title (relating to
Waiver Due to Failure to Contract in Local Markets), an annual network adequacy
report required under §
3.3709 of this title (relating to
Annual Network Adequacy Report), or an application for a network modification
under §
3.3722 of this title (relating to
Application for Preferred and Exclusive Provider Benefit Plan Approval;
Qualifying Examination; Network Modifications).
(b) A network configuration filing must be
submitted to the department using SERFF or another electronic method that is
acceptable to the department.
(c) A
network configuration filing must contain the following items.
(1) Provider listing data. The insurer must
use the provider listings form available at
www.tdi.texas.gov to provide a comprehensive
searchable and sortable listing of physicians and health care providers in the
plan's network that includes:
(A) information
about the insurer, including the insurer's name, National Association of
Insurance Commissioners number, network name, and network ID;
(B) information about each preferred
provider, including:
(i) the preferred
provider's name, address of practice location, county, and telephone
number;
(ii) the preferred
provider's national provider identifier (NPI) number and Texas license
number;
(iii) the preferred
provider's specialty type, license, or facility type, as applicable, using the
categories specified in the form; and
(iv) whether the preferred provider offers
telemedicine or telehealth; and
(C) information about a preferred provider
that is not a facility, including information on the preferred provider's
facility privileges.
(2)
Network compliance analysis. The insurer must use the network compliance and
waiver request form available at
www.tdi.texas.gov to provide a listing of each
county in the insurer's service area and data regarding network compliance for
each county, including:
(A) the number of each
type of preferred provider in the plan's network, using the provider specialty
types specified in the form;
(B)
information indicating whether the network adequacy standards specified in
§
3.3704 of this title (relating to
Freedom of Choice; Availability of Preferred Providers) are met with respect to
each type of physician or provider, including specifying the nature of the
deficiency (such as insufficient providers, insufficient choice, or deficient
appointment wait times);
(C) if the
network adequacy standards are not met for a given type of physician or
provider, a waiver request and an access plan consistent with §
3.3707 of this title (relating to
Waiver Due to Failure to Contract in Local Markets), including an explanation
of:
(i) the reason the waiver is needed,
including whether the waiver is needed because there are no physicians or
providers available with whom a contract would allow the insurer to meet the
network adequacy standards, or because of a failure to contract with available
providers;
(ii) if the waiver is
needed because of a failure to contract with available providers, each year for
which the waiver has previously been approved, beginning with 2024;
(iii) the total number of currently
practicing physicians or providers that are located within each county and the
source of this information; and
(iv) the access plan procedures the insurer
will use to assist insureds in obtaining medically necessary services when no
preferred provider is available within the network adequacy standards,
including procedures to coordinate care to limit the likelihood of balance
billing, consistent with the procedures established in §
3.3707(j) of
this title; and
(D)
except for a network offered in connection with an exclusive provider benefit
plan, an insurer must include a description of how the insurer provides access
to different types of facilities, as required by Insurance Code §
1301.0055(b)(6),
concerning Network Adequacy Standards.
(3) Online provider listing. The insurer must
include a link to the online provider listing made available to insureds and a
pdf copy of the provider listing that is made available to insureds that
request a nonelectronic version.
(4) Access plan for unforeseen network gaps.
The insurer must include a copy of the access plan required in §
3.3707(m) of
this title, which applies to any unforeseen circumstance in which an insured is
unable to access covered health care services within the network adequacy
standards provided in §
3.3704 of this title.
(d) The information submitted as
required under this section is considered public information under Government
Code Chapter 552, concerning Public Information, and the insurer may not submit
the provider listings form or network compliance and waiver request form in a
manner that precludes the public release of the information. The department
will use the data submitted under this section to publish network data
consistent with Insurance Code §§
1301.0055(a)(3),
concerning Network Adequacy Standards, 1301.00565(g), concerning Public Hearing
on Network Adequacy Standards Waivers, and 1301.009, concerning Annual
Report.
(e) Upon request by TDI, an
insurer must provide access to any information necessary for the commissioner
to evaluate and make a determination of compliance with quality of care and
network adequacy standards, including the information set forth in Insurance
Code §
1301.0056(e),
concerning Examinations and Fees.
