Current through Reg. 50, No. 13; March 28, 2025
(a)
Where to file application. An insurer that seeks to offer a preferred or
exclusive provider benefit plan must file an application for approval with the
Texas Department of Insurance as specified on the department's website and use
the form titled Application for Approval of Provider Benefit Plan, which is
available at www.tdi.texas.gov/forms.
(b) Filing requirements.
(1) An applicant must provide the department
with a complete application that includes the elements in the order set forth
in subsection (c) of this section.
(2) All pages must be clearly legible and
numbered.
(3) If the application is
revised or supplemented during the review process, the applicant must submit a
transmittal letter describing the revision or supplement plus the specified
revision or supplement.
(4) If a
page is to be revised, the applicant must submit a complete new page with the
changed item or information clearly marked.
(c) Contents of application. A complete
application includes the elements specified in paragraphs (1) - (12) of this
subsection.
(1) The applicant must provide a
statement that the filing is:
(A) an
application for approval; or
(B) a
modification to an approved application.
(2) The applicant must provide organizational
information for the applicant, including:
(A)
the full name of the applicant;
(B)
the applicant's Texas Department of Insurance license or certificate
number;
(C) the applicant's home
office address, including city, state, and ZIP code; and
(D) the applicant's telephone
number.
(3) The applicant
must provide the name and telephone number of an individual to be the contact
person who will facilitate requests from the department regarding the
application.
(4) The applicant must
provide an attestation signed by the applicant's corporate president, corporate
secretary, or the president's or secretary's authorized representative that:
(A) the person has read the application, is
familiar with its contents, and asserts that all of the information submitted
in the application, including the attachments, is true and complete;
and
(B) the network, including any
requested or granted waiver and any access plan as applicable, is adequate for
the services to be provided under the preferred or exclusive provider benefit
plan.
(5) The applicant
must provide a description and a map of the service area, with key and scale,
identifying the county or counties to be served. If the map is in color, the
original and all copies must also be in color.
(6) The applicant must provide a list of all
plan documents and each document's associated form filing ID number or the form
number of each plan document that is pending the department's approval or
review.
(7) The applicant must
provide the form(s) of physician contract(s) and provider contract(s) that
include the provisions required in §
3.3703 of this title (relating to
Contracting Requirements) or an attestation by the insurer's corporate
president, corporate secretary, or the president's or secretary's authorized
representative that the physician and provider contracts applicable to services
provided under the preferred or exclusive provider benefit plan comply with the
requirements of Insurance Code Chapter 1301, concerning Preferred Provider
Benefit Plans, and this subchapter.
(8) The applicant, if applying for approval
of an exclusive provider benefit plan offered under Insurance Code Chapter 1301
in commercial markets, must provide a description of the quality improvement
program and work plan that includes a process for physician review required by
Insurance Code §
1301.0051, concerning
Exclusive Provider Benefit Plans: Quality Improvement and Utilization
Management, and that explains arrangements for sharing pertinent medical
records between preferred providers and for ensuring the records'
confidentiality.
(9) The applicant
must provide network configuration information, as specified in §
3.3712 of this title (relating to
Network Configuration Filings).
(10) The applicant must provide documentation
demonstrating that its plan documents and procedures are compliant with §
3.3707(j)-(m) of
this title (relating to Waiver Due to Failure to Contract in Local Markets) and
§
3.3708 of this title (relating to
Payment of Certain Out-of-Network Claims).
(11) The applicant must provide documentation
demonstrating that the insurer maintains a complaint system that provides
reasonable procedures to resolve a written complaint initiated by a
complainant.
(12) The applicant
must provide notification of the physical address of all books and records
described in subsection (d) of this section.
(d) Qualifying examinations; documents to be
available. The following documents must be available during the qualifying
examination at the physical address designated by the insurer in accordance
with subsection (c)(12) of this section:
(1)
quality improvement--program description and work plan as required by §
3.3724 of this title (relating to
Quality Improvement Program) if the applicant is applying for approval of an
exclusive provider benefit plan offered under Insurance Code Chapter 1301, in
commercial markets;
(2) utilization
management--program description, policies and procedures, criteria used to
determine medical necessity, and examples of adverse determination letters,
adverse determination logs, and independent review organization logs;
(3) network configuration information as
outlined in §
3.3712 of this title that
demonstrates compliance with network adequacy requirements described in §
3.3704(f) of
this title (relating to Freedom of Choice; Availability of Preferred
Providers), and all executed physician and provider contracts applicable to the
network, which may be satisfied by contract forms and executed signature
pages;
(5) all written materials to
be presented to prospective insureds that discuss the provider network
available to insureds under the plan and how preferred and nonpreferred
physicians or providers will be paid under the plan;
(6) the policy and certificate of insurance;
and
(7) a complaint log that is
categorized and completed in accordance with §
21.2504 of this title (relating to
Complaint Record; Required Elements; Explanation and Instructions).
(e) Network modifications.
(1) An insurer must file a network
configuration filing as specified in §
3.3712 of this title for approval
with the department before the insurer may make changes to network
configuration that impact the adequacy of the network, expand an existing
service area, reduce an existing service area, or add a new service area. If
any insured will be nonrenewed as a result of a service area reduction, the
insurer must comply with the requirements under §
3.3038 of this title (relating to
Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical,
or Surgical Coverage; Exceptions).
(2) In accordance with paragraph (1) of this
subsection, if an insurer submits any of the following items to the department
and then replaces or materially changes them, the insurer must submit the new
item or any amendments to an existing item along with an indication of the
changes:
(A) descriptions and maps of the
service area, as required by subsection (c)(5) of this section;
(B) forms of contracts, as described in
subsection (c) of this section; or
(C) network configuration information, as
required by §
3.3712 of this
title.
(3) An insurer
must file with the department any information other than the information
described in paragraph (2) of this subsection that amends, supplements, or
replaces the items required under subsection (c) of this section no later than
30 days after the implementation of any change.
(f) Exceptions. Paragraphs (c)(9) and (d)(3)
and subsection (e) of this section do not apply to a preferred or exclusive
provider benefit plan written by an insurer for a contract with the Health and
Human Services Commission to provide services under the Texas Children's Health
Insurance Program (CHIP), Medicaid, or with the State Rural Health Care
System.